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entitled 'Influenza Pandemic: DOD Has Taken Important Actions to 
Prepare, but Accountability, Funding, and Communications Needed to be 
Clearer and Focused Departmentwide' which was released on October 23, 
2006. 

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Report to the Committee on Government Reform, House of Representatives: 

United States Government Accountability Office: 

GAO: 

September 2006: 

Influenza Pandemic: 

DOD Has Taken Important Actions to Prepare, but Accountability, 
Funding, and Communications Need to be Clearer and Focused 
Departmentwide: 

Influenza Pandemic: 

GAO-06-1042: 

GAO Highlights: 

Highlights of GAO-06-1042, a report to the Chairman and Ranking 
Minority Member, Committee on Government Reform, House of 
Representatives 

Why GAO Did This Study: 

An influenza pandemic would be of global and national significance and 
could affect large numbers of Department of Defense (DOD) personnel, 
seriously challenging DODís readiness. 

GAO was asked to examine DODís pandemic influenza preparedness efforts. 
This report focuses on DODís planning for its workforce, specifically 
(1) actions DOD has taken to prepare and (2) challenges DOD faces going 
forward. GAO analyzed guidance, contracts, and plans, and met with DOD 
officials. 

What GAO Found: 

DOD had taken a number of actions since September 2004 to prepare for 
an influenza pandemic, and its planning efforts continue to evolve. The 
Implementation Plan for the National Strategy for Pandemic Influenza, 
released in May 2006, tasked each federal department to develop its own 
implementation plan that details how it will carry out its 
responsibilities as outlined in the national plan and how it will 
prepare its workforce. DOD established working groups for its pandemic 
influenza planning efforts, including the Pandemic Influenza Task 
Force, which included representatives from across the department, 
including the Offices of the Assistant Secretary of Defense (ASD) for 
Homeland Defense, ASD for Health Affairs, ASD for Special Operations 
and Low Intensity Conflict, and the Joint Chiefs of Staff. In addition, 
the Office of the ASD for Health Affairs developed guidance that 
provided tasks for the Office of the Secretary of Defense, military 
departments, installation commanders, and others to complete to prepare 
for a pandemic. Further, several entities within DOD drafted plans and 
guidance, and DOD had taken other important steps, such as establishing 
Web sites, stockpiling vaccines and antivirals, and initiating projects 
to assist other nations with their preparedness efforts. 

Going forward, DOD faces four management challenges that it needs to 
address as it shifts its focus to the department as a whole. First, at 
the time of GAOís review, neither the Secretary of Defense nor the 
Deputy Secretary of Defense had yet issued guidance defining lead and 
supporting roles and responsibilities with clear lines of authority, 
oversight mechanisms, and goals and performance measures for DODís 
influenza pandemic planning efforts. The lack of these accountability 
mechanisms over time may hamper the leadershipís ability to ensure that 
planning efforts across the department are progressing as intended. 
Second, DOD had not yet requested funding for its pandemic influenza 
preparedness efforts linked to departmentwide goals. Therefore, it is 
unclear whether DOD can address the tasks assigned to it in the 
national implementation plan and pursue its own preparedness efforts 
for its workforce departmentwide within current resources. Third, DOD 
had not yet fully defined or communicated departmentwide which types of 
personnelómilitary and civilian personnel, contractors, beneficiaries, 
and dependentsóit plans to include in its distribution of vaccines and 
antivirals. Fourth, DOD had not yet fully developed its communications 
strategy or communicated information to its personnel departmentwide on 
what actions to take in the event of an influenza pandemic. Also, DOD 
had not yet developed a plan to communicate information on the safety 
and efficacy of vaccines and antivirals, if DOD decides to dispense 
them. While DOD established Web sites with some information on pandemic 
influenza, GAO identified some unevenness across the department in 
terms of the information personnel received. A comprehensive and 
effective communications strategy could ensure that DODís personnel 
departmentwide are aware of actions they should take in the event of an 
influenza pandemic. 

What GAO Recommends: 

GAO recommends that DOD 
(1) define and communicate roles and responsibilities, oversight 
mechanisms, and goals and performance measures for DODís efforts, (2) 
establish a framework to request funding, tied to its goals, (3) define 
and communicate departmentwide which types of personnel DOD plans to 
include in its vaccine and antiviral distribution, and (4) implement a 
comprehensive and effective departmentwide communications strategy. DOD 
generally concurred with four recommendations, and did not address one 
in its written comments. Based on DODís comments and additional 
information provided showing DOD designated a lead authority for its 
efforts, GAO combined two recommendations. GAO clarified another 
recommendation to focus on requesting funding tied to the departmentís 
goals. 

[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-06-1042]. 

To view the full product, including the scope and methodology, click on 
the link above. For more information, contact Davi M. D'Agostino at 
(202) 512-5431 or DAgostinoD@gao.gov. 

[End of Section] 

Contents: 

Letter: 

Results in Brief: 

Background: 

DOD Had Taken Actions to Prepare for an Influenza Pandemic: 

Going Forward, DOD Faces Four Key Management Challenges in Its Pandemic 
Influenza Planning and Preparedness Efforts for Its Workforce 
Departmentwide: 

Conclusions: 

Recommendations for Executive Action: 

Agency Comments and Our Evaluation: 

Appendix I: Scope and Methodology: 

Appendix II: Summary of DOD's Guidance for Pandemic Influenza and 
Related Force Health Protection Policies: 

Appendix III: Comments from the Department of Defense: 

Appendix IV: GAO Contact and Staff Acknowledgments: 

Related GAO Products: 

Table: 

Table 1: DOD's Current Priorities for Vaccine and Antiviral 
Distribution: 

Figures: 

Figure 1: Issues to Be Addressed in DOD's Pandemic Influenza 
Implementation Plan: 

Figure 2: Comparison of WHO Pandemic Phases and U.S. Government Stages: 

Figure 3: Timeline of Actions DOD Has Taken to Prepare for an Influenza 
Pandemic Compared to Key Homeland Security Council Plans: 

Abbreviations: 

ASD: Assistant Secretary of Defense: 

DOD: Department of Defense: 

HHS: Department of Health and Human Services: 

WHO: World Health Organization: 

United States Government Accountability Office: 
Washington, DC 20548: 

September 21, 2006: 

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

An influenza pandemic--a novel strain of influenza virus to which 
humans have little or no immunity that has the ability to infect and be 
passed efficiently between humans worldwide--would be of global and 
national significance. A large number of Department of Defense (DOD) 
personnel potentially could be affected by an influenza pandemic, which 
could adversely affect the military's readiness, jeopardize ongoing 
military operations overseas, and threaten the day-to-day functioning 
of the department and maintenance of its critical infrastructure. For 
example, approximately one-half of all of the deaths of U.S. 
servicemembers from World War I, at least 43,000 deaths, were due to 
influenza or influenza-related complications, and another 1 million 
servicemembers were hospitalized, limiting the military's resources to 
continue ongoing missions. An influenza pandemic outbreak not only 
would be a medical problem, but also a human capital and national 
security problem. The federal government anticipates an influenza 
pandemic would occur in multiple waves over a period of time, rather 
than as a discrete event. During the peak weeks of an outbreak of a 
severe influenza pandemic, an estimated 40 percent of the U.S. 
workforce may not be at work due to illness, the need to care for 
family members, or fear of infection. 

Planning for an influenza pandemic is a difficult and daunting task, 
particularly because so much is currently unknown about a potential 
pandemic. While some scientists and public health experts believe that 
the next influenza pandemic could be spawned by the H5N1 strain of 
avian influenza (also known as "bird flu") that is currently 
circulating in parts of Asia, the Middle East, Europe, and Africa, it 
is unknown when an influenza pandemic will occur, where it will begin, 
or whether a variant of the H5N1 strain or some other strain would be 
the cause. Moreover, the severity of an influenza pandemic, as well as 
the groups of people most at risk for infection, cannot be accurately 
predicted. Additionally, responding to an influenza pandemic would be 
more challenging than dealing with annual influenza in several ways. 
Each year, annual influenza causes approximately 226,000 
hospitalizations and 36,000 deaths in the United States. According to 
the World Health Organization (WHO), an influenza pandemic would spread 
throughout the world very quickly, usually in less than a year, and 
could sicken more than a quarter of the global population, including 
young, healthy individuals who are not normally as affected by the 
annual influenza. However, despite all of these uncertainties, sound 
planning and preparedness could lessen the impact of any influenza 
pandemic. 

To address the potential threat of an influenza pandemic, the Homeland 
Security Council issued its National Strategy for Pandemic Influenza in 
November 2005.[Footnote 1] The Implementation Plan for the National 
Strategy for Pandemic Influenza,[Footnote 2] which was released in May 
2006, proposes actions for federal departments--including DOD--in 
support of the national strategy and describes expectations for 
nonfederal entities, including state, local, and tribal governments; 
the private sector; international partners; and individuals. The 
national implementation plan tasked each federal agency to develop an 
implementation plan that addresses two issues, as shown in figure 1. 
First, each federal department was to detail how it would carry out the 
department's responsibilities in the national implementation plan. For 
example, of the more than 300 actions in the national implementation 
plan, DOD was responsible for 114 actions--31 actions as a lead agency 
and 83 actions as a supporting agency. Second, each federal department 
was to include the department's approach to employee safety, continuity 
of operations, and communications with stakeholders in its 
implementation plan. 

Figure 1: Issues to Be Addressed in DOD's Pandemic Influenza 
Implementation Plan: 

[See PDF for image] 

Source: GAO analysis. 

[End of figure] 

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

Figure 2: Comparison of WHO Pandemic Phases and U.S. Government Stages: 

[See PDF for image] 

Source: Homeland Security Council. 

[End of figure] 

You asked that we examine DOD's planning and preparedness efforts for 
an influenza pandemic. Because DOD's implementation plan was still 
being drafted at the time of our review, we focused our work on DOD's 
pandemic influenza planning and preparedness efforts to date for its 
own workforce. DOD is a large, complex organization of departments, 
agencies, and other components with a workforce spread around the 
world, which, as of April 30, 2006, included nearly 1.4 million active 
duty military personnel and nearly 675,000 civilian personnel. This 
total does not include the numerous reserve and mobilized National 
Guard personnel,[Footnote 3] contractors, dependents, and beneficiaries 
for which DOD also is responsible. 

We are reporting to you at this time to highlight some of our 
observations to date on DOD's approach to planning and preparing to 
protect its workforce so DOD can consider and address them as the 
department continues its ongoing planning efforts. This report is 
largely focused on DOD's plans to protect its own workforce and 
addresses (1) actions DOD has taken to date to prepare for an influenza 
pandemic and (2) management challenges DOD faces going forward as the 
department continues its planning efforts. We expect to issue another 
report at a later date on DOD's plans and preparedness for an influenza 
pandemic, which will include our evaluation of DOD's final 
implementation plan, the combatant command plans, and selected 
installation plans. 

To address these objectives, we reviewed a draft of the department's 
implementation plan for pandemic influenza dated March 2006;[Footnote 
4] guidance and planning orders for pandemic influenza issued by the 
Assistant Secretary of Defense (ASD) for Health Affairs, the Joint 
Chiefs of Staff, Army Medical Command, and Army Installation Management 
Agency; and the department's existing directives for force health 
protection. Also, we reviewed the Implementation Plan for the National 
Strategy for Pandemic Influenza, the Department of Health and Human 
Services' (HHS) contract with a vaccine manufacturer, and DOD's 
contracts with two antiviral manufacturers. Additionally, we met in the 
Washington, D.C., area with cognizant DOD officials from the Office of 
the Secretary of Defense, including officials from the Offices of the 
ASD for Homeland Defense, ASD for Health Affairs, and ASD for Special 
Operations and Low Intensity Conflict; the Joint Chiefs of Staff; and 
each of the military services. Some officials from these offices were 
involved in the development of the National Strategy for Pandemic 
Influenza and its implementation plan. We conducted our review from 
December 2005 through August 2006 in accordance with generally accepted 
government auditing standards. Further details on our scope and 
methodology are in appendix I. 

Results in Brief: 

DOD has taken a number of important actions to prepare for an influenza 
pandemic since September 2004, well before the federal government 
released the National Strategy for Pandemic Influenza in November 2005 
and its implementation plan in May 2006, and these efforts continue to 
evolve. Going forward, DOD faces several management challenges as it 
continues its ongoing planning efforts. Certain offices within DOD 
established working groups, such as the Pandemic Influenza Task Force, 
which coordinated and implemented DOD's pandemic influenza policies and 
plans. Also, in September 2004 and January 2006, the ASD for Health 
Affairs issued guidance to the military departments, which, among other 
things, provided tasks for several DOD organizations to complete for 
each of WHO's phases of an influenza pandemic. The guidance also 
established generic priorities for the distribution of vaccines and 
antivirals. For example, deployed forces engaged in or supporting armed 
conflict and those personnel necessary to provide essential health care 
for the force are in the top tier of DOD's prioritization system. 
Further, at the time of our review, two of the three military 
departments--the Departments of the Navy and the Air Force--planned to 
issue servicewide instructions related to pandemic influenza 
preparedness. The Department of the Army did not plan to issue a 
similar instruction, but two organizations within the Army issued 
guidance to installations on developing pandemic influenza plans. DOD 
also was undertaking influenza pandemic planning efforts at several 
different levels. Specifically, DOD completed its implementation plan 
for an influenza pandemic, as required by the Implementation Plan for 
the National Strategy for Pandemic Influenza. The department started 
drafting its implementation plan in November 2005. The Joint Chiefs of 
Staff tasked the geographic combatant commands to develop plans, which 
were to address force health protection and defense support to civil 
authorities, among other things. According to officials from the Joint 
Staff, these plans were near completion at the time of our review. 
Installations were tasked by the ASD for Health Affairs to develop 
pandemic influenza plans or revise existing plans to address pandemic 
influenza. Also, DOD established Web sites, including the Pandemic 
Influenza Watchboard, that provided information for servicemembers and 
their families about avian and pandemic influenza. Moreover, DOD 
procured more than 2 million treatment courses of one antiviral, which 
were prepositioned in the continental United States, Europe, and the 
Far Eas[Footnote 5]t. Additionally, DOD procured over 2 million doses 
of an existing H5N1 vaccine, based on the strain that circulated in 
Vietnam in 2004, and planned to purchase in fiscal year 2007 additional 
doses of the Vietnam strain and a strain that circulated in Indonesia 
in 20[Footnote 6]05. Internationally, the department initiated projects 
to help build host nation capacity to prepare for, mitigate, and 
respond to a potential influenza pandemic. 

At the time of our review, DOD's planning efforts to protect its 
personnel focused primarily on the military departments, geographic 
combatant commands, and installations. However, as DOD's focus shifts 
to the workforce departmentwide, including the civilian workforce and 
personnel in defense agencies, we identified four key management 
challenges that DOD faces going forward as it continues its planning 
and preparedness efforts for pandemic influenza. In our prior work, we 
identified six desirable characteristics of national strategies, 
including defining organizational roles, responsibilities, and 
coordination; identifying goals, subordinate objectives, activities, 
and performance measures; and addressing resources, investments, and 
risk management.[Footnote 7] However, to date, DOD's pandemic influenza 
planning may not be as effective as it could be because the department 
had not yet (1) clearly and fully defined and communicated 
departmentwide roles and responsibilities with clear lines of 
authority, oversight mechanisms, and goals and performance measures; 
(2) requested funding that is tied to the departmentwide goals of 
pandemic influenza to complete the tasks in the national implementation 
plan and to protect DOD's own workforce; (3) clearly defined the types 
of personnel--military personnel, civilian personnel, contractors, 
dependents, and beneficiaries--to be included in DOD's vaccine and 
antiviral distribution; and (4) implemented a departmentwide 
communications strategy. Specifically, at the time of our review, the 
following conditions existed. 

* First, neither the Secretary of Defense nor the Deputy Secretary of 
Defense had yet issued guidance clearly and fully defining and 
communicating lead and supporting roles and responsibilities for DOD's 
pandemic influenza planning with clear lines of authority; oversight 
mechanisms, including reporting requirements; and departmentwide goals--
such as a description of a desired end-state--and performance measures. 
Some officials told us that the lines of authority for DOD's pandemic 
influenza planning efforts were unclear. For example, officials told us 
that some installation personnel were confused about whether or not 
they were supposed to be developing plans, since it was unusual for the 
ASD for Health Affairs to task installations directly with developing 
plans, and we observed differences in the military departments' 
approaches to installation planning. Further, DOD instituted reporting 
requirements for the organizations responsible for implementing the 31 
tasks from the national implementation plan; however, there were not 
similar oversight mechanisms in place for tasks that were not part of 
the national implementation plan. For example, the January 2006 Health 
Affairs guidance tasked installations with developing pandemic 
influenza plans or modifying existing plans to address pandemic 
influenza and DOD's implementation plan tasked all DOD organizations 
with developing or modifying continuity of operations plans to address 
pandemic influenza; however, there were no reporting requirements for 
these tasks. Finally, Navy officials said that they started developing 
plans for pandemic influenza, but it was difficult because the Office 
of the Secretary of Defense had not provided specific goals for what 
would be expected of the services in the event of an influenza 
pandemic. Over time, a lack of clear lines of authority, oversight 
mechanisms, and goals and performance measures could hamper the 
leadership's abilities to ensure that planning efforts across the 
department are progressing as intended as DOD continues its pandemic 
influenza planning and preparedness efforts. Additionally, without 
clear departmentwide goals, it may be difficult for all DOD components 
to develop effective plans and guidance. 

* Second, at the time of our review, DOD had started identifying 
funding requirements, but had not yet identified an appropriate funding 
mechanism or requested funding, tied to its departmentwide goals, for 
its pandemic influenza planning efforts. An official from the Office of 
the ASD for Homeland Defense said the department had options for 
requesting the required funding, including incorporating the request in 
future budget submissions or submitting a supplemental request to the 
Congress. Because DOD had not yet requested funding, it is unclear 
whether DOD can address the tasks assigned to it in the national 
implementation plan and pursue its own preparedness efforts for its 
workforce departmentwide within current resources. 

* Third, at the time of our review, DOD had not yet clearly defined or 
communicated departmentwide which types of personnel--military 
personnel, civilian personnel, contractors, beneficiaries, and 
dependents--the department planned to include in its distribution of 
vaccines and antivirals in the event of an influenza pandemic. The ASD 
for Health Affairs issued generic priorities for the department's 
vaccine and antiviral distribution and noted that these priorities 
would be clarified when more was known about a pandemic strain. An 
official in the Office of the ASD for Homeland Defense said 
distinctions in the types of personnel who would be included in the 
distribution of DOD-purchased vaccines and antivirals would be based on 
whether the individual was identified as critical to the execution of 
an essential function, as determined by components as they develop or 
modify their continuity of operations plans to address pandemic 
influenza. A factor affecting DOD's ability to clarify priorities for 
distributing vaccines among its personnel is that the department's 
priority for receiving additional vaccines, including the vaccine for 
the pandemic strain, from HHS was not yet defined at the time of our 
review. As a result the department cannot realistically determine how 
well it will be able to meet its priorities for vaccinating personnel, 
and without knowing a rough estimate of how many vaccines will be 
available, DOD cannot accurately determine the funding required to 
purchase vaccines or, if needed, additional antivirals. 

* Fourth, DOD had communicated information to many of its personnel 
about what actions they should take in the event of an influenza 
pandemic; however, these communication efforts were inconsistent 
departmentwide. Also, although DOD had not yet decided when, whether, 
or under what conditions it would dispense the vaccines and antivirals 
it purchased to date, DOD did not yet have a plan to communicate with 
personnel information on the safety and efficacy of vaccines and 
antivirals it purchased to date.[Footnote 8] However, DOD had posted on 
one of its Web sites the package inserts for the two antivirals that it 
purchased. While DOD established Web sites with some information on 
pandemic influenza, we identified unevenness across the department in 
terms of offices that regularly received actively distributed messages 
and other information. Without a comprehensive and effective 
communications strategy departmentwide, DOD personnel's awareness of 
actions that should be taken in the event of an influenza pandemic 
could become uneven and lead to confusion and increased numbers of 
affected personnel. 

As DOD continues its planning efforts going forward, and to enhance 
DOD's ongoing planning efforts, we are making recommendations to the 
Secretary of Defense. Specifically, we are recommending that the 
Secretary of Defense (1) instruct the ASD for Homeland Defense, as the 
individual accountable for DOD's pandemic influenza planning and 
preparedness efforts, to clearly and fully define and communicate 
departmentwide the roles and responsibilities of the organizations that 
will be involved in DOD's efforts with clear lines of authority; the 
oversight mechanisms, including reporting requirements, for all aspects 
of DOD's pandemic influenza planning efforts, to include those tasks 
that are not part of the national implementation plan; and the goals 
and performance measures of DOD's preparedness efforts; (2) instruct 
the ASD for Homeland Defense to work with the Under Secretary of 
Defense (Comptroller) to establish a framework for requesting funding 
for the department's preparedness efforts that includes the appropriate 
funding mechanism and controls to ensure needed funding for DOD's 
pandemic influenza preparedness efforts is tied to the department's 
goals; (3) instruct the ASD for Health Affairs to clarify DOD's 
guidance to explicitly define and communicate departmentwide whether 
and how all types of personnel--military and civilian personnel, 
contractors, dependents, and beneficiaries--would be included in DOD's 
distribution of vaccines and antivirals, and (4) instruct the ASD for 
Public Affairs to implement a comprehensive and effective 
communications strategy for personnel departmentwide. 

In written comments on a draft of this report, DOD generally concurred 
with four of our recommendations, and did not address one 
recommendation. DOD's comments and our evaluation of them are in the 
agency comments section of this report. Based on DOD's comments and 
additional documentation that DOD provided, we combined two of our 
recommendations and clarified another. Specifically, DOD provided 
additional documentation showing that the Deputy Secretary of Defense 
designated the ASD for Homeland Defense to lead the department's 
pandemic influenza efforts. Therefore, we deleted part of the original 
recommendation that the Secretary of Defense or Deputy Secretary of 
Defense designate an individual to be accountable for DOD's efforts. 
Additionally, DOD commented that it had started to determine funding 
requirements for its pandemic influenza efforts. We recognized this in 
our draft report and, subsequently, we clarified the recommendation to 
focus on requesting funding that is tied to the department's goals. 

Background: 

Occasionally, worldwide influenza epidemics--called pandemics--occur 
that can have successive "waves" of disease that can last for up to 3 
years. Three influenza pandemics occurred in the twentieth century. 
Notable among these was the influenza pandemic of 1918, called the 
"Spanish flu," which killed at least 20 million people worldwide, 
including 500,000 in the United States.[Footnote 9] The past pandemics 
have spread worldwide within months and a future pandemic is expected 
to spread even more quickly given modern travel patterns. The major 
implication of such a rapid spread is that many, if not most, countries 
will have minimal time to implement preparations and responses once a 
pandemic virus begins to spread. 

The current pandemic influenza threat stems from an unprecedented 
outbreak of H5N1 avian influenza that began in Hong Kong in 1997 and 
has spread in bird populations across parts of Asia, the Middle East, 
Europe, and Africa, with limited infections in humans. The Food and 
Agriculture Organization of the United Nations reported in August 2006 
that more than 220 million poultry were culled as a preventive measure 
or died from the H5N1 strain. From January 2003 through August 2006, 
WHO reported more than 240 confirmed human cases and more than 140 
confirmed human deaths from the H5N1 virus. Scientists and public 
health officials agree that the rapid spread of the H5N1 virus in birds 
and the occurrence of limited infections in humans have increased the 
risk that this disease may mutate into a form that is easily 
transmissible among humans, resulting in an influenza pandemic. Some 
experts at WHO and elsewhere believe that the world is now closer to 
another influenza pandemic than at any time since the last influenza 
pandemic in 1968. According to Central Intelligence Agency officials, 
the likelihood of an influenza pandemic occurring within the next 5 
years is greater than any other time in the past 40 years. Furthermore, 
the agency officials reported that H5N1 is the most likely of all 
influenza viruses to cause a pandemic. Three conditions must be met 
before an influenza pandemic begins: (1) a new influenza virus subtype 
that has not previously circulated in humans must emerge, (2) the virus 
must be capable of causing disease in humans, and (3) the virus must be 
capable of being passed easily among humans. The H5N1 virus meets the 
first two of these three conditions. 

We previously reported vaccination is considered the first line of 
defense for preventing or reducing influenza-related illness and death; 
however, vaccines may be unavailable, in short supply, or ineffective 
for certain portions of the population during the first wave of a 
pandemic.[Footnote 10] Because a pandemic strain has not emerged and an 
effective vaccine needs to be a close match to the actual pandemic 
virus, vaccine production for the pandemic strain cannot begin until a 
pandemic virus emerges.[Footnote 11] Vaccine production generally takes 
at least 6 to 8 months after a virus strain has been identified. The 
length of time required to produce the vaccine, combined with limited 
U.S. manufacturing capability, could lead to a shortage of vaccines for 
the first wave of an influenza pandemic. We previously reported that 
limited studies have shown that when a vaccine produces a good antibody 
response to a virus, approximately 70 to 90 percent of healthy young 
adults may be protected from influenza. This protection drops to about 
30 to 40 percent for the elderly and those suffering from chronic 
illness or disease.[Footnote 12] 

While vaccination has been the primary strategy for preventing 
influenza, antiviral drugs can also contribute to the prevention and 
treatment of influenza. The Food and Drug Administration has approved 
four antiviral medications for the prevention and treatment of 
influenza. If taken within 2 days of symptoms, these drugs can reduce 
symptoms and make someone with influenza less contagious to others. 
According to the Centers for Disease Control and Prevention, these 
antivirals are about 70 to 90 percent effective for preventing illness 
in healthy adults. However, influenza virus strains can become 
resistant, so these drugs may not always be effective. While antiviral 
drugs may help prevent or mitigate influenza-related illness or death 
until an effective vaccine becomes available, these drugs are expected 
to be in short supply during an influenza pandemic. 

We previously reported that DOD provides health care to over 9 million 
active duty personnel, retirees, and their dependents through the 
department's TRICARE program.[Footnote 13] DOD's military health system 
has a dual role of medically supporting wartime deployments while 
caring for active duty members, retirees, and their families in 
peacetime. TRICARE beneficiaries can obtain health care through DOD's 
direct care system of military hospitals and clinics, commonly referred 
to as military treatment facilities, and through DOD's purchased care 
system of civilian providers. The Army, the Navy, and the Air Force 
provide most of the system's care through their own medical centers, 
hospitals, and clinics, while regional networks of civilian providers 
supply the remaining care. 

DOD Had Taken Actions to Prepare for an Influenza Pandemic: 

DOD began its pandemic influenza planning and preparedness efforts as 
early as September 2004, well before the White House issued the 
National Strategy for Pandemic Influenza in November 2005 and its 
implementation plan in May 2006, and has taken a number of important 
actions since then to ensure that the department is ready in the event 
of an influenza pandemic. To date, DOD's actions to prepare for an 
influenza pandemic include establishing working groups, issuing 
guidance, developing plans, establishing Web sites, stockpiling 
vaccines and antivirals, and initiating projects to assist other 
nations' preparedness efforts. Figure 3 summarizes DOD's efforts to 
date related to pandemic influenza planning and preparedness. 

Figure 3: Timeline of Actions DOD Has Taken to Prepare for an Influenza 
Pandemic Compared to Key Homeland Security Council Plans: 

[See PDF for image] 

Source: GAO analysis. 

[End of figure] 

Certain DOD Offices Established Pandemic Influenza Working Groups: 

The ASD for Homeland Defense and ASD for Health Affairs, as well as the 
Chief of Naval Operations and Commandant of the Marine Corps, 
established pandemic influenza working groups. The ASD for Homeland 
Defense and ASD for Health Affairs established the Pandemic Influenza 
Task Force in November 2005, which was led by the ASD for Homeland 
Defense and met bimonthly. As the lead entity for pandemic influenza 
policy within the department, the Pandemic Influenza Task Force 
coordinated and implemented policies and plans that would (1) prepare 
for, prevent, and contain the effects of an influenza pandemic in 
military forces, (2) ensure DOD protects U.S. interests at home and 
abroad, and (3) render appropriate assistance to civilian authorities 
in the United States. The members of the Pandemic Influenza Task Force 
included the following: 

* Office of the ASD for Homeland Defense: 

* Office of the ASD for Health Affairs: 

* Office of the ASD for Special Operations and Low Intensity Conflict: 

* Joint Chiefs of Staff: 

* Office of the Under Secretary of Defense for Intelligence: 

* Office of the Under Secretary of Defense for Acquisition, Technology 
and Logistics: 

* Office of the Under Secretary of Defense (Comptroller): 

* Office of the Deputy Under Secretary of Defense for Military 
Personnel Policy: 

* Office of the Deputy Under Secretary of Defense for Civilian 
Personnel Policy: 

* Office of the Assistant Secretary of Defense for Public Affairs: 

The Deputy Secretary of Defense verbally designated the ASD for 
Homeland Defense as the lead for DOD's pandemic influenza planning 
efforts and DOD identified four functional leads to oversee the 31 
tasks assigned to DOD as a lead agency in the national implementation 
plan. In addition to its overall lead role, the Office of the ASD for 
Homeland Defense was the functional lead for those tasks in the 
national implementation plan related to providing defense support to 
civil authorities. The Office of the ASD for Health Affairs was the 
functional lead for force health protection tasks in the national 
implementation plan. The Office of the ASD for Special Operations and 
Low Intensity Conflict was the functional lead for tasks in the 
national implementation plan related to stability operations and 
international support. Finally, the Joint Chiefs of Staff were 
overseeing the combatant commands' planning and implementation efforts. 
According to officials in the Offices of the ASD for Homeland Defense 
and ASD for Health Affairs, DOD intentionally organized its functional 
lead offices to mirror the federal government's organization for 
pandemic influenza to improve coordination between DOD and other 
federal government agencies. For example, in general, the Office of the 
ASD for Health Affairs coordinated with HHS on medical issues and the 
Office of the ASD for Special Operations and Low Intensity Conflict 
coordinated with the Department of State on international issues. 

In addition to the Pandemic Influenza Task Force, in June 2006 the ASD 
for Homeland Defense convened a senior officer steering group comprised 
of senior military and civilian officials. The steering group was to 
meet quarterly and submit a report to the Homeland Security Council 
detailing DOD's progress on the actions assigned to the department in 
the national implementation plan. The Chief of Naval Operations also 
developed a working group, called the Navy Pandemic Influenza Council, 
in January 2006, which met quarterly to examine issues related to an 
influenza pandemic. The Commandant of the Marine Corps originally 
established his own working group that merged with the Navy Pandemic 
Influenza Council to create one working group for the Department of the 
Navy. 

Some Offices and Components Issued Guidance on and Developed Plans for 
Pandemic Influenza: 

In September 2004, the ASD for Health Affairs issued guidance to the 
military departments related to preparing for an influenza 
pandemic,[Footnote 14] with the most recent guidance issued in January 
2006.[Footnote 15] This guidance is in addition to the department's 
existing policies on force health protection. The January 2006 
guidance, which supersedes the September 2004 guidance, was developed 
by preventive medicine experts in the Office of the ASD for Health 
Affairs to provide comprehensive policy guidance for writing the 
combatant command and installation pandemic influenza plans. The 
guidance also provided information on assumptions to use when 
developing plans, such as the percentage of people that could be 
affected by a pandemic and that antiviral supplies will likely be 
insufficient to meet demands. The guidance listed tasks, such as 
developing and exercising plans, for the Office of the Secretary of 
Defense, Joint Chiefs of Staff, military departments, installation 
commanders, military treatment facility commanders, and Public Health 
Emergency Officers to complete for each of WHO's phases of an influenza 
pandemic. Additionally, the guidance tasked installations with 
developing community containment plans to contain infections at their 
source or slow the spread of the disease. The guidance also provided 
information on home care infection control that recommended infection 
control measures, such as hand washing. Finally, the guidance included 
a generic prioritization system for DOD's limited supplies of vaccines 
and antivirals and noted that these priorities would be clarified in 
the event of an influenza pandemic. Table 1 lists DOD's current generic 
priorities for vaccines and antivirals. 

Table 1: DOD's Current Priorities for Vaccine and Antiviral 
Distribution: 

Tier: Tier 1; 
Personnel included in tier: Those personnel necessary to respond to 
global military contingencies and provide essential health care for the 
force structure, including (1) those required to maintain national 
strategic and critical operational capabilities, as defined by the 
Joint Chiefs of Staff, (2) deployed forces engaged in or supporting 
armed conflict, and (3) those personnel necessary to maintain a 
functioning health care system. 

Tier: Tier 2; 
Personnel included in tier: Nondeployed forces that are on alert or 
designated to conduct critical contingency operations as defined by the 
Joint Chiefs of Staff. 

Tier: Tier 3; 
Personnel included in tier: Personnel necessary to maintain critical 
mission-essential capabilities at each organizational level. 

Tier: Tier 4; 
Personnel included in tier: All other Active Component or mobilized 
reserve component personnel. 

Tier: Tier 5; 
Personnel included in tier: All other beneficiaries not included 
previously according to the Centers for Disease Control and Prevention 
priority tiers. 

Source: DOD. 

Note: DOD's antiviral priorities are the same as its vaccine priorities 
except for individuals who are hospitalized due to a pandemic influenza 
are in the top tier for antivirals. 

[End of table]  

The Department of the Navy and the Department of the Air Force planned 
to issue servicewide instructions related to pandemic influenza 
preparedness. Navy and Marine Corps officials said that the Department 
of the Navy was drafting an instruction that would cover all biological 
hazards and would include information on an influenza pandemic. 
According to a Navy official, the instruction was expected to be 
released in the fall of 2006. Similarly, Air Force officials said that 
the Department of the Air Force was developing a servicewide 
instruction on disease containment that would include guidance on 
actions that personnel should take in the event of an influenza 
pandemic. The instruction was expected to be released by the end of the 
summer of 2006. At the time of our review, the Department of the Army 
had not drafted or released a servicewide instruction related to 
pandemic influenza for the department; however, its Medical Command and 
Installation Management Agency had released guidance to Army military 
treatment facilities and installations. In November 2004, the Army 
Medical Command tasked its military treatment facilities, including 
hospitals and clinics, on Army installations with updating existing 
plans for Severe Acute Respiratory Syndrome (SARS).[Footnote 16] The 
tasking included guidance to address issues related to influenza 
pandemics in the installations' revised plans, such as identifying 
facilities other than normal hospital or clinic locations at which mass 
vaccinations could be administered. In May 2006, the Army Installation 
Management Agency tasked Army installations to develop or update 
Installation Emergency Response Plans by the end of June 2006 to 
address a response to an influenza pandemic.[Footnote 17] The tasking 
included specific guidance on what should be included in the 
installation plans, such as incorporating pandemic-specific information 
into continuity of operations plans to account for a potential 
reduction of staff. 

The Office of the ASD for Homeland Defense, with support from the 
Offices of the ASD for Health Affairs and ASD for Special Operations 
and Low Intensity Conflict and the Joint Chiefs of Staff, completed 
DOD's implementation plan for an influenza pandemic, as required by the 
national implementation plan. DOD started drafting its implementation 
plan in November 2005 and had a draft implementation plan in December 
2005. DOD submitted its implementation plan to the Homeland Security 
Council in August 2006; however, according to an official in the Office 
of the ASD for Homeland Defense, DOD cannot release its implementation 
plan externally until after it is coordinated and approved by the 
Homeland Security Council. The official said that DOD's implementation 
plan provided some guidance on protecting DOD's military and civilian 
personnel, contractors, dependents, and beneficiaries in the event of 
an influenza pandemic; however, the plan focused on the actions 
assigned to DOD in the national implementation plan because force 
health protection measures already exist. Appendix II summarizes the 
guidance and existing force health protection policies related to DOD's 
efforts to protect its workforce in the event of an influenza pandemic. 
The officials indicated that DOD expected to update its implementation 
plan as needed. DOD's implementation plan also tasked all offices, 
components, and agencies departmentwide to begin developing or 
modifying existing continuity of operations plans in preparation for an 
influenza pandemic. 

Additionally, DOD's geographic combatant commands--U.S. Central 
Command, U.S. European Command, U.S. Northern Command, U.S. Pacific 
Command, and U.S. Southern Command--and installations were tasked with 
developing pandemic influenza plans. In November 2005, the Joint Chiefs 
of Staff requested that the geographic combatant commands develop plans 
for DOD's response to an influenza pandemic that addressed force health 
protection, defense support to civil authorities, and support to 
humanitarian assistance and disaster relief operations. According to an 
official in the Office of the ASD for Homeland Defense, the combatant 
command plans would further define how DOD would implement its assigned 
actions from the national implementation plan. According to officials 
with the Joint Staff, the combatant command plans were almost complete 
at the time of our review. Furthermore, the January 2006 Health Affairs 
guidance tasked installation commanders with developing pandemic 
influenza plans for their installations. According to officials in the 
offices of the ASD for Homeland Defense and ASD for Health Affairs, the 
military services were responsible for overseeing the installations' 
planning efforts. 

DOD Established Web Sites for Pandemic and Avian Influenza Information: 

The Office of the Deputy ASD for Force Health Protection and Readiness 
developed a Web site, the Pandemic Influenza Watchboard, which provided 
information to servicemembers and their families on pandemic and avian 
influenza.[Footnote 18] The Web site provided answers to frequently 
asked questions about avian influenza; links to two of DOD's policies 
for pandemic influenza; data on confirmed human and animal H5N1 
influenza cases; links to some WHO information on response to and 
containment of an influenza pandemic; links to federal government 
documents, such as the national implementation plan; and other federal 
government Web sites, such as the federal government's pandemic 
influenza Web site (www.pandemicflu.gov). Additionally, there was a 
link from the Watchboard to DOD's Deployment Health Web site, which is 
described below. According to an official from the Office of the ASD 
for Homeland Defense, by September 2006, all servicemembers, their 
families, and military health system providers will be directed to use 
the Watchboard as the primary DOD platform for messages and information 
on pandemic influenza, with appropriate hyperlinks to other non-DOD Web 
sites. 

Additionally, the Deployment Health Support Directorate, within the 
Office of the ASD for Health Affairs, established in November 2005 an 
informational Web site on avian and pandemic influenza for 
servicemembers and their families.[Footnote 19] It included strategies 
for personnel to protect themselves, such as avoiding poultry farms in 
countries that have had avian influenza outbreaks and washing hands 
with soap and water or using alcohol-based hand sanitizer. In addition, 
it provided links to additional resources, such as the federal 
government's pandemic influenza Web site. At the time of our review, 
there was a link from the Deployment Health Web site to the DOD 
Military Vaccine Agency's pandemic influenza Web site, but not to DOD's 
other pandemic influenza Web sites. 

As part of its Disaster Preparedness and Response Information Web site, 
DOD's Civilian Personnel Management Service developed a Web site with 
some information on pandemic influenza.[Footnote 20] The Web site 
provided information for employees, supervisors, and managers, such as 
a list of phone numbers that civilian employees could call for 
assistance and information; statutory authorities for evacuations; and 
general information on pay, leave, telework, and benefits in a natural 
disaster or declared emergency. The Web site also provided links to 
other resources, such as DOD's Pandemic Influenza Watchboard, 
additional information on avian and pandemic influenza on WHO's and the 
Centers for Disease Control and Prevention's Web sites, and the Office 
of Personnel Management's guidance on human capital planning for an 
influenza pandemic.[Footnote 21] The Civilian Personnel Management 
Service Web site stated that additional information will be posted as 
it becomes available. 

Additionally, DOD's Military Vaccination Agency Web site provided 
information on pandemic influenza.[Footnote 22] The Web site provided 
links to news articles on avian influenza; some of DOD's pandemic 
influenza policies and planning documents; two service messages related 
to pandemic influenza; questions and answers on avian and pandemic 
influenza; and some links to related information, including links to 
the Centers for Disease Control and Prevention, WHO, and some DOD 
components' Web sites. 

DOD Procured Antiviral Medications and Vaccines: 

The Office of the ASD for Health Affairs procured antivirals and an 
existing H5N1 vaccine. DOD purchased more than 2 million treatment 
courses of one antiviral and has prepositioned it at three storage 
sites around the world--40 percent of the stockpile is in the 
continental United States, 30 percent is in Europe, and 30 percent is 
in the Far East.[Footnote 23] According to officials in the Office of 
the ASD for Health Affairs, DOD purchased an additional 470,000 
treatment courses of the antiviral, which were expected to be delivered 
by December 2006, and 241,000 treatment courses of another antiviral, 
which were expected to be delivered by March 2007. The additional 
treatment courses of the first antiviral would be located at DOD's 
military treatment facilities on installations, and the second 
antiviral would be distributed among the three antiviral storage sites. 
Additionally, DOD purchased an additional 530,000 treatment courses of 
the first antiviral, which will increase DOD's stockpile of antivirals 
to 3.4 million treatment courses once all of the antivirals are 
delivered. The Office of the ASD for Health Affairs purchased more than 
2 million doses of an existing H5N1 vaccine based on the strain that 
circulated in Vietnam in 2004 and, in fiscal year 2007, planned to 
purchase an additional 3.6 million doses of the Vietnam strain and 2.5 
million doses of a strain that circulated in Indonesia in 2005. 
Officials said that even though a vaccine based on existing strains of 
the H5N1 virus will not necessarily protect its recipients from a 
further mutated pandemic strain, one option is to vaccinate personnel 
with an existing H5N1 vaccine before an influenza pandemic starts, 
which may provide personnel some immunity from the disease.[Footnote 
24] Officials said that no decision had been made on whether to 
vaccinate personnel before a pandemic, but an official in the Office of 
the ASD for Health Affairs said that the current plan was not to 
administer the vaccine until it had been approved or licensed by the 
Food and Drug Administration. According to officials in the Office of 
the ASD for Health Affairs, DOD had a verbal agreement with HHS to 
purchase additional vaccines for future strains of the virus, including 
a pandemic strain. 

DOD Initiated Projects to Assist Other Nations' Preparedness: 

The ASD for Special Operations and Low Intensity Conflict and the 
Defense Security Cooperation Agency issued guidance and accepted 
proposals from the combatant commands for projects to build host nation 
military capacity for preparing for, mitigating, and responding to a 
potential influenza pandemic. The combatant commands could request 
funding for projects in four categories: (1) influenza planning and 
preparedness assessments, (2) influenza preparedness training programs, 
(3) response training and exercise programs, and (4) increasing 
military infrastructure capacity. Through the end of July 2006, the 
Office of the ASD for Special Operations and Low Intensity Conflict and 
the Defense Security Cooperation Agency had approved nearly 50 
proposals from the U.S. European Command, U.S. Pacific Command, and 
U.S. Southern Command for projects covering 30 countries. Individual 
project costs ranged from about $17,000 to $150,000 and totaled over $3 
million for fiscal years 2006 and 2007. For example, the U.S. Pacific 
Command requested a total of about $72,000 to provide the Chinese and 
Indonesian militaries with subject matter experts to share experiences 
in operational planning, health surveillance, laboratory testing, and 
other preparedness and control activities, including tools and 
mechanisms for detecting and tracking cases. Additionally, the U.S. 
European Command requested $100,000 to assess the Zambian Defense 
Force's current capabilities related to avian influenza and to develop 
and implement the capabilities necessary to respond to an avian 
influenza outbreak within Zambia. 

Going Forward, DOD Faces Four Key Management Challenges in Its Pandemic 
Influenza Planning and Preparedness Efforts for Its Workforce 
Departmentwide: 

DOD began its planning efforts in September 2004 and, to date, efforts 
related to protecting DOD's personnel have focused primarily on the 
personnel in the military departments, geographic combatant commands, 
and installations. However, as the focus shifts to the workforce 
departmentwide, including its civilian workforce and personnel at 
defense agencies, DOD faces four key management challenges going 
forward as the department continues its planning and preparedness 
efforts related to an influenza pandemic. First, neither the Secretary 
of Defense nor the Deputy Secretary of Defense had yet issued 
departmentwide guidance that fully defined an accountability framework 
for DOD's pandemic influenza planning efforts, including defining lead 
and supporting roles and responsibilities with clear lines of 
authority, formal oversight mechanisms, and goals and performance 
measures. Establishing an accountability framework could help the 
Secretary of Defense or Deputy Secretary of Defense monitor the 
department's preparedness for an influenza pandemic. Second, at the 
time of our review, DOD had not yet requested funding for its 
preparedness efforts that was tied to its departmentwide goals. 
Additional funding was necessary to ensure that DOD could complete the 
actions assigned to the department in the national implementation plan. 
Third, DOD had not yet fully defined and communicated departmentwide 
which types of its personnel the department expected to include in its 
distribution of vaccines and antivirals in the event of an influenza 
pandemic. Clarifying this information before a pandemic may lessen the 
confusion over who is to receive DOD-purchased vaccines and antivirals 
during an influenza pandemic. Fourth, while certain parts of DOD 
received actively distributed guidance and other information, DOD had 
not yet fully communicated key information to personnel departmentwide 
on actions they should take in the event of an influenza pandemic, as 
well as information on the safety and efficacy of vaccines and 
antivirals. Ensuring that personnel departmentwide receive information 
in advance of an influenza pandemic may lessen confusion about what 
actions personnel should take to protect themselves in the event of an 
influenza pandemic. 

DOD Had Not Yet Fully Defined Departmentwide Lead and Supporting Roles 
and Responsibilities, Formal Oversight Mechanisms, and Goals and 
Performance Measures for Pandemic Influenza: 

At the time of our review, neither the Secretary of Defense nor the 
Deputy Secretary of Defense had yet issued guidance that fully and 
clearly defined the lead and supporting roles and responsibilities and 
clear lines of authority for the organizations involved in 
departmentwide pandemic influenza planning efforts, formal oversight 
mechanisms, and goals and performance measures for what the leadership 
expects from DOD's preparedness efforts. In our prior work, we have 
identified six desirable characteristics of strategies.[Footnote 25] 
One of these characteristics is that the strategy should address who is 
implementing the strategy, what the roles of organizations will be 
compared to others, and mechanisms to coordinate efforts. Similarly, in 
our work on the federal government's response to Hurricane Katrina, we 
found that, in the event of a catastrophic disaster, the leadership 
roles, responsibilities, and lines of authority for response at all 
levels must be clearly defined and effectively communicated to 
facilitate rapid and effective decision making, especially in preparing 
for and in the early hours and days after the disaster.[Footnote 26] 

Neither the Secretary of Defense nor the Deputy Secretary of Defense 
had issued guidance on the specific roles and responsibilities of the 
lead and supporting organizations with clear lines of authority for 
DOD's pandemic influenza planning efforts. Officials from the Offices 
of the ASD for Homeland Defense and ASD for Health Affairs said that 
the Deputy Secretary of Defense verbally designated the ASD for 
Homeland Defense to lead the department's pandemic influenza planning 
and preparedness efforts with the ASD for Health Affairs providing 
support on medical force health protection issues. However, at the time 
of our review, we were not able to corroborate this information because 
a memorandum documenting this verbal agreement had not been distributed 
throughout the department. In commenting on a draft of this report, DOD 
provided a memorandum dated July 25, 2006, from the Principal Deputy to 
the ASD for Homeland Defense that documented this information. 

An official from the Office of the ASD for Homeland Defense stated 
that, in preparing for an influenza pandemic, organizations would 
handle issues for which they are responsible in their existing 
directives. However, we observed that the ASD for Homeland Defense had 
not issued a directive outlining its office's general roles and 
responsibilities. While existing policies and directives outline the 
general roles and responsibilities of most DOD organizations, we found 
that some organizations within the department were unclear about other 
organizations' specific roles and responsibilities related to preparing 
for an influenza pandemic. For example, an official from one combatant 
command said that clarification was needed on the roles and 
responsibilities of the service headquarters compared to the combatant 
commands. Moreover, an official in one of the services said that more 
guidance was needed on the services' responsibilities in planning for 
and responding to an influenza pandemic. Also, a defense agency 
official was unsure about the agency's role in preparing for an 
influenza pandemic. 

In addition to not yet clearly defining the roles and responsibilities 
for organizations involved in DOD's pandemic influenza planning 
efforts, lines of authority were not yet clearly defined. An official 
from the Office of the ASD for Homeland Defense stated that 
organizations would maintain their current lines of authority for DOD's 
pandemic influenza planning efforts; however, as noted earlier, the ASD 
for Homeland Defense currently did not have a directive, which should 
outline the office's relationship with others. Additionally, officials 
from different DOD organizations told us that the current lines of 
authority for DOD's pandemic influenza planning efforts were unclear. 
For example, officials from two of the military services said that it 
was unusual for the ASD for Health Affairs to task installations 
directly with developing plans; rather, the tasking usually comes 
through the military services. One official said that installation 
personnel in that service were confused about whether or not they were 
supposed to be developing plans. We further observed differences in the 
military departments' approach to installation planning. Specifically, 
the Army Medical Command and Installation Management Agency issued 
guidance directing Army installations to plan. On the other hand, an 
Air Force official said that the Air Force had not yet tasked its 
installations servicewide to develop plans for an influenza pandemic, 
but planned to task installations to develop disease containment plans, 
which would include information about pandemic influenza, after the Air 
Force's related instruction is published. Defining the roles and 
responsibilities of the lead and supporting offices and organizations 
participating in DOD's pandemic influenza planning efforts 
departmentwide with clear lines of authority could better ensure that 
there are not gaps in DOD's policies and plans for pandemic influenza 
or uncertainty about each organization's authorities and 
responsibilities. 

While the ASD for Homeland Defense established reporting requirements 
for the 31 tasks assigned to DOD in the national implementation plan, 
there was no oversight mechanism for those tasks that were not part of 
the national implementation plan. DOD's July 25, 2006, memorandum 
stated that organizations identified as the lead implementers for the 
31 tasks assigned to DOD as a lead agency in the national 
implementation plan should report their progress on these tasks each 
month. However, this reporting requirement does not apply to other 
efforts that DOD has undertaken, including the tasking in DOD's 
implementation plan that all DOD organizations develop or revise their 
continuity of operations plans in preparation for an influenza 
pandemic. 

Because of the lack of reporting mechanisms for tasks that are not part 
of the national implementation plan, it is unclear whether anyone in 
the department had an accurate picture of the status of DOD's 
preparedness. At the time of our review, we identified some gaps in 
DOD's planning efforts. For example, at that time, only the geographic 
combatant commands and installations were required to develop plans for 
pandemic influenza. However, numerous DOD personnel would not have been 
covered by these plans, such as personnel located in the Pentagon or in 
DOD-leased space, functional combatant commands, and defense agencies. 
An official in the Office of the ASD for Homeland Defense acknowledged 
the gap in planning for personnel in the Pentagon and DOD-leased space. 
DOD has since addressed this gap by tasking all DOD organizations to 
develop or revise their respective continuity of operations plans in 
preparation for an influenza pandemic in DOD's implementation plan. 
Additionally, we identified some overlaps in DOD's planning efforts. 
For example, the January 2006 Health Affairs guidance tasked the 
military departments to develop plans for providing support to civil 
authorities and humanitarian assistance, but the combatant commands 
were already tasked to address these issues by the Joint Chiefs of 
Staff. Without oversight mechanisms that address the full range of 
DOD's preparedness efforts, to include those tasks that are not part of 
the 31 tasks for which DOD is named as a lead in the national 
implementation plan, it is unclear whether anyone in the department has 
an accurate picture of the status of DOD's preparedness. As DOD 
continues its planning and preparedness efforts for an influenza 
pandemic, this lack of a formal oversight mechanism for those tasks 
that are not part of the national implementation plan may hamper the 
leadership's abilities to ensure that departmentwide planning efforts 
are progressing as intended. 

Moreover, DOD had not yet established goals or performance measures for 
its pandemic influenza preparedness efforts. Another desirable 
characteristic of strategies is that they should establish goals for 
what the strategy strives to achieve--such as a description of a 
desired end-state--and performance measures to gauge progress toward 
results. Identifying goals and performance measures aids implementing 
parties in achieving results and enables more effective oversight and 
accountability. Additionally, the goals would provide a baseline, or 
minimum expectation, of what the Secretary of Defense or the Deputy 
Secretary of Defense expects from DOD organizations as they move 
forward in their planning efforts. 

One example of a potential goal, with some modification, for DOD's 
pandemic influenza preparedness efforts comes from the department's 
January 2006 Health Affairs guidance. The purpose of the January 2006 
guidance was to maintain operational effectiveness by minimizing death, 
disease, and lost duty time due to an influenza pandemic. While the 
purpose of the January 2006 Health Affairs guidance may serve as the 
underpinning of a goal for DOD's overall preparedness efforts, we 
previously reported that goals should have quantifiable, numerical 
targets or other measurable values, which facilitate assessments of 
whether overall goals were achieved. Other examples of goals for DOD's 
efforts could be ensuring 100 percent of DOD's organizations develop 
plans or update existing plans to address pandemic influenza and 
communicate this information to personnel, or identifying personnel 
supporting critical operations and have a backup plan for their 
absence. After DOD has established overall goals for its preparedness 
efforts, performance measures can assist DOD in assessing its progress 
toward its goals. 

Navy officials said that they had started developing plans for pandemic 
influenza, but it was difficult because the Office of the Secretary of 
Defense had not provided specific information to the military services 
on what is expected of the military services in the event of an 
influenza pandemic. The Navy officials explained that if the Office of 
the Secretary of Defense set goals, such as required readiness levels, 
then Navy officials could develop detailed plans for an influenza 
pandemic. Without overall goals for DOD's preparedness efforts and 
performance measures, it could be difficult for combatant commands, the 
military services, and installations to develop plans for an influenza 
pandemic and for the Secretary of Defense to gauge the department's 
progress toward preparedness as DOD continues its ongoing planning 
efforts. 

Issuing departmentwide guidance detailing roles and responsibilities, 
reporting mechanisms, and goals is not without precedent. For example, 
in November 2002, the Secretary of Defense issued a memorandum 
initiating DOD's Base Realignment and Closure process. The memorandum 
specifically: 

* Identified the Deputy Secretary of Defense as the individual 
responsible for overseeing the departmentwide process and the Under 
Secretary of Defense for Acquisition, Technology and Logistics as the 
individual responsible for issuing operating policies and detailed 
direction necessary to conduct the process. 

* Established two senior groups to oversee the departmentwide efforts 
and identified the members of these groups. 

* Described the roles of the organizations involved in the effort. 

* Established the reporting mechanisms for the process and future 
memoranda more clearly defined the specific reporting time frames. 

* Established goals for the process. 

DOD Had Not Yet Identified an Appropriate Funding Mechanism or 
Requested Funding Tied to Departmentwide Goals: 

At the time of our review, DOD had started identifying funding 
requirements, but had not yet identified an appropriate funding 
mechanism or requested funding, tied to its departmentwide goals, for 
its pandemic influenza planning efforts. Another desirable 
characteristic of a strategy is that the strategy should address 
resources, investments, and risk management--what the strategy will 
cost; where resources will be targeted to achieve the end-state; and 
how the strategy balances benefits, risks, and costs. Using a risk 
management approach helps implementing parties allocate resources 
according to priorities; track costs and performance; and shift 
resources, as appropriate. This information also would assist DOD in 
developing a more effective strategy to achieve its desired end-state. 

DOD started collecting information on funding requirements for its 
pandemic influenza preparedness efforts. In June 2006, the Joint Chiefs 
of Staff requested that the combatant commands and military services 
identify funding necessary to meet the requirements in the national 
implementation plan and the combatant command plans, which could 
include funding for force health protection, training and exercises, 
laboratory surveillance, and other activities. According to most 
officials we met with in the Office of the Secretary of Defense and the 
military services, funding was a challenge regarding the department's 
influenza pandemic preparedness efforts. For example, according to an 
official in the Office of the ASD for Homeland Defense, the national 
implementation plan tasked DOD with increased surveillance activities, 
which will require substantial additional funding to complete, but DOD 
had not yet included this requirement in a budget request to the 
Congress. 

While DOD had started identifying its funding requirements, at the time 
of our review, DOD had not yet identified a mechanism to request 
funding to complete the tasks assigned to DOD in the national 
implementation plan and protect its own personnel. An official from the 
Office of the ASD for Homeland Defense said the department had options 
for requesting the required funding, including incorporating the 
request in future budget submissions or submitting a supplemental 
request to the Congress. An official from the Office of the ASD for 
Health Affairs noted that it was difficult for the department to 
accurately identify the department's funding requirements before DOD 
completed its implementation plan. Additionally, according to the 
official, the department was not aware of the funding requirements in 
support of the national implementation plan before the department's 
previous budget submissions to the Congress. However, there were more 
than 50 tasks in the national implementation plan for which DOD was 
either a lead or support agency that were to be completed before the 
end of 2006. Because DOD had not yet requested funding, it is unclear 
whether DOD can address the tasks assigned to it in the national 
implementation plan and pursue its own preparedness efforts for its 
workforce departmentwide within current resources. 

DOD Had Not Yet Defined the Types of Personnel Included in Its Vaccine 
and Antiviral Distribution Plans or Communicated That Information 
Departmentwide: 

At the time of our review, DOD had not yet clearly defined or 
communicated departmentwide which types of DOD personnel--military and 
civilian personnel, contractors, dependents, and beneficiaries--the 
department planned to include in its distribution of vaccines and 
antivirals in the event of an influenza pandemic. We have reported on 
the importance of DOD managing its workforce from a total force 
perspective, which includes active duty and reserve military personnel, 
civilian personnel, and contractor personnel.[Footnote 27] In addition 
to providing medical care to active duty and reserve personnel, DOD is 
required by law to provide medical care to dependents of military 
personnel and certain beneficiaries.[Footnote 28] At the same time, 
planning to protect all of DOD's active duty and reserve personnel, 
civilian personnel, and contractor personnel--as well as beneficiaries 
and dependents--with vaccines and antivirals in the event of an 
influenza pandemic would require extensive resources and likely is 
unrealistic. It will take 6 to 8 months after the pandemic strain is 
identified to produce a vaccine and there are only two manufacturers 
producing vaccines domestically and a limited number of antiviral 
manufacturers. Moreover, there will be widespread demand for vaccines 
and antiviral medications. 

DOD's guidance was vague as to the types of personnel to be included in 
the department's distribution of vaccines and antivirals. The ASD for 
Health Affairs developed generic priorities for distributing vaccines 
to its personnel, as detailed in table 1, which would be clarified in 
the event of an influenza pandemic. While DOD's vaccine and antiviral 
priorities specifically mentioned DOD beneficiaries, the guidance did 
not clearly state which types of DOD's employees--military personnel, 
civilian personnel, and contractors--would receive vaccines and 
antivirals from the DOD stockpile. An official in the Office of the ASD 
for Homeland Defense said that the primary purpose of DOD's vaccine and 
antiviral stockpiles was to preserve the department's ability to meet 
the mission requirements of national defense and domestic support. The 
official stated that distinctions regarding types of employees-- 
military personnel, civilian personnel, and contractors--were not made 
because whether an individual would be included in the distribution of 
vaccines and antivirals was based on whether the individual was 
identified as critical to the execution of an essential mission, which 
would be determined by components as they developed their continuity of 
operations plans. However, this information was not stated in the 
January 2006 Health Affairs guidance or DOD's implementation plan. 
Additionally, DOD's January 2006 Health Policy guidance stated that 
military treatment facilities would obtain vaccines for civilian 
beneficiaries through their usual logistics channels or local or state 
health departments. Similarly, the military treatment facilities would 
obtain antivirals for civilian beneficiaries through their usual 
logistics channels or through the local health department to access the 
Strategic National Stockpile. An official in the Office of the ASD for 
Homeland Defense stated that specific use of the antiviral supply 
through the Strategic National Stockpile would be described in an 
updated antiviral release policy that was expected to be issued soon. 
The lack of clarity of which types of personnel DOD plans to include in 
its distribution of vaccines and antivirals could lead to confusion 
among personnel as to whether they will receive vaccines and antivirals 
from the department or should try to obtain them from other sources. 

A major factor affecting DOD's ability to clarify priorities for the 
department's current and future vaccine supplies is that DOD's priority 
for receiving future influenza vaccines from HHS had not yet been 
defined. The Office of the ASD for Health Affairs had a verbal 
agreement with HHS to purchase vaccines for future strains of 
influenza, including the pandemic strain. In the event of an influenza 
pandemic, there will likely be high, widespread demand for a vaccine 
across the United States and vaccine production capabilities will be 
limited, particularly compared to the demand. At the time of our 
review, DOD's priority compared to others for receiving vaccines for 
future strains--including the pandemic strain--and how many vaccines it 
will receive was not defined and DOD did not have a written agreement 
with HHS addressing these issues. An official from the Office of the 
ASD for Health Affairs said that the prioritization of vaccines for 
future influenza strains, including the pandemic strain, from the HHS 
contract with the vaccine manufacturer was being reevaluated by the 
Homeland Security Council; however, the official said that previous 
discussions had placed DOD in the first tier of agencies to receive the 
vaccine for a pandemic strain when it becomes available. The exact 
number of vaccine doses for future influenza strains that will be 
available is unknown, in part because of the unknown production output 
for a pandemic-specific vaccine. Under these circumstances, the 
department cannot realistically determine how well it will be able to 
meet its priorities for vaccinating personnel. Additionally, without 
knowing a rough estimate of how much vaccine will be available, DOD 
cannot accurately determine the funding required to purchase vaccines 
or, if needed, additional antivirals. 

Although a Communications Strategy Was under Development, DOD's 
Communication Efforts to Date Were Inconsistent Departmentwide: 

At the time of our review, DOD was developing a communications strategy 
for an influenza pandemic, and while not fully developed, it continues 
to evolve. We reported that communication on threats should be timely 
and include specific information on the nature, location, and timing of 
the threat as well as guidance on actions to take in response to the 
threat to ensure early and comprehensive information sharing and allow 
for informed decision making.[Footnote 29] These risk communication 
concepts have been used in a variety of warning contexts, including 
warnings of infectious disease outbreaks. Additionally, the national 
implementation plan states that government officials must communicate 
clearly and continuously with the public now and throughout a pandemic, 
and public officials at all levels of government must provide 
unambiguous and consistent guidance on what individuals can do to 
protect themselves, how to care for family members at home, when and 
where to seek medical care, and how to protect others and minimize the 
risks of disease transmission. However, so much is unknown about a 
potential influenza pandemic that it is difficult to provide extensive 
information on preparing for an influenza pandemic. 

Some, but not all, organizations received frequent communications about 
avian or pandemic influenza. Several officials across the department 
said their organizations distributed information about the current 
avian influenza threat and pandemic influenza to their personnel. For 
example, an official from U.S. Northern Command's Washington office 
mentioned receiving frequent e-mails from the command on the status of 
avian influenza. In contrast, it was unclear whether other DOD 
organizations, such as the defense agencies, received and distributed 
such information to their personnel. For example, at least one defense 
agency had not received any information on planning or preparing for an 
influenza pandemic, including what actions its personnel should take in 
the event of an influenza pandemic. DOD officials said the department's 
communications with its personnel were currently limited, in part 
because DOD's communications strategy for an influenza pandemic still 
was under development and had been implemented only to a limited 
extent. As a result, there currently may be gaps and unevenness in 
awareness among DOD's personnel across the department, including 
military and civilian personnel, contractors, dependents, and 
beneficiaries, about actions they should take in the event of an 
influenza pandemic, which could lead to confusion and increased numbers 
of personnel affected by a pandemic. 

Officials from the Offices of the ASD for Homeland Defense and ASD for 
Health Affairs said that DOD planned to use communications strategies 
already in place in addition to those created specifically for an 
influenza pandemic to share information on the disease to ensure that 
personnel know how to protect themselves. DOD's January 2006 Health 
Affairs guidance, which was issued to the military departments but not 
departmentwide, provided some information on actions, such as hand 
washing, that personnel should take in the event of an influenza 
pandemic. According to a public affairs official with the Joint Staff, 
the department planned to use its existing influenza Web sites, as well 
as key messages that will be distributed at the installation level, to 
let personnel know what actions to take in the event of an influenza 
pandemic. Existing Web sites had some information on what personnel 
should do to protect themselves, but as DOD continues its planning and 
preparedness efforts, more information could be added. For example, one 
Web site mentioned, among other things, that personnel should wash 
hands and cover coughs and sneezes; however, there was no information 
on what personnel should do specifically in the event of an influenza 
pandemic, such as the department's policies on who should seek medical 
care at DOD's military treatment facilities or whether personnel should 
telework from home during an influenza pandemic. Using multiple 
methods--both active and passive--of sharing information on what 
actions to take in the event of an influenza pandemic will be useful. 
For example, some of DOD's personnel are deployed in austere or rural 
environments and may not have access to the Internet and, therefore, 
may not have access to the information currently posted on various Web 
sites. 

In addition to providing information passively on Web sites and 
actively through distributed messages, there is a need to communicate 
with employees deemed "critical" and in the top tiers for vaccine and 
antiviral distribution. These personnel will need to know who they are 
and when and where they should obtain vaccines and antivirals. 
Conversely, employees in the lower tiers for vaccine and antiviral 
distribution will need to be told that they will need to rely on other 
resources to obtain these treatments, such as HHS's Strategic National 
Stockpile or other state and local public health sources. 

DOD also had not yet developed a plan to communicate information to its 
personnel on the efficacy of vaccines and antivirals, in the event DOD 
decides to dispense those it has purchased to date, but it had posted 
the package inserts for the two antivirals that it purchased on one of 
its Web sites. In 2002, we reported that survey respondents from the 
Air National Guard and Air Force Reserve were generally dissatisfied 
with the information DOD provided about its Anthrax Vaccine 
Immunization Program. They were particularly concerned about the (1) 
military threat from anthrax, (2) anthrax vaccine's battlefield 
effectiveness, (3) vaccine's history and past usage, (4) short-term and 
long-term safety risks of the vaccine, and (5) possible side effects 
from reactions to the vaccine.[Footnote 30] As indicated earlier, DOD 
is considering whether or not to vaccinate personnel before an 
influenza pandemic to possibly provide personnel some degree of 
immunity from the pandemic strain. Based on DOD's experience with the 
anthrax vaccine, if DOD decides to vaccinate its personnel early or 
after an influenza pandemic starts, then the department would benefit 
from a plan addressing how it will communicate information to its 
personnel on the threat of an influenza pandemic and the vaccine's 
efficacy, risks, and potential side effects. 

Conclusions: 

To date, DOD's efforts to protect its personnel from an influenza 
pandemic have focused primarily on the military departments, geographic 
combatant commands, and installations. However, going forward, as the 
department's focus shifts to the workforce departmentwide, DOD faces 
some key management challenges as it continues its planning and 
preparedness efforts related to an influenza pandemic. While we 
recognize that DOD's planning for an influenza pandemic continues to 
evolve, we believe DOD's planning efforts would benefit from taking 
steps to address the challenges and gaps we have identified. Planning 
in an environment of tremendous uncertainty for a large workforce 
deployed worldwide is an extremely difficult and complex task. Although 
DOD has mechanisms, systems, and processes in place for force health 
protection, an influenza pandemic would create a different set of 
challenges for DOD. Unlike most diseases, an influenza pandemic would 
spread quickly around the world and, according to government estimates, 
the disease could result in a 40 percent absenteeism rate in general 
through illness, taking care of someone who is ill, or fear of becoming 
ill. Although DOD has taken many appropriate and important steps to 
prepare for an influenza pandemic, challenges remain. First, DOD's 
planning efforts would benefit from an accountability framework, with 
clearly defined roles and responsibilities, an oversight mechanism, and 
goals and performance measures. Such an accountability framework could 
help the Secretary of Defense or Deputy Secretary of Defense to monitor 
the department's readiness for an influenza pandemic and the Secretary 
of Defense--and the Congress--could better ascertain when and to what 
extent the Armed Forces and critical functions departmentwide are 
prepared to meet this potential emergency at home and abroad. Second, 
by identifying an appropriate funding mechanism and requesting funding 
for pandemic influenza preparedness efforts that is tied to the 
department's goals, the Secretary of Defense can better ensure that the 
department can accomplish its tasks in the national implementation plan 
and protect its personnel. Third, going forward, DOD would benefit from 
clarifying in advance and communicating with personnel which types of 
personnel it plans to include in its distribution of vaccines and 
antivirals, which may lessen the confusion over who is to receive DOD- 
purchased vaccines and antivirals during an influenza pandemic. Fourth, 
by developing a departmentwide strategy that communicates key 
information to all of its workforce, DOD's military and civilian 
personnel, contractors, dependents, and beneficiaries may better know 
what actions to take to protect themselves in the event of an influenza 
pandemic. 

Recommendations for Executive Action: 

To improve accountability and oversight of planning efforts across DOD 
as the department continues its pandemic influenza planning for its 
workforce, we recommend that the Secretary of Defense do the following. 

* Instruct the Assistant Secretary of Defense for Homeland Defense, as 
the individual accountable for DOD's pandemic influenza planning and 
preparedness efforts, to clearly and fully define and communicate 
departmentwide the roles and responsibilities of the organizations that 
will be involved in DOD's efforts, with clear lines of authority; the 
oversight mechanisms, including reporting requirements, for all aspects 
of DOD's pandemic influenza planning efforts, to include those tasks 
that are outside of the national implementation plan; and the goals and 
performance measures for DOD's planning and preparedness efforts. 

* Instruct the Assistant Secretary of Defense for Homeland Defense to 
work with the Under Secretary of Defense (Comptroller) to establish a 
framework for requesting funding for the department's preparedness 
efforts. The framework should include the appropriate funding mechanism 
and controls to ensure that needed funding for DOD's pandemic influenza 
preparedness efforts is tied to the department's goals. 

* Instruct the Assistant Secretary of Defense for Health Affairs to 
clarify DOD's guidance to explicitly define whether or how all types of 
personnel--including DOD's military and civilian personnel, 
contractors, dependents, and beneficiaries--would be included in DOD's 
distribution of vaccines and antivirals and communicate this 
information departmentwide. 

* Instruct the Assistant Secretary of Defense for Public Affairs to 
implement a comprehensive and effective communications strategy 
departmentwide that is transparent as to what actions each group of 
personnel should take and the limitations of the efficacy, risks, and 
potential side effects of vaccines and antivirals. 

Agency Comments and Our Evaluation: 

In written comments on a draft of this report, DOD concurred, with 
comment, with four of our five original recommendations, and did not 
address one recommendation. DOD also provided technical comments, which 
we have incorporated in the report, as appropriate. Based on DOD's 
written and technical comments and supporting documentation DOD 
provided in response to our draft report, we combined two of our 
recommendations and modified another recommendation, as discussed 
below. 

In written comments, DOD stated that the recommendations in the draft 
report reflected information that was over a year old. As stated in our 
scope and methodology in appendix I, we based our report on information 
gathered from December 2005 through August 2006. Notwithstanding, after 
reviewing a draft of this report, DOD provided some additional 
documentation, which we incorporated, as discussed below. 

We originally recommended that the Secretary of Defense designate a 
lead individual within DOD who is accountable to the Secretary for 
influenza pandemic planning and preparedness efforts, and provide the 
individual with the authority to establish oversight mechanisms, 
including reporting requirements, for the department's pandemic 
influenza efforts. We also recommended that this lead individual 
identify and communicate roles and responsibilities of the offices and 
components involved in DOD's preparedness efforts, and the goals and 
performance measures for DOD's efforts. In its written and technical 
comments, DOD stated that the Deputy Secretary of Defense verbally 
designated the ASD for Homeland Defense to lead the department's 
preparation for a potential influenza pandemic. Our draft report 
reflected this statement and noted we could not corroborate or find 
documentation of this verbal designation. DOD's comments referred to a 
July 25, 2006, memorandum from the Principal Deputy to the ASD for 
Homeland Defense, which we subsequently obtained. This memorandum 
states that the Deputy Secretary of Defense designated the ASD for 
Homeland Defense to lead the department's preparation for a potential 
pandemic influenza. The memorandum also directs individual offices to 
carry out each of the 31 tasks for which DOD is the lead agency in the 
national implementation plan and report each month on their progress on 
the 31 tasks. However, the 31 tasks do not address the entirety of 
DOD's planning efforts and specifically exclude DOD organizations' 
planning efforts to protect its workforce departmentwide. With regard 
to our recommendation to establish goals and performance measures, DOD 
concurred and commented that the January 2006 Health Affairs guidance 
and the national and DOD implementation plans describe the roles and 
responsibilities of several DOD organizations. While we agree that 
these documents list specific tasks for some organizations to complete, 
they do not address overall roles and responsibilities for 
departmentwide pandemic influenza planning efforts. DOD also commented 
that the national implementation plan and DOD's implementation plan 
already provide specific tasks with specific time frames for 
completion. We agree that these implementation plans, as well as the 
July 25, 2006, memorandum from the Principal Deputy to the ASD for 
Homeland Defense, provide time frames to complete individual tasks. 
Nevertheless, the intent of our recommendation is that DOD develop 
departmentwide goals and performance measures for DOD's overall 
pandemic influenza planning and preparedness efforts, including that 
for its total workforce, rather than time frames for individual tasks. 
In light of the additional information DOD provided on the role of the 
ASD for Homeland Defense as the lead for DOD's pandemic influenza 
planning efforts, we revised our recommendation to read that the 
Secretary of Defense instruct the ASD for Homeland Defense to clearly 
and fully define and communicate departmentwide the roles and 
responsibilities of organizations involved in DOD's efforts with clear 
lines of authority, oversight mechanisms, and goals and performance 
measures for DOD's efforts. 

DOD concurred, with comment, with our recommendation that the 
Secretary's designated lead for DOD's influenza pandemic planning and 
preparedness efforts task the combatant commands and military 
departments to identify funding requirements that are linked to the 
department's preparedness goals and build them into DOD's future budget 
requests. DOD commented, and we acknowledged in our draft report, that 
DOD had begun to gather funding requirements for the department's 
pandemic influenza efforts. Nevertheless, we modified our 
recommendation to include a focus on requesting needed funding that is 
tied to departmentwide goals. 

DOD's written comments did not address our recommendation that the 
Secretary's designated lead for DOD's planning and preparedness efforts 
instruct the ASD for Health Affairs to clarify DOD's guidance to more 
clearly define the types of personnel included in DOD's distribution of 
vaccines and antivirals and communicate this information 
departmentwide. However, in its technical comments, DOD stated that the 
department's prioritization list for vaccines and antivirals is based 
on functional roles in the organization and distinctions in the type of 
personnel are not made because these divisions do not reflect function. 
DOD also stated that individual components are responsible for 
determining which individuals are critical when updating their 
continuity of operations plans. We incorporated this information into 
our report. We continue to believe our recommendation has merit and 
should be implemented because DOD's existing guidance remains unclear 
on what types of personnel are included in DOD's distribution of 
vaccines and antivirals and components' continuity of operations plans 
are not yet complete. 

Additionally, DOD concurred, with comment, with our recommendation that 
the ASD for Public Affairs clarify and implement a comprehensive and 
effective communications strategy. In its written and technical 
comments, DOD stated that the Office of the ASD for Public Affairs 
developed an annex for DOD's implementation plan and plans to issue an 
integrated internal communications plan in September 2006. We are 
encouraged that the ASD for Public Affairs is developing an integrated 
internal communications plan for reaching DOD's internal audiences. 
Because the plan is not yet complete, we continue to believe our 
recommendation has merit and should be implemented. 

As we agreed with your office, unless you publicly announce the 
contents of this report earlier, we plan no further distribution of it 
until 30 days from the date of this letter. We will then send copies to 
the Chairmen and Ranking Members of the Senate and House Committees on 
Appropriations; the Chairmen and Ranking Members, Senate and House 
Committees on Armed Services; and other interested congressional 
parties. We also are sending copies to the Secretary of Defense; 
Secretary of Health and Human Services; Secretary of Homeland Security; 
and Director, Office of Management and Budget. We will make copies 
available to others upon request. In addition, the report will be 
available at no charge on GAO's Web site at [Hyperlink, 
http://www.gao.gov]. 

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

Signed by: 

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

[End of section] 

Appendix I: Scope and Methodology: 

As part of our review of the Department of Defense's (DOD) planning and 
preparedness for a pandemic influenza, we determined (1) actions that 
DOD has taken to date to prepare for an influenza pandemic and (2) 
management challenges that DOD faces going forward as the department 
continues its planning efforts. We are reporting on these issues now so 
that DOD can consider and address our findings as the department 
continues its planning and preparedness efforts. We have not yet 
assessed DOD's implementation plan for pandemic influenza, since it was 
not yet complete at the time of our review; however, we plan to assess 
DOD's implementation plan, the combatant commands' implementation 
plans, and selected installation plans in another report that will be 
issued at a later date. 

To determine the actions that DOD has taken to date to prepare for an 
influenza pandemic, we reviewed a draft of DOD's implementation plan 
for pandemic influenza dated March 2006.[Footnote 31] Additionally, we 
reviewed guidance issued by the Office of the Assistant Secretary of 
Defense (ASD) for Health Affairs in September 2004 and January 2006; a 
planning order issued by the Joint Chiefs of Staff to the combatant 
commands in November 2005; planning guidance issued by the Army Medical 
Command to the Army regional medical commands in November 2004; and 
planning guidance issued by the Army Installation Management Agency to 
Army installations in May 2006. We also reviewed the department's 
existing force health protection directives, which were identified in 
DOD's January 2006 Health Affairs guidance and DOD's draft 
implementation plan and by officials in the Office of the ASD for 
Health Affairs. These directives are summarized in appendix II. We 
reviewed the Implementation Plan for the National Strategy for Pandemic 
Influenza to understand what was required of federal departments-- 
including DOD--in their pandemic influenza preparedness efforts. 
Furthermore, we reviewed HHS's contract with a vaccine manufacturer and 
DOD's antiviral contracts with two manufacturers. Additionally, we met 
in the Washington, D.C., area with DOD officials from the Office of the 
Under Secretary of Defense for Policy, Office of the ASD for Homeland 
Defense, Office of the ASD for Health Affairs, Office of the ASD for 
Reserve Affairs, Office of the Deputy Under Secretary of Defense for 
Logistics and Materiel Readiness, Office of the Deputy ASD for 
Stability Operations, Office of Force Transformation (Defense), 
National Guard Bureau, Joint Chiefs of Staff, Department of the Army, 
Department of the Navy, Marine Corps Headquarters, and Department of 
the Air Force. 

To better understand the threat of an influenza pandemic, we met with 
officials from the Defense Intelligence Agency's Armed Forces Medical 
Intelligence Center, Fort Detrick, Maryland, and the Central 
Intelligence Agency, McLean, Virginia. 

To determine management challenges that DOD faces as it continues its 
planning efforts, we compared the department's actions to date to best 
practices that we have identified in our prior work. Specifically, we 
compared DOD's actions to date to the desirable characteristics of 
national strategies, which state that a national strategy should 
include: 

* purpose, scope, and methodology; 

* problem definition and risk assessment; 

* goals, subordinate objectives, activities, and performance measures; 

* resources, investments, and risk management; 

* organizational roles, responsibilities, and coordination; and: 

* integration and implementation. 

While we are not yet assessing DOD's draft implementation plan and it 
is not a national strategy, we determined that some of the 
characteristics are applicable to planning efforts in general, 
specifically those related to identifying goals and performance 
measures, resources and investments, and organizational roles and 
responsibilities. Because we are not yet assessing DOD's implementation 
plan, we used the characteristics as guidance for how DOD could 
approach its planning efforts, as opposed to a checklist of what DOD 
should be doing. Additionally, we relied on our previous work on total 
force management to determine which types of personnel DOD should 
include in its plans for vaccine and antiviral distribution. 
Furthermore, we relied on our previous work on risk communication 
principles to determine whether DOD's current communications strategy 
meets these principles. Finally, we reviewed our prior work on 
influenza pandemics. 

We conducted our review from December 2005 through August 2006 in 
accordance with generally accepted government auditing standards. 

[End of section] 

Appendix II: Summary of DOD's Guidance for Pandemic Influenza and 
Related Force Health Protection Policies: 

Table 2: 

Title of guidance, responsible office or organization, and date: 
Department of Defense Influenza Pandemic Preparation and Response 
Health Policy Guidance (January 2006); 
Purpose of guidance: To provide policy and instructions to prepare for 
and respond to an influenza pandemic; facilitate integration into the 
National Strategy for Pandemic Influenza, outline an appropriate 
response for military installations and contingency operations 
worldwide, and provide guidance for defense support to civil 
authorities; 
Applicability of the guidance: Military departments, the Joint Staff, 
and the combatant commands; the guidance was provided to the Coast 
Guard as a reference. 

Title of guidance, responsible office or organization, and date: Policy 
for Release of Tamifluģ (Oseltamivir) Antiviral Stockpile During an 
Influenza Pandemic (January 2006); 
Purpose of guidance: To provide guidance for the release of the 
Department of Defense's (DOD) Tamiflu stockpile; establishes generic 
prioritization tiers for Tamiflu; 
Applicability of the guidance: Applicability was not listed, but 
guidance was addressed to the secretaries of the military departments, 
Chairman of the Joint Chiefs of Staff, Under Secretaries of Defense, 
Commandant of the U.S. Coast Guard, Assistant Secretaries of Defense, 
DOD General Counsel, DOD Inspector General, and directors of defense 
agencies. 

Title of guidance, responsible office or organization, and date: Policy 
for the Use of Influenza Vaccine for the 2005-2006 Influenza Season 
(November 2005); 
Purpose of guidance: To set policy and priorities for use of influenza 
vaccine for the 2005-2006 influenza season; 
Applicability of the guidance: Applicability was not listed, but 
guidance was addressed to the Assistant Secretaries of the Military 
Departments for Manpower and Reserve Affairs; Director, Joint Staff; 
ASD for Reserve Affairs; Military Department Surgeons General; and 
Defense Supply Center Philadelphia. 

Title of guidance, responsible office or organization, and date: DOD 
Directive 6490.2, Comprehensive Health Surveillance (October 2004); 
Purpose of guidance: To establish policy and assign responsibility for 
routine, comprehensive health surveillance of all military 
servicemembers during active federal service; 
Applicability of the guidance: Office of the Secretary of Defense, 
military departments, Chairman of the Joint Chiefs of Staff, combatant 
commands, defense agencies, DOD field activities, and all other 
organizational entities in DOD. 

Title of guidance, responsible office or organization, and date: DOD 
Directive 6200.4, Force Health Protection (October 2004); 
Purpose of guidance: To establish policy and assign responsibility for 
implementing force health protection measures on behalf of all military 
servicemembers during active and reserve military service; 
Applicability of the guidance: Office of the Secretary of Defense, 
military departments, Chairman of the Joint Chiefs of Staff, combatant 
commands, Office of the Inspector General, defense agencies, DOD field 
activities, and all other organizational entities in DOD. 

Title of guidance, responsible office or organization, and date: 
Department of Defense Guidance for Preparation and Response to an 
Influenza Pandemic Caused by the Bird Flu (Avian Influenza) (September 
2004); 
Purpose of guidance: To provide instruction on actions to take in 
preparation for the possibility of an influenza pandemic, to implement 
recommendations from the Department of Health and Human Services' 
National Pandemic Influenza Response Plan; 
Applicability of the guidance: Military departments, nonmilitary 
persons under military jurisdiction, selected federal employees, and 
family members and other people eligible for care within the military 
health system. 

Title of guidance, responsible office or organization, and date: DOD 
Directive 6200.3, Emergency Health Powers on Military Installations 
(May 2003); 
Purpose of guidance: To establish policy to protect installations, 
facilities, and personnel in the event of a public health emergency due 
to biological warfare, terrorism, other public health emergency, or a 
communicable disease epidemic; 
Applicability of the guidance: Office of the Secretary of Defense, 
military departments, Chairman of the Joint Chiefs of Staff, Office of 
the Inspector General, combatant commands, defense agencies, DOD field 
activities, and all other organizational entities in DOD. 

Title of guidance, responsible office or organization, and date: Policy 
for Use of Force Health Protection Prescription Products (April 2003); 
Purpose of guidance: To establish policy to comply with the statutory 
requirement regarding use of prescription-only drugs, vaccines, and 
other medical products; 
Applicability of the guidance: Applicability was not listed, but 
guidance was addressed to the Assistant Secretaries of the Military 
Services for Manpower and Reserve Affairs; Director, Joint Staff; 
Surgeons General of the Military Departments; and Deputy Director for 
Medical Readiness, Joint Staff. 

Title of guidance, responsible office or organization, and date: DOD 
Directive 6200.2, Use of Investigational New Drugs for Force Health 
Protection (August 2000); 
Purpose of guidance: To establish policy and assign responsibility 
regarding legal requirements for use of investigational new drugs and 
designates the Secretary of the Army as the Executive Agent for the use 
of investigational new drugs for force health protection; 
Applicability of the guidance: Office of the Secretary of Defense, 
military departments, Chairman of the Joint Chiefs of Staff, combatant 
commands, Office of the DOD Inspector General, defense agencies, DOD 
field activities, and all other organizational entities within DOD. 

Title of guidance, responsible office or organization, and date: Policy 
for DOD Global, Laboratory-Based Influenza Surveillance (February 
1999); 
Purpose of guidance: To set DOD policy to conduct global, operationally 
relevant laboratory-based influenza surveillance; 
Applicability of the guidance: Applicability was not listed, but 
guidance was addressed to the Surgeons General of the Military 
Services; and Deputy Director for Medical Readiness, J-4, Joint Staff. 

Title of guidance, responsible office or organization, and date: Joint 
Tactics, Techniques, and Procedures for Noncombatant Evacuation 
Operations Joint Report 3-07.51 (September 1997); 
Purpose of guidance: To guide combatant commanders and their 
subordinate joint force and component commanders in preparing for and 
conducting noncombatant evacuation operations; 
Applicability of the guidance: Commanders of combatant commands, 
subunified commands, joint task forces, and subordinate components of 
the commands. 

Title of guidance, responsible office or organization, and date: DOD 
Instruction 3020.37, Continuation of Essential DOD Contractor Services 
During Crises (November 1990), Administrative Reissuance Incorporating 
Change 1 (January 1996), Enclosure E3, Guidelines for Theater Admission 
Procedures; 
Purpose of guidance: Enclosure E3 sets policy for civilian contractors 
entering a theater of operations, including ensuring them the same 
medical care given to military personnel; 
Applicability of the guidance: Office of the Secretary of Defense; 
military departments including the Coast Guard when operating as a 
service in the Navy; Chairman of the Joint Chiefs of Staff and the 
Joint Staff; combatant commands; Inspector General; and defense 
agencies. 

Title of guidance, responsible office or organization, and date: DOD 
Directive 1404.10, Emergency Essential (E-E) DOD U.S. Citizen Civilian 
Employees (April 1992); 
Purpose of guidance: Updates policy, responsibilities, and procedures 
regarding employees in civilian positions designated emergency 
essential; 
Applicability of the guidance: Office of the Secretary of Defense; 
military departments, including the Coast Guard when operating as a 
service in the Navy; Chairman of the Joint Chiefs of Staff and the 
Joint Staff; combatant commands; Inspector General; defense agencies; 
and DOD field activities. 

Title of guidance, responsible office or organization, and date: DOD 
Directive 3025.14, Protection and Evacuation of U.S. Citizens and 
Designated Aliens in Danger Areas Abroad (November 1990); 
Purpose of guidance: Updates policies, responsibilities, and procedures 
for protection and evacuation of U.S. citizens and designated aliens in 
danger areas abroad, and assigns responsibilities for noncombatant 
evacuation operations planning and implementation; 
Applicability of the guidance: Office of the Secretary of Defense; 
military departments, including the Coast Guard when operating as a 
service in the Navy; Chairman of the Joint Chiefs of Staff and the 
Joint Staff; combatant commands; and defense agencies. 

Title of guidance, responsible office or organization, and date: DOD 
Directive 6205.2, Immunization Requirements (October 1986); 
Purpose of guidance: Addresses immunization policies for all armed 
forces members, DOD civilian employees, and eligible beneficiaries of 
the military health care system; 
Applicability of the guidance: Office of the Secretary of Defense; 
military departments, including their guard and reserve components; 
Organization of the Joint Chiefs of Staff; and defense agencies. 

Source: GAO analysis. 

[End of table] 

[End of section] 

Appendix III: Comments from the Department of Defense: 

Assistant Secretary Of Defense: 
2600 Defense Pentagon: 
Washington, DC 20301-2600: 

Homeland Defense: 

Ms. Davi M. D'Agostino: 
Director, Defense Capabilities and Management: 
U.S. Government Accountability Office: 
441 G Street, N.W. 
Washington, DC 20548: 

Aug 31 2006: 

Dear Ms. D'Agostino: 

The Department of Defense (DoD) concurs with comment to all four 
recommendations in the report. Our concurrence is contingent on the 
following adjustments to the GAO report: 

* The report needs to reflect the most current actions by DoD. The 
recommendations in the report reflect information that is now over a 
year old. The Department has or is currently taking actions addressed 
in the report's recommendations. 

* The report contains technical errors that must be corrected to 
reflect a more accurate picture of the Department's efforts. 

Our responses to the recommendations and technical comments are 
attached. My point of contact for this action is Colonel Richard M. 
Chavez, (703) 697-5415. 

Sincerely, 

Signed by: 

Peter F. Verga: 
Principal Deputy: 

Attachments: 

1. DoD Response to the Recommendations 
2. DoD Technical Response: 

GAO Draft Report - Dated August 17, 2006 GAO Code 350890/GAO-06-1042: 

"Influenza Pandemic: DoD Has Taken Important Actions to Prepare, but 
Accountability, Funding, and Communications Need to be Clearer and 
Focused Departmentwide" 

Department Of Defense Comments To The Recommendations: 

Recommendation 1: The GAO recommended that the Secretary of Defense 
designate a lead individual within DOD who is accountable to the 
Secretary of Defense for influenza pandemic planning and preparedness 
efforts, and provide the individual with the authority to establish 
oversight mechanisms, including reporting requirements, for the 
department's pandemic influenza efforts. 

DOD Response: DoD concurs with comment. The Deputy Secretary of Defense 
designated the Assistant Secretary of Defense for Homeland Defense, 
working in coordination with the Assistant Secretary of Defense for 
Health Affairs, to lead the Department's preparation for a potential 
pandemic influenza. To integrate and optimize all Department 
preparedness and response efforts, a Pandemic Influenza Task Force was 
created, chaired by Mr. Paul McHale, the Assistant Secretary of Defense 
for Homeland Defense. Dr. William Winkenwerder, Assistant Secretary of 
Defense for Health Affairs, has responsibility for avian influenza 
force health protection programs and actions, and supports the task 
force to ensure optimal public health support to civilian health 
authorities. This response is derived from the following documents: 
Department of Defense Implementation of the National Plan for Pandemic 
Influenza, signed by Mr. Pete Verga, July 25, 2006 and the Avian 
Influenza Pandemic Task Force memo, (no date) signed jointly by Mr. 
McHale and Dr. Winkenwerder to all Departmental entities. 

Recommendation 2: The GAO recommended that the Secretary of Defense 
designates a lead to communicate the roles and responsibilities of the 
offices and components that will be involved in DOD's preparedness 
efforts and the goals and performance measures for DOD's efforts. 

DOD Response: DoD concurs with comment. The January 25, 2006, 
Department of Defense Influenza Pandemic Preparation and Response 
Health Policy Guidance lays out specific roles and responsibilities of 
the Office of the Secretary of Defense, the Joint Staff, the Military 
Departments, Installation Commanders, and Military Treatment Facility 
Commanders. In addition, the National and the DoD Implementation Plans 
list specific tasks designed to make the U.S. government prepared in 
the face of a pandemic. These tasks come with very specific timelines 
for completion and individuals have been assigned as leads for each 
task. Some of these tasks require DOD to work with the other 
Departments and Agencies to further define specific roles and 
responsibilities - many of which will not be realized until all 
Department and COCOM plans are completed. Additionally, the Departments 
plan is specific to addressing the concerns of the National 
Implementation Plan. The measures of performance are clearly outlined 
within each task and the goals are to complete the actions within the 
identified timeline. In support of this effort, DoD is required to 
submit a bi-monthly status report on these tasks to the White House. 
The SES General Officer/Flag Officer Steering Committee is the 
oversight committee within DoD to track and monitor that status of 
these tasks and approve the submission of the bi-monthly report to the 
White House. 

Recommendation 3: The GAO recommended that the Secretary of Defense 
designates a lead to task the Combatant Commands and Military 
Departments to identify funding requirements that are linked to the 
Department's preparedness goals and build them into DOD's future budget 
requests. 

DOD Response: DoD concurs with comment. Prior to assessing potential 
Pandemic Influenza preparedness costs, several baseline plans had to be 
completed in at least draft final status; The National Pandemic 
Influenza Implementation plan, The DoD Implementation Plan and the 
Geographic Combatant Command plans. The plans provided the draft 
framework by which we could then judge our funding requirements. All 
the above referenced plans are now complete or in draft. DoD has 
conducted a data call to all Services and Combatant Commands for PI 
Preparedness costs for FY07 and FY08. We have captured those projected 
costs and are now working the appropriate funding vehicle. Options 
include, but are not limited to, inclusion in the 08-13 Program 
Objective Memorandum, or pursuing supplemental funding. 

Recommendation 4: The GAO recommended that the Secretary of Defense 
designates a lead to instruct the Assistant Secretaries of Defense for 
Public and Health Affairs to clarify and implement a comprehensive and 
effective communications strategy Departmentwide that is transparent as 
to what actions each group of personnel should take and limitations of 
the efficacy, risks, and potential side effects of vaccines and 
antivirals. 

DOD Response: DoD concurs with comment. OASD(PA) has developed an 
annex, which was submitted earlier this year, for the Department's 
implementation plan and public affairs guidance that will be issued in 
September. 

In addition, an integrated internal communications plan for pandemic 
influenza is being developed by OASD(PA)'s internal communications 
division. This plan identifies opportunities to reach and inform DoD's 
internal audiences, including military and civilian personnel, 
dependents and retirees about PI and the government's PI response plan, 
how to protect against avian flu, and the role of DoD and service 
members facing a pandemic threat in the U.S. and internationally. 

The plan will utilize broadcast, web, print and outreach tools to 
educate and prepare personnel. Internal communications resources 
include: Pentagon Channel (Public Service Announcements), Defense Link, 
American Forces Press Service, American Forces Radio Television 
Services, Stars and Stripes, and American Forces Network. 

[End of section] 

Appendix IV: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Davi M. D'Agostino, Director, 202-512-5431, dagostinod@gao.gov: 

Staff Acknowledgments: 

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

[End of section] 

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FOOTNOTES 

[1] Homeland Security Council, National Strategy for Pandemic Influenza 
(Washington, D.C.: Nov. 2005). 

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

[3] According to DOD officials, DOD would be responsible for National 
Guard personnel who have been mobilized under Title 10, United States 
Code. Otherwise, the individual states would be responsible for 
National Guard personnel serving under Title 32, United States Code, or 
under State Active Duty. 

[4] DOD released its implementation plan to the Homeland Security 
Council on August 16, 2006, as we were completing our review. However, 
according to an official in the Office of the ASD for Homeland Defense, 
DOD cannot release its implementation plan externally until it is 
coordinated and approved by the Homeland Security Council. We reviewed 
the final plan and determined that it was not significantly different 
from the March 2006 draft that we previously reviewed. 

[5] DOD has purchased an additional 470,000 treatment courses of the 
antiviral, which are scheduled for delivery by the end of 2006. 
Additionally, DOD has ordered another 530,000 treatment courses of the 
antiviral, which will increase its stockpile to 3.4 million courses. 
DOD has not yet received these two orders. 

[6] These vaccines, which have not been approved by the Food and Drug 
Administration, may not be effective against a future pandemic strain, 
because the pandemic strain has not yet emerged. 

[7] GAO, Combating Terrorism: Evaluation of Selected Characteristics in 
National Strategies Related to Terrorism, GAO-04-408T (Washington, 
D.C.: Feb. 3, 2004). 

[8] Although information about the safety and efficacy of treatments 
that DOD has purchased to date is available for dissemination, it is 
not known whether these treatments would be effective against a future 
strain of the virus because an influenza pandemic involving the H5N1 
virus has not occurred. 

[9] The pandemics of 1957 ("Asian flu") and 1968 ("Hong Kong flu") 
caused dramatically fewer fatalities--70,000 and 34,000, respectively, 
in the United States--partly because of antibiotic treatment of 
secondary infections and more aggressive supportive care. 

[10] GAO, Influenza Pandemic: Plan Needed for Federal and State 
Response, GAO-01-4 (Washington, D.C.: Oct. 27, 2000). 

[11] Although a vaccine for a pandemic strain cannot be developed until 
the pandemic strain emerges, some vaccine manufacturers have developed 
vaccines based on the H5N1 strain isolated in Vietnam in 2004. 

[12] GAO-01-4. 

[13] GAO, Defense Health Care: Implementation Issues for New TRICARE 
Contracts and Regional Structure, GAO-05-773 (Washington, D.C.: July 
27, 2005). 

[14] Department of Defense, Office of the Assistant Secretary of 
Defense for Health Affairs, Department of Defense Guidance for 
Preparation and Response to an Influenza Pandemic Caused By the Bird 
Flu (Avian Influenza) (Washington, D.C.: Sept. 21, 2004). 

[15] Department of Defense, Office of the Assistant Secretary of 
Defense for Health Affairs, Department of Defense Influenza Pandemic 
Preparation and Response Health Policy Guidance (Washington, D.C.: Jan. 
25, 2006). 

[16] United States Army Medical Command, Avian Influenza Planning 
Guidance and Tasking (Fort Sam Houston, Tx.: 2004). 

[17] United States Army Installation Management Agency, Influenza 
Pandemic Preparation and Response (Arlington, Va.: 2006). 

[18] See https://fhp.osd.mil/aiWatchboard/index.html. 

[19] See http://deploymentlink.osd.mil/medical/medical_issues/immun/ 
avian_flu.shtml. 

[20] See http://www.cpms.osd.mil/disasters/pan.htm. 

[21] Office of Personnel Management, Agency Guidance - Human Capital 
Management Policy for a Pandemic Influenza (Washington, D.C.: Aug. 
2006). 

[22] See http://www.vaccines.mil/. 

[23] A treatment course consists of two capsules per day for 5 days if 
used for treatment, and one capsule per day for at least 10 days for 
prevention. 

[24] There is currently some scientific debate regarding the 
appropriateness of using a pre-pandemic vaccine. In addition to 
concerns about the vaccine's effectiveness against a pandemic strain, 
some health experts have expressed concern that vaccinating individuals 
with a pre-pandemic vaccine could reduce the effectiveness of vaccines 
subsequently produced from the pandemic strain for these individuals. 

[25] GAO-04-408T. 

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

[27] GAO, DOD Personnel: DOD Actions Needed to Strengthen Civilian 
Human Capital Strategic Planning and Integration with Military 
Personnel and Sourcing Decisions, GAO-03-475 (Washington, D.C: Mar. 28, 
2003). 

[28] 10 U.S.C. 1071 et. seq. 

[29] GAO, Homeland Security: Communication Protocols and Risk 
Communication Principles Can Assist in Refining the Advisory System, 
GAO-04-682 (Washington, D.C.: June 25, 2004). 

[30] GAO, Anthrax Vaccine: GAO's Survey of Guard and Reserve Pilots and 
Aircrew, GAO-02-445 (Washington, D.C.: Sept. 20, 2002). 

[31] DOD released its implementation plan to the Homeland Security 
Council on August 16, 2006, as we were completing our review. However, 
according to an official in the Office of the ASD for Homeland Defense, 
DOD cannot release its implementation plan externally until it is 
coordinated and approved by the Homeland Security Council. We reviewed 
the final plan and determined that it was not significantly different 
from the March 2006 draft that we previously reviewed. 

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