Technical Articles

International Journal of Auditing – January 2007

The Role of SAIs in Preparing for and Responding to an Influenza Pandemic

Editor's Note: This article describes the strategy the U.S. GAO has developed to address issues related to an influenza pandemic. GAO is interested in feedback on its strategy and would welcome opportunities to work with other SAIs on these important issues.

An influenza pandemic is a real and significant worldwide threat. Pandemics occur
when a new influenza virus emerges that infects and can be effectively transmitted
between humans who have little immunity to it. The last three worldwide pandemics
occurred in 1918, 1957, and 1968 and killed approximately 40 million, 2 million, and
1 million people, respectively.

SAIs can play an important role in helping their nations prepare for an influenza pandemic
by drawing on past experiences and lessons learned and looking ahead at what
needs to be done. SAIs can

  • help ensure sound planning and preparedness;
  • help ensure that investments and activities provide value, whether or not a pandemic occurs; and
  • strengthen existing or emerging networks, thereby contributing to each nation's overall infrastructure for emergency preparations and response.

Because of the global nature of pandemics, it will be important for SAIs to work
together to enhance worldwide preparedness and also to strengthen countries’ capabilities
to respond to and recover from a pandemic.

While health experts cannot predict with certainty which strain of influenza virus will be
involved in the next pandemic, some suggest that the avian influenza virus identified in
Asia, known as H5N1, is the most likely candidate. To date, the virus has spread among
domestic and wild birds in about 50 countries in Asia, Africa, the Middle East, and
Europe. Although H5N1 remains largely a disease among birds, a pandemic could result
if the virus mutates to spread quickly from person to person. According to the World
Health Organization, as of November 29, 2006, 258 persons in 10 countries had been
infected with the virus since 2003. Of those infected, 154 died.

The potential scale of an influenza pandemic will depend on whether all national
capabilities are leveraged and coordinated action is taken by all segments of government
and society. Therefore, a strategy that extends well beyond health and medical
boundaries is necessary—one that includes sustaining critical infrastructure, private
sector activities, the movement of goods and services across the nation and the globe,
and economic and security considerations.

This article describes the strategy that the U.S. Government Accountability Office
(GAO) has developed to integrate its efforts to examine the programs, functions,
and tools that the United States will need to effectively prepare for, respond to, and
recover from an influenza pandemic. This strategy could involve a range of approaches, including reports and testimonies, briefings, partnerships, forums, expert panels, and
constructive engagements. GAO will continue to look for opportunities to consult
with other organizations and draw on their expertise as appropriate, leverage ongoing
efforts, and limit potential overlap or duplication of efforts.

Key Themes Requiring Attention

GAO developed its strategy to help inform the U.S. Congress’ decision making and
oversight of pandemic-related efforts and to help the United States prepare for a
pandemic in ways that are sustainable over the longer term. The strategy builds upon a
large body of work, contained in over 120 reports and testimonies that GAO has conducted
over many years on areas such as prior disasters, assessments of public health
capacities, and efforts to address the year 2000 computer challenges. Based on lessons
learned from prior work and consideration of the unique characteristics of an influenza
pandemic, GAO developed six key themes to guide its work (see figure 1).

Figure 1: Key Themes of GAO’s Proposed Pandemic Work

Leadership, Authority, and Coordination

GAO’s past work has highlighted the particular importance of leadership, authority, and coordination, a theme that touches on all aspects of preparing for, responding to, and recovering from an influenza pandemic. In November 2005, the President of the United States released a national strategy for influenza pandemics that outlines how the United States is preparing for, and will detect and respond to, a potential pandemic. In May 2006 a companion plan was issued to guide efforts to implement the strategy. Under the U.S. national strategy and implementation plan, individual federal agencies were assigned important leadership responsibilities in different areas.

Given the multitude of organizations within the federal, state, and local governments, the private sector, and other countries that will be involved, it is important for all to have (1) a clear understanding of leadership roles and responsibilities and (2) the authorities needed to operate effectively and ensure accountability for collaborative efforts. Key issues include the extent to which leadership roles and responsibilities are clearly defined and have appropriate authorities in place. GAO will also be looking for innovative leadership approaches that can be used to improve efforts to address crosscutting and multisector 21st century challenges, such as influenza pandemics and other catastrophic events.

Detecting Threats and Managing Risks

International disease surveillance is a key component in detecting threats. The U.S. Centers for Disease Control and Prevention (CDC) collaborate with multiple public health partners, including the World Health Organization (WHO), to obtain data on national and international influenza activity. Disease surveillance, although improved through efforts such as those of the CDC and WHO to improve influenza surveillance in Asia, still presents challenges. Many countries lack health care infrastructures and public health laboratories, and others lack systems for reporting crucial disease information to authorities.

Key issues to be addressed include examining what U.S. agencies and international organizations are doing to strengthen domestic and international efforts to detect and report animal and human outbreaks.

Planning, Training, and Exercising

By their very nature, catastrophic events can overwhelm responders, making sound advance planning critical. Robust training and exercise programs to test plans in advance of a real disaster are also essential. However, GAO's work over the years has shown that these have been lacking in relationship to the challenges of preparing for and responding to the annual influenza season.

Two key issues to be addressed include (1) assessing the extent to which the various planning efforts at all levels of government and sectors represent a comprehensive, coherent, and integrated national framework for a possible influenza pandemic and (2) identifying the processes for testing and exercising implementation plans and those who are responsible for ensuring that the results are used to address any issues or problems identified.

Capacity to Respond and Recover

In addition to the profound human costs from illnesses and deaths, the economic and societal repercussions of a moderate to severe pandemic would be significant. A World Bank official noted that the disruptions associated with SARS led to an economic loss of about 2 percent in regional gross domestic product in the second quarter of 2003. The U.S. Congressional Budget Office has estimated that a pandemic on the scale of the 1918 pandemic could result in a 5-percent reduction of gross domestic product in the United States over the subsequent year. Rates of employee absences would depend on the severity of the pandemic and, according to the CDC, might reach 40 percent during the peak weeks of an outbreak.

Issues to be addressed include assessing what is being done to provide the necessary surge capacity in the human and animal health care infrastructure to address likely needs during a pandemic (e.g., availability of hospital beds; medical supplies, including vaccine; and key human capital capacities, including doctors, nurses, and veterinarians); examining how ethical issues concerning the sharing and distribution of scarce resources are being considered and addressed; and evaluating the extent to which the United States and its international partners are addressing critical resource constraints that impact the capacity of countries to respond to an influenza pandemic.

Information Sharing and Communication

GAO's evaluations of public health and natural disaster preparedness, response, and recovery show that insufficient collaboration has created challenges for sharing public health information and developing interoperable communications for first responders. Effective coordination between public health and animal health surveillance activities is also necessary to detect a new influenza strain as early as possible.

In a variety of public warning contexts, citizens need to be given an accurate portrayal of risk that does not overstate the threat or provide false assurances of security. The U.S. Department of Health and Human Services recently undertook a number of communications efforts, including establishing an influenza pandemic Web site (www. and sponsoring national summits with the U.S. states. It also released a series of planning checklists for state and local governments, businesses, and community organizations.

Issues to be addressed include the extent to which information related to a possible influenza pandemic will be shared among international, federal, state, and local agencies and other organizations, as well as the ways the information will be used. Another issue to be addressed is the effectiveness of communication and information sharing between human and animal health systems, including laboratories.

Performance and Accountability

Several challenges are associated with national planning efforts. Without outcomeoriented goals and clear performance measures, it will be difficult for any nation's Congress or Parliament, the federal government, and others to assess the overall effectiveness of preparedness efforts. Ensuring that agencies develop complementary goals and measures with others, as appropriate, will be important. Finally, internal controls and appropriate oversight mechanisms, such as controls to ensure the performance and accountability of grants and contracts, will be needed to track funds recieved and spent.

Going Forward: The Role of SAIs

In summary, just as a pandemic would cut across national borders, SAIs' audit strategies should cut across jurisdictional boundaries. SAIs can collaborate in the following ways.

  • They can work together to develop and apply consistent methodologies to assess
    national preparedness. This would help each individual country in its own efforts as well as provide a basis for independent comparisons across nations.
  • They can engage in coordinated audits of key issues that cut across national
  • They can engage in joint audits of international preparedness and response efforts.

For additional information, contact the author at:

1 Partnering contracts include any mutually beneficial contractual relationships between public and private sector
parties that involve a collaborative approach to achieving public sector outcomes.
2 The guidance, Achieving Public Sector Outcomes with Private Sector Partners, is available on our Web site,