However, they generally agree that the level of risk that H5N1  will spark a pandemic varies with (1) environmental factors, defined as the  extent to which a country or region has already become infected with the  virus—or may become infected from a neighboring country—and provides  conditions in which the virus can spread in poultry and infect humans, and  (2) preparedness factors, defined as the extent to which the country or  region is prepared to detect the virus in poultry and humans and respond  appropriately. This increases the potential for mutations, and thus the  emergence of a pandemic strain. Four of these focus in large measure on improving  capacity to forestall a pandemic:Improve animal health practices and the performance of veterinary  services. Assessment efforts that we examined, carried out by U.S. and  international agencies from late 2005 through late 2006, illustrate these  gaps. Efforts to assemble more comprehensive information are under  way, but will take time to produce results. USAID, State Department, and UN Data Collection Efforts Have Found Widespread Preparedness Weaknesses but Have Not Resulted in Clear Country Comparisons

USAID, the State Department, and the UN System Influenza Coordinator  have each administered questionnaires to assess country-by-country avian  and pandemic influenza preparedness. These efforts identified widespread preparedness shortfalls. For example, the UN found  that about one-third of the countries lacked the capacity to diagnose avian  influenza in humans. World Bank-Led Missions Have Provided Additional Information for Some Countries but Have Not Provided Basis for Comprehensive Comparisons

The World Bank has conducted more in-depth assessments of both  environmental and preparedness-related risk factors in some countries  (those that have expressed interest in World Bank assistance), but they do  not provide a basis for making complete or comprehensive global  comparisons. The United States Has Prioritized Countries Based on Available Information

The United States has prioritized countries for U.S. assistance, with the  Homeland Security Council identifying about 20 “priority countries,” and  agency officials have determined that the United States should focus in  particular on certain of these countries where pandemic risk levels appear  comparatively high. In May 2006, the Homeland Security Council categorized countries, using  the limited information available on environmental and preparedness- related risks from U.S. and international agencies, and also taking U.S.  foreign policy concerns into account. The United States Has Played a Prominent Role in Global Efforts to Improve Preparedness

The United States has played a prominent role in global efforts to improve  avian and pandemic influenza preparedness, committing more funds than  any other donor country and creating a framework for monitoring its  efforts. USAID and HHS have provided most of the U.S. funds,  while the State Department coordinates the United States’ international  efforts. The U.S. National Strategy for Pandemic Influenza  Implementation Plan establishes a framework for U.S. efforts to improve  international (and domestic) preparedness, listing specific action items,  assigning agencies responsibility for completing them, and specifying  performance measures and time frames for determining whether they have  been completed. The council reported in December  2006 that all action items due to be completed by November had been  completed, and provided evidence of timely completion for the majority of  the items. Most Country-Specific Commitments Have Gone to U.S. According to data compiled by the World Bank, about 72  percent of U.S. country-specific commitments and about 76 percent of  overall donor country-specific commitments through December 2006 were  to U.S. priority countries. These agencies generally concurred with our findings, and  we incorporated their technical comments in the report as appropriate. To describe the overall  strategy that the United States and its international partners have  developed to respond to the H5N1 epidemic, we interviewed and  examined relevant documents from U.S. and UN agencies, including the  U.S. National Strategy for Pandemic Influenza and strategy statements  and progress reports produced by the UN System Influenza Coordinator  and the World Bank. To examine the extent to which U.S. and international agencies have been  able to assess the pandemic risk that H5N1 presents in individual  countries and prioritize them for international assistance, we reviewed  and analyzed assessments of environmental risk and preparedness.
Why GAO Did This Study

Since 2003, a global epidemic of avian influenza has raised concern about the risk of an influenza pandemic among humans, which could cause millions of deaths. The United States and its international partners have begun implementing a strategy to forestall (prevent or delay) a pandemic and prepare to cope should one occur. Disease experts generally agree that the risk of a pandemic strain emerging from avian influenza in a given country varies with (1) environmental factors, such as disease presence and certain high-risk farming practices, and (2) preparedness factors, such as a country's capacity to control outbreaks. This report describes (1) U.S. and international efforts to assess pandemic risk by country and prioritize countries for assistance and (2) steps that the United States and international partners have taken to improve the ability to forestall a pandemic. To address these objectives, we interviewed officials and analyzed data from U.S. agencies, international organizations, and nongovernmental experts. The U.S. and international agencies whose efforts we describe reviewed a draft of this report. In general, they concurred with our findings. Several provided technical comments, which we incorporated as appropriate.

What GAO Found

Assessments by U.S. agencies and international organizations have identified widespread risks of the emergence of pandemic influenza and the United States has identified priority countries for assistance, but information gaps limit the capacity for comprehensive comparisons of risk levels by country. Several assessments we examined, which have considered environmental or preparedness-related risks or both, illustrate these gaps. For example, a U.S. Agency for International Development (USAID) assessment categorized countries according to the level of environmental risk--considering factors such as disease presence and the likelihood of transmission from nearby countries, but factors such as limited understanding of the role of poultry trade or wild birds constrain the reliability of the conclusions. Further, USAID, the State Department, and the United Nations have administered questionnaires to assess country preparedness and World Bank-led missions have gathered detailed information in some countries, but these efforts do not provide a basis for making comprehensive global comparisons. Efforts to get better information are under way but will take time. The U.S. Homeland Security Council has designated priority countries for assistance, and agencies have further identified several countries as meriting the most extensive efforts, but officials acknowledge that these designations are based on limited information. The United States has played a prominent role in global efforts to improve avian and pandemic influenza preparedness, committing the greatest share of funds and creating a framework for managing its efforts. Through 2006, the United States had committed about $377 million, 27 percent of the $1.4 billion committed by all donors. USAID and the Department of Health and Human Services have provided most of these funds for a range of efforts, including stockpiles of protective equipment and training foreign health professionals in outbreak response. The State Department coordinates international efforts and the Homeland Security Council monitors progress. More than a third of U.S. and overall donor commitments have gone to individual countries, with more than 70 percent of those going to U.S. priority countries. The U.S. National Strategy for Pandemic Influenza Implementation Plan provides a framework for U.S. international efforts, assigning agencies specific action items and specifying performance measures and time frames for completion. The Homeland Security Council reported in December 2006 that all international actions due to be completed by November had been completed, and provided evidence of timely completion for the majority of those items.