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

United States Government Accountability Office:

GAO:

June 2007:

Influenza Pandemic:

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

GAO-07-696:

GAO Highlights:

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

Why GAO Did This Study:

An influenza pandemic could impair the militaryís readiness, jeopardize 
ongoing military operations abroad, and threaten the day-to-day 
functioning of the Department of Defense (DOD) due to a large 
percentage of sick or absent personnel. GAO was asked to examine DODís 
pandemic influenza planning and preparedness efforts. GAO previously 
reported that DOD had taken numerous actions to prepare departmentwide, 
but faced four management challenges as it continued its efforts. GAO 
made recommendations to address these challenges and DOD generally 
concurred with them. This report focuses on DODís combatant commands 
(COCOM) and addresses (1) actions the COCOMs have taken to prepare and 
(2) management challenges COCOMs face going forward. GAO reviewed 
guidance, plans, and after-action reports and interviewed DOD officials 
and more than 200 officials at the 9 COCOMs.

What GAO Found:

An influenza pandemic could impair the militaryís readiness, jeopardize 
ongoing military operations abroad, and threaten the day-to-day 
functioning of the Department of Defense (DOD) due to a large 
percentage of sick or absent personnel. GAO was asked to examine DODís 
pandemic influenza planning and preparedness efforts. GAO previously 
reported that DOD had taken numerous actions to prepare departmentwide, 
but faced four management challenges as it continued its efforts. GAO 
made recommendations to address these challenges and DOD generally 
concurred with them. This report focuses on DODís combatant commands 
(COCOM) and addresses (1) actions the COCOMs have taken to prepare and 
(2) management challenges COCOMs face going forward. GAO reviewed 
guidance, plans, and after-action reports and interviewed DOD officials 
and more than 200 officials at the 9 COCOMs.

What GAO Recommends:

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

[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-696]. 

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

[End of Section]

Contents:

Letter:

Results in Brief:

Background:

COCOMs Have Taken Numerous Actions to Prepare for an Influenza Pandemic:

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

Conclusions:

Recommendations for Executive Action:

Agency Comments and Our Evaluation:

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

Appendix II: Scope and Methodology:

Appendix III: Comments from the Department of Defense:

Appendix IV: GAO Contact and Staff Acknowledgments:

Related GAO Products:

Tables:

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

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

Figures:

Figure 1: Geographic COCOMs' Areas of Responsibility:

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

Figure 3: Timeline of COCOMs' Pandemic Influenza Planning Efforts:

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

Abbreviations:

ASD: Assistant Secretary of Defense:

ASD(HD&ASA): Assistant Secretary of Defense for Homeland Defense and 
Americas' Security Affairs:

CENTCOM: Central Command:

COCOM: Combatant command:

DOD: Department of Defense:

EUCOM: European Command:

JFCOM: Joint Forces Command:

NORTHCOM: Northern Command:

PACOM: Pacific Command:

SOCOM: Special Operations Command:

SOUTHCOM: Southern Command:

STRATCOM: Strategic Command:

TRANSCOM: Transportation Command:

WHO: World Health Organization:

United States Government Accountability Office:
Washington, DC 20548:
June 20, 2007:

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

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

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

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

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

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

Figure 1: Geographic COCOMs' Areas of Responsibility:

[See PDF for image]

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

[A] The state of Alaska is assigned to NORTHCOM's area of 
responsibility. Forces based in Alaska, however, remain assigned to 
PACOM.

[End of figure]

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

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

Results in Brief:

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

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

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

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

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

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

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

Background:

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

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

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

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

[See PDF for image]

Source: Homeland Security

[End of figure]

COCOMs Have Taken Numerous Actions to Prepare for an Influenza Pandemic:

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

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

Combatant command: CENTCOM; 
Established working groups: X; 
Developed plans: X; 
Conducted exercises: X; 
Informed personnel: [Empty]; 
Coordinated with other nations: X.

Combatant command: EUCOM; 
Established working groups: X; 
Developed plans: X; 
Conducted exercises: X; 
Informed personnel: X; 
Coordinated with other nations: X.

Combatant command: JFCOM; 
Established working groups: [Empty]; 
Developed plans: X; 
Conducted exercises: [Empty]; 
Informed personnel: [Empty]; 
Coordinated with other nations: [Empty].

Combatant command: NORTHCOM; 
Established working groups: X; 
Developed plans: X; 
Conducted exercises: X; 
Informed personnel: X; 
Coordinated with other nations: X.

Combatant command: PACOM; 
Established working groups: X; 
Developed plans: X; 
Conducted exercises: X; 
Informed personnel: X; 
Coordinated with other nations: X.

Combatant command: SOCOM; 
Established working groups: [Empty]; 
Developed plans: a; 
Conducted exercises: [Empty]; 
Informed personnel: [Empty]; 
Coordinated with other nations: [Empty].

Combatant command: SOUTHCOM; 
Established working groups: X; 
Developed plans: X; 
Conducted exercises: [Empty]; 
Informed personnel: X; 
Coordinated with other nations: X.

Combatant command: STRATCOM; 
Established working groups: X; 
Developed plans: X; 
Conducted exercises: X; 
Informed personnel: X; 
Coordinated with other nations: [Empty].

Combatant command: TRANSCOM; 
Established working groups: X; 
Developed plans: X; 
Conducted exercises: [Empty]; 
Informed personnel: [Empty]; 
Coordinated with other nations: [Empty].

Source: GAO analysis of DOD data.

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

[End of table]

COCOMs Have Established Working Groups to Address Pandemic Influenza:

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

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

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

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

COCOMs Have Developed Pandemic Influenza Plans for Their Areas of 
Responsibility:

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

Figure 3: Timeline of COCOMs' Pandemic Influenza Planning Efforts:

[See PDF for image]

Source: GAO analysis of DOD information

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

[End of figure]

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

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

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

COCOMs Have Conducted Exercises for Pandemic Influenza Plans:

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

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

COCOMs Have Started to Provide Information to Personnel about Pandemic 
Influenza:

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

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

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

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

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

[See PDF for image]

Source: GAO

[End of figure]

COCOMs Have Coordinated with Other Nations:

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

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

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

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

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

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

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

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

* serving as a conduit between the Joint Staff or Office of the 
Secretary of Defense and the COCOMs, military services, and defense 
agencies on pandemic influenza-related issues;

*assessing and advocating for resources for the COCOMs, military 
services, and defense agencies; and

*leading planning efforts for the COCOMs, military services, and 
defense agencies, but not the execution of those plans in the other 
COCOMs' areas of responsibility.

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

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

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

Action number: 4.1.1.3; 
Action assigned to DOD: Conduct military-to- military assistance 
planning; 
CENTCOM: X; 
EUCOM: X; 
NORTHCOM: X; 
PACOM: X; 
SOUTHCOM: X.

Action number: 4.1.2.6; 
Action assigned to DOD: Priority country military-to-military infection 
control training; 
CENTCOM: X; 
EUCOM: X; 
NORTHCOM: X; 
PACOM: X; 
SOUTHCOM: X.

Action number: 4.1.8.4; 
Action assigned to DOD: Open source information sharing; 
CENTCOM: [Empty]; EUCOM: X; 
NORTHCOM: [Empty]; 
PACOM: [Empty]; 
SOUTHCOM: [Empty].

Action number: 4.2.2.5; 
Action assigned to DOD: Inpatient and outpatient disease surveillance; 
CENTCOM: X; 
EUCOM: X; 
NORTHCOM: [Empty]; 
PACOM: [Empty]; 
SOUTHCOM: X.

Action number: 4.2.2.6; 
Action assigned to DOD: Monitoring health of military forces worldwide; 
CENTCOM: X; 
EUCOM: X; 
NORTHCOM: [Empty]; 
PACOM: X; 
SOUTHCOM: [Empty].

Action number: 4.2.2.7; 
Action assigned to DOD: Assist with influenza surveillance in host 
nations; 
CENTCOM: X; 
EUCOM: X; 
NORTHCOM: [Empty]; 
PACOM: [Empty]; 
SOUTHCOM: X.

Action number: 4.2.3.8; 
Action assigned to DOD: Develop/enhance DOD network of overseas 
infrastructure[A]; 
CENTCOM: [Empty]; 
EUCOM: [Empty]; 
NORTHCOM: [Empty]; 
PACOM: [Empty]; 
SOUTHCOM: [Empty].

Action number: 4.2.3.9; 
Action assigned to DOD: Refinement of DOD laboratory methods; 
CENTCOM: [Empty]; 
EUCOM: [Empty]; 
NORTHCOM: [Empty]; 
PACOM: X; 
SOUTHCOM: X.

Action number: 4.2.3.10; 
Action assigned to DOD: Assess foreign country military laboratory 
capacity; 
CENTCOM: X; 
EUCOM: X; 
NORTHCOM: X; 
PACOM: X; 
SOUTHCOM: X.

Action number: 4.2.4.2; 
Action assigned to DOD: COCOM public health reports for area personnel; 
CENTCOM: X; 
EUCOM: X; 
NORTHCOM: X; 
PACOM: X; 
SOUTHCOM: X.

Action number: 4.3.2.2; 
Action assigned to DOD: Identify DOD facilities to serve as points of 
entry from outbreak countries; 
CENTCOM: X; 
EUCOM: X; 
NORTHCOM: X; 
PACOM: [Empty]; 
SOUTHCOM: X.

Action number: 5.1.1.5; 
Action assigned to DOD: Assessment of military support for 
transportation and borders; 
CENTCOM: [Empty]; 
EUCOM: [Empty]; 
NORTHCOM: X; 
PACOM: X; 
SOUTHCOM: X.

Action number: 5.3.4.8; 
Action assigned to DOD: Strategic military deployment use of airports 
and seaports; 
CENTCOM: X; 
EUCOM: X; 
NORTHCOM: X; 
PACOM: [Empty]; 
SOUTHCOM: X.

Action number: 5.3.5.5; 
Action assigned to DOD: Monitor and report on military assets requested 
for border protection; 
CENTCOM: [Empty]; 
EUCOM: [Empty]; 
NORTHCOM: X; 
PACOM: [Empty]; 
SOUTHCOM: [Empty].

Action number: 6.1.6.3; 
Action assigned to DOD: Conduct medical materiel requirements gap 
analysis; 
CENTCOM: X; 
EUCOM: X; 
NORTHCOM: [Empty]; 
PACOM: [Empty]; 
SOUTHCOM: X.

Action number: 6.1.6.4; 
Action assigned to DOD: Maintain antiviral and vaccine stockpiles[A]; 
CENTCOM: [Empty]; 
EUCOM: [Empty]; 
NORTHCOM: [Empty]; 
PACOM: [Empty]; 
SOUTHCOM: [Empty].

Action number: 6.1.7.4; 
Action assigned to DOD: Establish stockpiles of vaccine against H5N1[A];
CENTCOM: [Empty]; 
EUCOM: [Empty]; 
NORTHCOM: [Empty]; 
PACOM: [Empty]; 
SOUTHCOM: [Empty].

Action number: 6.1.9.3; 
Action assigned to DOD: Procure 2.4 million antiviral medications[A]; 
CENTCOM: [Empty]; 
EUCOM: [Empty]; 
NORTHCOM: [Empty]; 
PACOM: [Empty]; 
SOUTHCOM: [Empty].

Action number: 6.1.13.8; 
Action assigned to DOD: Supply military units/ bases with influenza 
medication; 
CENTCOM: [Empty]; 
EUCOM: [Empty]; 
NORTHCOM: [Empty]; 
PACOM: [Empty]; 
SOUTHCOM: X.

Action number: 6.2.2.9; 
Action assigned to DOD: Enhance public health response capabilities; 
CENTCOM: X; 
EUCOM: X; 
NORTHCOM: [Empty]; 
PACOM: X; 
SOUTHCOM: [Empty].

Action number: 6.2.3.4; 
Action assigned to DOD: Access to improved rapid diagnostic tests; 
CENTCOM: X; 
EUCOM: X; 
NORTHCOM: [Empty]; 
PACOM: [Empty]; 
SOUTHCOM: [Empty].

Action number: 6.2.4.3; 
Action assigned to DOD: Provide health statistics on influenza-like 
illnesses; 
CENTCOM: [Empty]; 
EUCOM: X; 
NORTHCOM: [Empty]; 
PACOM: [Empty]; 
SOUTHCOM: [Empty].

Action number: 6.3.2.4; 
Action assigned to DOD: DOD guidance to personnel on protective 
measures; 
CENTCOM: X; 
EUCOM: X; 
NORTHCOM: X; 
PACOM: X; 
SOUTHCOM: X.

Action number: 6.3.2.5; 
Action assigned to DOD: Implement infection control campaigns; 
CENTCOM: X; 
EUCOM: [Empty]; 
NORTHCOM: X; 
PACOM: [Empty]; 
SOUTHCOM: [Empty].

Action number: 6.3.4.7; 
Action assigned to DOD: Enhance influenza surveillance reporting 
techniques; 
CENTCOM: X; 
EUCOM: X; 
NORTHCOM: [Empty]; 
PACOM: [Empty]; 
SOUTHCOM: [Empty].

Action number: 6.3.7.2; 
Action assigned to DOD: Be prepared to augment state/local government 
medical response; 
CENTCOM: [Empty]; 
EUCOM: [Empty];
NORTHCOM: X; 
PACOM: X; 
SOUTHCOM: [Empty].

Action number: 6.3.7.5; 
Action assigned to DOD: Reserve medical personnel mobilization; 
CENTCOM: [Empty]; 
EUCOM: [Empty]; 
NORTHCOM: [Empty]; 
PACOM: [Empty]; 
SOUTHCOM: [Empty].

Action number: 6.3.8.2; 
Action assigned to DOD: Update risk communication material; 
CENTCOM: [Empty]; 
EUCOM: X; 
NORTHCOM: [Empty]; 
PACOM: X; 
SOUTHCOM: [Empty].

Action number: 8.1.2.5; 
Action assigned to DOD: National Guard training for state law 
enforcement[A]; 
CENTCOM: [Empty]; 
EUCOM: [Empty]; 
NORTHCOM: [Empty]; 
PACOM: [Empty]; 
SOUTHCOM: [Empty].

Action number: 8.1.2.6; 
Action assigned to DOD: Requests for assistance from states/governors; 
CENTCOM: [Empty]; 
EUCOM: [Empty]; 
NORTHCOM: [Empty]; 
PACOM: X; 
SOUTHCOM: [Empty].

Action number: 8.3.2.1; 
Action assigned to DOD: Plans for quarantine enforcement; 
CENTCOM: [Empty]; 
EUCOM: X; 
NORTHCOM: X; 
PACOM: X; 
SOUTHCOM: [Empty].

Total; 
CENTCOM: 15; 
EUCOM: 18; 
NORTHCOM: 12; 
PACOM: 13; 
SOUTHCOM: 13.

Source: GAO analysis of DOD data.

* None of the COCOMs indicated that they were responsible for 
implementing six of the actions assigned to DOD in the national 
implementation plan. Therefore, these rows are blank.

[End of table]

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

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

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

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

DOD Has Not Identified Resources to Complete Planning and Preparedness 
Activities:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Conclusions:

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

Recommendations for Executive Action:

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

* Which of the actions assigned to DOD in the Implementation Plan for 
the National Strategy for Pandemic Influenza and other pandemic 
influenza- related planning tasks apply to the individual COCOMs, 
military services, and other organizations within DOD, as well as what 
constitutes fulfillment of these actions.

* NORTHCOM's roles and responsibilities as global synchronizer relative 
to the roles and responsibilities of the various organizations leading 
and supporting the department's pandemic influenza planning.

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

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

Agency Comments and Our Evaluation:

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

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

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

[End of section]

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

Action number: 4.1.1.3; 
Action: DOD, in coordination with the Department of State and other 
appropriate federal agencies, host nations, and regional alliance 
military partners, shall, within 18 months: (1) conduct bilateral and 
multilateral assessments of the avian and pandemic preparedness and 
response plans of the militaries in partner nations or regional 
alliances, such as NATO, focused on preparing for and mitigating the 
effects of an outbreak on assigned mission accomplishment; (2) develop 
solutions for identified national and regional military gaps; and (3) 
develop and execute bilateral and multilateral military-to-military 
influenza exercises to validate preparedness and response plans; 
Measure of performance: all countries with endemic avian influenza 
engaged by U.S. efforts; initial assessment and identification of 
exercise timeline for the military of each key partner nation 
completed; 
Deadline to complete action[A]: Within 18 months; 
Lead Department of Defense (DOD) organization responsible for 
implementing action: Joint Staff.

Action number: 4.1.2.6; 
Action: DOD, in coordination with the Department of State, host 
nations, and regional alliance military partners, shall assist in 
developing priority country military infection control and case 
management capability through training programs, within 18 months; 
Measure of performance: training programs carried out in all priority 
countries with increased military infection control and case management 
capability; 
Deadline to complete action[A]: Within 18 months; 
Lead Department of Defense (DOD) organization responsible for 
implementing action: Joint Staff.

Action number: 4.1.8.4; 
Action: The Department of Health and Human Services and DOD, in 
coordination with the Department of State, shall enhance open source 
information sharing efforts with international organizations and 
agencies to facilitate the characterization of genetic sequences of 
circulating strains of novel influenza viruses within 12 months; 
Measure of performance: publication of all reported novel influenza 
viruses which are sequenced; 
Deadline to complete action[A]: Within 12 months; 
Lead Department of Defense (DOD) organization responsible for 
implementing action: Assistant Secretary of Defense (ASD) for Health 
Affairs.

Action number: 4.2.2.5; 
Action: DOD shall develop active and passive systems for inpatient and 
outpatient disease surveillance at its institutions worldwide, with an 
emphasis on index case and cluster identification, and develop 
mechanisms for utilizing DOD epidemiological investigation experts in 
international support efforts, to include validation of systems/tools 
and improved outpatient/inpatient surveillance capabilities, within 18 
months; Measure of performance: monitoring system and program to 
utilize epidemiological investigation experts internationally are in 
place; 
Deadline to complete action[A]: Within 18 months; 
Lead Department of Defense (DOD) organization responsible for 
implementing action: ASD for Health Affairs.

Action number: 4.2.2.6; 
Action: DOD shall monitor the health of military forces worldwide 
(bases in the continental United States and outside of the continental 
United States, deployed operational forces, exercises, units, etc.), 
and in coordination with the Department of State, coordinate with 
allied, coalition, and host nation public health communities to 
investigate and respond to confirmed infectious disease outbreaks on 
DOD installations, within 18 months; Measure of performance: medical 
surveillance "watchboard" reports show results of routine monitoring, 
number of validated outbreaks, and results of interventions; 
Deadline to complete action[A]: Within 18 months; 
Lead Department of Defense (DOD) organization responsible for 
implementing action: ASD for Health Affairs.

Action number: 4.2.2.7; 
Action: DOD, in coordination with the Department of State and with the 
cooperation of the host nation, shall assist with influenza 
surveillance of host nation populations in accordance with existing 
treaties and international agreements, within 24 months; Measure of 
performance: medical surveillance "watchboard" expanded to include host 
nations; 
Deadline to complete action[A]: Within 24 months; 
Lead Department of Defense (DOD) organization responsible for 
implementing action: ASD for Health Affairs.

Action number: 4.2.3.8; 
Action: DOD, in coordination with the Department of Health and Human 
Services, shall develop and refine its overseas virologic and 
bacteriologic surveillance infrastructure through Global Emerging 
Infections Surveillance and Response System and the DOD network of 
overseas labs, including fully developing and implementing seasonal 
influenza laboratory surveillance and an animal/ vector surveillance 
plan linked with World Health Organization (WHO) pandemic phases, 
within 18 months; Measure of performance: animal/ vector surveillance 
plan and DOD overseas virologic surveillance network developed and 
functional; 
Deadline to complete action[A]: Within 18 months; 
Lead Department of Defense (DOD) organization responsible for 
implementing action: ASD for Health Affairs.

Action number: 4.2.3.9; 
Action: DOD, in coordination with the Department of Health and Human 
Services, shall prioritize international DOD laboratory research 
efforts to develop, refine, and validate diagnostic methods to rapidly 
identify pathogens, within 18 months; Measure of performance: 
completion of prioritized research plan, resources identified, and 
tasks assigned across DOD medical research facilities; 
Deadline to complete action[A]: Within 18 months; 
Lead Department of Defense (DOD) organization responsible for 
implementing action: Joint Staff.

Action number: 4.2.3.10; 
Action: DOD shall work with priority nations' military forces to assess 
existing laboratory capacity, rapid response teams, and portable field 
assay testing equipment, and fund essential commodities and training 
necessary to achieve an effective national military diagnostic 
capability, within 18 months; Measure of performance: assessments 
completed, proposals accepted, and funding made available to priority 
countries; 
Deadline to complete action[A]: Within 18 months; 
Lead Department of Defense (DOD) organization responsible for 
implementing action: Joint Staff.

Action number: 4.2.4.2; 
Action: DOD shall incorporate international public health reporting 
requirements for exposed or ill military international travelers into 
the geographic combatant commanders' pandemic influenza plans within 18 
months; Measure of performance: reporting requirements incorporated 
into geographic combatant commanders' pandemic influenza plans; 
Deadline to complete action[A]: Within 18 months; 
Lead Department of Defense (DOD) organization responsible for 
implementing action: ASD for Health Affairs.

Action number: 4.3.2.2; 
Action: DOD, in coordination with the Department of State, the 
Department of Health and Human Services, the Department of 
Transportation, and the Department of Homeland Security, shall limit 
official DOD military travel between affected areas and the United 
States; Measure of performance: DOD identifies military facilities in 
the United States and outside of the continental United States that 
will serve as the points of entry for all official travelers from 
affected areas, within 6 months; 
Deadline to complete action[A]: Within 6 months; 
Lead Department of Defense (DOD) organization responsible for 
implementing action: Joint Staff.

Action number: 5.1.1.5; Action: DOD, in coordination with the 
Department of Homeland Security, the Department of Transportation, the 
Department of Justice, and the Department of State, shall conduct an 
assessment of military support related to transportation and borders 
that may be requested during a pandemic and develop a comprehensive 
contingency plan for Defense Support of Civil Authorities, within 18 
months; Measure of performance: Defense Support of Civil Authorities 
plan in place that addresses emergency transportation and border 
support; 
Deadline to complete action[A]: Within 18 months; 
Lead Department of Defense (DOD) organization responsible for 
implementing action: Joint Staff.

Action number: 5.3.4.8; 
Action: DOD, in coordination with the Department of Homeland Security 
and the Department of State, shall identify those domestic and foreign 
airports and seaports that are considered strategic junctures for major 
military deployments and evaluate whether additional risk-based 
protective measures are needed, within 18 months; Measure of 
performance: identification of critical air and seaports and evaluation 
of additional risk-based procedures, completed; 
Deadline to complete action[A]: Within 18 months; 
Lead Department of Defense (DOD) organization responsible for 
implementing action: Joint Staff.

Action number: 5.3.5.5; Action: DOD, when directed by the Secretary of 
Defense and in accordance with law, shall monitor and report the status 
of the military transportation system and those military assets that 
may be requested to protect the borders, assess impacts (to include 
operational impacts), and coordinate military services in support of 
federal agencies and state, local, and tribal entities; Measure of 
performance: when DOD activated, regular reports provided, impacts 
assessed, and services coordinated as needed; 
Deadline to complete action[A]: In response to an influenza pandemic; 
Lead Department of Defense (DOD) organization responsible for 
implementing action: Joint Staff.

Action number: 6.1.6.3; 
Action: DOD, as part of its departmental implementation plan, shall 
conduct a medical materiel requirements gap analysis and procure 
necessary materiel to enhance Military Health System surge capacity, 
within 18 months; Measure of performance: gap analysis completed and 
necessary materiel procured; 
Deadline to complete action[A]: Within 18 months; 
Lead Department of Defense (DOD) organization responsible for 
implementing action: ASD for Health Affairs.

Action number: 6.1.6.4; 
Action: The Department of Health and Human Services, DOD, the 
Department of Veterans Affairs, and the states shall maintain antiviral 
and vaccine stockpiles in a manner consistent with the requirements of 
the Food and Drug Administration's Shelf Life Extension Program and 
explore the possibility of broadening the Shelf Life Extension Program 
to include equivalently maintained state stockpiles, within 6 months; 
Measure of performance: compliance with the Shelf Life Extension 
Program requirements documented; 
decision made on broadening the Shelf Life Extension Program to state 
stockpiles; 
Deadline to complete action[A]: Within 6 months; 
Lead Department of Defense (DOD) organization responsible for 
implementing action: ASD for Health Affairs.

Action number: 6.1.7.4; 
Action: DOD shall establish stockpiles of vaccine against H5N1 and 
other influenza subtypes determined to represent a pandemic threat 
adequate to immunize approximately 1.35 million persons for military 
use within 18 months of availability; Measure of performance: 
sufficient vaccine against each influenza virus determined to represent 
a pandemic threat in DOD stockpile to vaccinate 1.35 million persons; 
Deadline to complete action[A]: Within 18 months of availability; 
Lead Department of Defense (DOD) organization responsible for 
implementing action: ASD for Health Affairs.

Action number: 6.1.9.3; 
Action: DOD shall procure 2.4 million treatment courses of antiviral 
medications and position them at locations worldwide within 18 months. 
Measure of performance: aggregate 2.4 million treatment courses of 
antiviral medications in DOD stockpiles; 
Deadline to complete action[A]: Within 18 months; 
Lead Department of Defense (DOD) organization responsible for 
implementing action: ASD for Health Affairs.

Action number: 6.1.13.8; 
Action: DOD shall supply military units and posts, installations, 
bases, and stations with vaccine and antiviral medications according to 
the schedule of priorities listed in the DOD pandemic influenza policy 
and planning guidance, within 18 months; 
Measure of performance: vaccine and antiviral medications procured; 
DOD policy guidance developed on use and release of vaccine and 
antiviral medications; 
and worldwide distribution drill completed; 
Deadline to complete action[A]: Within 18 months; 
Lead Department of Defense (DOD) organization responsible for 
implementing action: Joint Staff.

Action number: 6.2.2.9; 
Action: DOD shall enhance influenza surveillance efforts within 6 
months by: (1) ensuring that medical treatment facilities monitor the 
Electronic Surveillance System for Early Notification of Community-
based Epidemics and provide additional information on suspected or 
confirmed cases of pandemic influenza through their service 
surveillance activities; 
(2) ensuring that Public Health Emergency Officers report all suspected 
or actual cases through appropriate DOD reporting channels, as well as 
to the Centers for Disease Control and Prevention, state public health 
authorities, and host nations; 
and (3) posting results of aggregated surveillance on the DOD Pandemic 
Influenza Watchboard; 
all within 18 months; 
Measure of performance: number of medical treatment facilities 
performing Electronic Surveillance System for Early Notification of 
Community- based Epidemics surveillance greater than 80 percent; 
DOD reporting policy for public health emergencies, including pandemic 
influenza, completed; 
Deadline to complete action[A]: Within 18 months; 
Lead Department of Defense (DOD) organization responsible for 
implementing action: ASD for Health Affairs.

Action number: 6.2.3.4; 
Action: Department of Health and Human Services-, DOD-, and Department 
of Veterans Affairs-funded hospitals and health facilities shall have 
access to improved rapid diagnostic tests for influenza A, including 
influenza with pandemic potential, within 6 months of when tests become 
available; 
Deadline to complete action[A]: Within 6 months of when tests become 
available; 
Lead Department of Defense (DOD) organization responsible for 
implementing action: ASD for Health Affairs.

Action number: 6.2.4.3; 
Action: DOD and the Department of Veterans Affairs shall be prepared to 
track and provide personnel and beneficiary health statistics and 
develop enhanced methods to aggregate and analyze data documenting 
influenza-like illness from their surveillance systems within 12 
months; 
Measure of performance: influenza tracking systems in place and 
capturing beneficiary clinical encounters; 
Deadline to complete action[A]: Within 12 months; 
Lead Department of Defense (DOD) organization responsible for 
implementing action: ASD for Health Affairs.

Action number: 6.3.2.4; 
Action: As appropriate, DOD, in consultation with its combatant 
commanders, shall implement movement restrictions and individual 
protection and social distancing strategies (including unit shielding, 
ship sortie, cancellation of public gatherings, drill, training, etc.) 
within its posts, installations, bases, and stations. DOD personnel and 
beneficiaries living off-base should comply with local community 
containment guidance with respect to activities not directly related to 
the installation. DOD shall be prepared to initiate within 18 months; 
Measure of performance: the policies/procedures are in place for at-
risk DOD posts, installations, bases, stations, and for units to 
conduct an annual training evaluation that includes restriction of 
movement, shielding, personnel protection measures, health unit 
isolation, and other measures necessary to prevent influenza 
transmission; 
Deadline to complete action[A]: Within 18 months; 
Lead Department of Defense (DOD) organization responsible for 
implementing action: Joint Staff.

Action number: 6.3.2.5; 
Action: All Department of Health and Human Services-, DOD-, and 
Department of Veterans Affairs-funded hospitals and health facilities 
shall develop, test, and be prepared to implement infection control 
campaigns for pandemic influenza, within 3 months; 
Measure of performance: guidance materials on infection control 
developed and disseminated on www.pandemicflu.gov and through other 
channels; 
Deadline to complete action[A]: Within 3 months; 
Lead Department of Defense (DOD) organization responsible for 
implementing action: ASD for Health Affairs.

Action number: 6.3.4.7; 
Action: DOD shall enhance its public health response capabilities by: 
(1) continuing to assign epidemiologists and preventive medicine 
physicians within key operational settings; 
(2) expanding ongoing DOD participation in the Centers for Disease 
Control and Prevention's Epidemic Intelligence Service program; 
and (3) within 18 months, fielding specific training programs for 
Public Health Emergency Officers that address their roles and 
responsibilities during a public health emergency; 
Measure of performance: all military Public Health Emergency Officers 
fully trained within 18 months; 
increase military trainees in the Centers for Disease Control and 
Prevention's Epidemic Intelligence Service program by 100 percent 
within 5 years; 
Deadline to complete action[A]: Within 18 months; 
Lead Department of Defense (DOD) organization responsible for 
implementing action: Joint Staff.

Action number: 6.3.7.2; 
Action: DOD and Department of Veterans Affairs assets and capabilities 
shall be postured to provide care for military personnel and eligible 
civilians, contractors, dependants, other beneficiaries, and veterans 
and shall be prepared to augment the medical response of state, 
territorial, tribal, or local governments and other federal agencies 
consistent with their Emergency Support Function #8--Public Health and 
Medical Services support roles, within 3 months; 
Measure of performance: DOD and Department of Veterans Affairs' 
pandemic preparedness plans developed; 
in a pandemic, adequate health response provided to military and 
associated personnel; 
Deadline to complete action[A]: Within 3 months; 
Lead Department of Defense (DOD) organization responsible for 
implementing action: Joint Staff.

Action number: 6.3.7.5; 
Action: DOD shall develop and implement guidelines defining conditions 
under which Reserve Component medical personnel providing health care 
in nonmilitary health care facilities should be mobilized and deployed, 
within 18 months; 
Measure of performance: guidelines developed and implemented; 
Deadline to complete action[A]: Within 18 months; 
Lead Department of Defense (DOD) organization responsible for 
implementing action: ASD for Health Affairs.

Action number: 6.3.8.2; 
Action: DOD and the Department of Veterans Affairs, in coordination 
with the Department of Health and Human Services, shall develop and 
disseminate educational materials, coordinated with and complementary 
to messages developed by the Department of Health and Human Services 
but tailored for their respective departments, within 6 months; 
Measure of performance: up- to-date risk communication material 
published on DOD and; 
Department of Veterans Affairs pandemic influenza Web sites, Department 
of Health and Human Services Web site www.pandemicflu.gov, and in other 
venues; 
Deadline to complete action[A]: Within 6 months; 
Lead Department of Defense (DOD) organization responsible for 
implementing action: ASD for Health Affairs.

Action number: 8.1.2.5; 
Action: DOD, in consultation with the Department of Justice and the 
National Guard Bureau, and in coordination with the states as such 
training applies to support state law enforcement, shall assess the 
training needs for National Guard forces in providing operational 
assistance to state law enforcement under either federal (Title 10) or 
state (Title 32 or State Active Duty) in a pandemic influenza outbreak 
and provide appropriate training guidance to the states and territories 
for units and personnel who will be tasked to provide this support, 
within 18 months; 
Measure of performance: guidance provided to all states; 
Deadline to complete action[A]: Within 18 months; 
Lead Department of Defense (DOD) organization responsible for 
implementing action: Joint Staff.

Action number: 8.1.2.6; 
Action: DOD, in consultation with the Department of Justice, shall 
advise state governors of the procedures for requesting military 
equipment and facilities, training, and maintenance support as 
authorized by 10 U.S.C. ßß 372-74, within 6 months; 
Measure of performance: all state governors advised; 
Deadline to complete action[A]: Within 6 months; 
Lead Department of Defense (DOD) organization responsible for 
implementing action: Joint Staff.

Action number: 8.3.2.1; 
Action: The Department of Justice, the Department of Homeland Security, 
and DOD shall engage in contingency planning and related exercises to 
ensure they are prepared to maintain essential operations and conduct 
missions, as permitted by law, in support of quarantine enforcement 
and/or assist state, local, and tribal entities in law enforcement 
emergencies that may arise in the course of an outbreak, within 6 
months; 
Measure of performance: completed plans (validated by exercise[s]) for 
supporting quarantine enforcement and/or law enforcement emergencies; 
Deadline to complete action[A]: Within 6 months; 
Lead Department of Defense (DOD) organization responsible for 
implementing action: Joint Staff.

Source: Homeland Security Council and DOD.

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

[End of table]

[End of section]

Appendix II: Scope and Methodology:

[End of section]

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


*Headquarters, U.S. Central Command, MacDill Air Force Base, Florida;


*Headquarters, U.S. European Command, Patch Barracks, Germany;

*Marine Forces Europe, Patch Barracks, Germany;

*Naval Forces Europe, Patch Barracks, Germany;

*Special Operations Command Europe, Patch Barracks, Germany;

*U.S. Air Forces Europe, Ramstein Air Base, Germany;

*U.S. Army Europe, Campbell Barracks, Germany;

*Installation Management Command Europe, Campbell Barracks, Germany;

*European Regional Medical Command, Campbell Barracks, Germany;

*U.S. Army Medical Materiel Command Europe, Pirmasens, Germany;

*Headquarters, U.S. Joint Forces Command, Norfolk, Virginia;

*Headquarters, U.S. Northern Command, Peterson Air Force Base, Colorado;

*Headquarters, U.S. Pacific Command, Camp H.M. Smith, Hawaii;

*Marine Forces Pacific, Camp H.M. Smith, Hawaii;

*Pacific Air Force, Hickam Air Force Base, Hawaii;

*Pacific Fleet, Naval Station Pearl Harbor, Hawaii;

*Special Operations Command Pacific, Camp H.M. Smith, Hawaii;

*U.S. Army Pacific, Fort Shafter, Hawaii;

*U.S. Forces Korea, Yongsan Army Garrison, South Korea;

*U.S. Naval Forces Korea, Yongsan Army Garrison, South Korea;

*7th Air Force, Osan Air Base, South Korea;

*18th Medical Command, Yongsan Army Garrison, South Korea;

*Installation Management Command Korea Regional Office, Yongsan Army 
Garrison, South Korea;

*Installation Management Command Pacific, Fort Shafter, Hawaii;

*Tripler Army Medical Center, Hawaii;

*Headquarters, U.S. Southern Command, Miami, Florida;

*Headquarters, U.S. Special Operations Command, MacDill Air Force Base, 
Florida;

*Headquarters, U.S. Strategic Command, Offutt Air Force Base, Nebraska; 
and:

*Headquarters, U.S. Transportation Command, Scott Air Force Base, 
Illinois;

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

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

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

[End of section]

Appendix III: Comments from the Department of Defense:

Assistant Secretary Of Defense:
2600 Defense Pentagon: 
Washington, Dc 20301-2600:
Homeland Defense:

MAY 2 2 2007:

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

Dear Ms. D'Agostino:

Thank you for the opportunity to respond to the GAO Draft Report, 
"Influenza Pandemic: DoD Combatant Commands' Preparedness Efforts Could 
Benefit from More Clearly Defined Roles, Resources, and Risk 
Mitigation," dated April 25, 2007, (GAO Code 350786/GAO-07-696). The Department of Defense concurs with comments. Please find the attached matrix and supporting documentation. While it is policy not to release plans outside of the Department, DoD Components have been directed to establish reading rooms to facilitate GAO's review of applicable plans.

The report represents a snapshot in time and much has been accomplished 
to facilitate the Department's planning efforts. We are confident that 
future plans will adequately address specific roles, resources, and 
risk mitigation.

Sincerely,

Signed by: 

Peter F. Verga: 
Acting Director:

Enclosure: 
As stated:

GAO Draft Report:

"Influenza Pandemic: DoD Combatant Commands' Preparedness Efforts Could 
Benefit from More Clearly Defined Roles, Resources, and Risk 
Mitigation," April 25, 2007, (GAO Code 350786/GAO-07-696):

Department Of Defense Comments To The Recommendations:

Recommendation 1: Recommend that the Secretary of Defense instruct the 
ASD for Homeland Defense and Americas' Security Affairs to issue 
guidance that specifies the following:

Which of the actions assigned to DOD in the Implementation Plan for the 
National Strategy for Pandemic Influenza and other pandemic influenza-
related planning tasks apply to the individual COCOMs, military 
services, and other organizations within DOD, as well as what 
constitutes fulfillment of these actions.

* NORTHCOM's roles and responsibilities as global synchronizer relative 
to the roles and responsibilities of the various organizations leading 
and supporting the department's pandemic influenza planning.

DOD Response: DoD concurs.

Recommendation 2: Recommend that the Secretary of Defense instruct the 
Assistant Secretary of Defense for Homeland Defense and Americas' 
Security Affairs to work with the Under Secretary of Defense 
(Comptroller) to identify the sources and types of resources that 
COCOMS need to accomplish their pandemic influenza planning and 
preparedness activities.

DOD Response: DoD concurs.

Recommendation 3: Recommend that the Secretary of Defense instruct the 
Joint Staff to work with the COCOMs to develop options to mitigate the 
effects of factors that are beyond the COCOMs' control, such as limited 
detailed information from other federal agencies on the support 
expected from DOD, lack of control over to DOD's antiviral stockpile, 
limited information on decisions that other nations may make during an 
influenza pandemic, reliance on civilian medical providers for medical 
care, and reliance on military services for medical material.

DOD Response: DoD concurs.

[End of section]

Appendix IV: GAO Contact and Staff Acknowledgments:

[End of section]

GAO Contact:

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

Staff Acknowledgments:

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

[End of section]

Related GAO Products:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(350786):

FOOTNOTES

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

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

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

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

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

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

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

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

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

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

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

[12] GAO-06-1042.

[13] GAO-07-395T.

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

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

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

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

[GAO-07-395T] and GAO-06-467T.

[18] GAO-06-1042.

[19] GAO/GGD/AIMD-10.1.18.

[20] GAO-06-1042.

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

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

[GAO-07-386T] and GAO-06-442T.

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

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

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

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

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