oversight

Emergency Assistance for Zika: USAID Supported Activities Overseas but Could Improve Funds Tracking and Response Planning

Published by the Government Accountability Office on 2019-05-13.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

             United States Government Accountability Office
             Report to Congressional Committees




             EMERGENCY
May 2019




             ASSISTANCE FOR
             ZIKA

             USAID Supported
             Activities Overseas
             but Could Improve
             Funds Tracking and
             Response Planning




GAO-19-356
                                            May 2019

                                            EMERGENCY ASSISTANCE FOR ZIKA
                                            USAID Supported Activities Overseas but Could
                                            Improve Funds Tracking and Response Planning
Highlights of GAO-19-356, a report to
congressional committees




Why GAO Did This Study                      What GAO Found
The World Health Organization (WHO)         The U.S. Agency for International Development (USAID) and the Department of
declared the Zika virus a public health     State (State) obligated $385 million of the total $390 million available for
emergency of international concern in       international Zika response and disbursed $264 million as of September 2018.
February 2016. According to WHO, as         USAID obligated 95 percent of the total funding. USAID and State provided
of March 2017, 79 countries and             some country information to Congress but did not provide, or take steps to track,
territories—including 48 in the Western     funding on a country basis. According to USAID officials, tracking funding
Hemisphere—reported evidence of             information by country would be helpful in the future. The ability to compile
ongoing Zika transmission. In April         funding by country when responding to future infectious disease outbreaks would
2016, USAID and State repurposed
                                            enable USAID to provide additional information to key decision makers to better
$215 million for Zika from funds
                                            support spending oversight and inform budgetary and planning decisions.
appropriated for Ebola. Subsequently,
the Zika Response and Preparedness          In response to the Zika outbreak, USAID and State supported a broad range of
Appropriations Act, 2016, provided          activities overseas, including mosquito control, research efforts, and medical
over $175 million in supplemental           evacuations. In one activity, USAID implementing partners monitored mosquito
funding to USAID and State to support       populations; in another, they researched methods to reduce Zika virus
Zika response efforts overseas. The         transmission rates. USAID implementing partners reported various outputs from
act also included a provision for GAO       selected activities. For example, an implementing partner reported that its
to review the status of USAID and           awareness campaign on Zika prevention reached more than 5 million people.
State actions to respond to Zika. In
March 2019, the Centers for Disease         USAID-Supported Worker Collects Insects for Monitoring Purposes in a Home in Honduras
Control and Prevention downgraded its       (left), and Mosquito That Carries the Zika Virus Viewed under a Microscope (right)
international travel warning for Zika.
This report examines (1) the status of
USAID and State funding for U.S. Zika
response overseas, (2) activities
supported by these funds, and (3)
implementation challenges, if any, and
responses to any challenges. GAO
reviewed information from U.S.
agencies and met with U.S. and host
country officials in Washington, D.C.
GAO also conducted fieldwork in a
nongeneralizable sample of countries        USAID faced sustainability and timeliness challenges in implementing its Zika
in Latin America and the Caribbean          response. According to agency and other officials, one-time funding and a short
where agencies implemented key              time frame posed a challenge related to sustainability of Zika response activities.
response activities.                        In response, USAID worked to align activities with those of host governments
What GAO Recommends                         and other organizations so they could continue in the long term. However,
                                            USAID’s emergency response planning did not fully address the challenge of
USAID should (1) take steps to ensure       timely implementation of response activities in countries without bilateral USAID
it is able to compile funding information   health programs. Twenty-two of 26 countries with Zika response activities did not
by country for future infectious disease    have bilateral USAID health programs when the Zika outbreak began. As a
emergency responses and (2) take            result, response activities took additional time to deploy in some countries where
steps to improve its infectious disease     USAID first had to establish relationships with key host country officials. Although
response planning. USAID concurred
                                            USAID developed an infectious disease response plan in 2018, the plan does
with GAO’s recommendations.
                                            not provide guidance on how to address the timely implementation challenge in
View GAO-19-356. For more information,      countries without bilateral health programs. By improving its planning, such as by
contact David Gootnick, (202) 512-3149 or   adding such guidance in its 2018 plan, USAID would be better positioned to
gootnickd@gao.gov.
                                            respond quickly to future disease outbreaks.
                                                                                       United States Government Accountability Office
Contents


Letter                                                                                      1
               Background                                                                  4
               USAID and State Obligated Almost All Funding Available for the
                 Zika Response but Did Not Report Funding by Country                       9
               USAID and State Supported a Broad Range of Activities in
                 Response to Zika                                                         16
               USAID Took Steps to Address Sustainability Challenge but Only
                 Partially Mitigated Challenge to Timely Implementation                   23
               Conclusions                                                                27
               Recommendations for Executive Action                                       27
               Agency Comments and Our Evaluation                                         28

Appendix I     Objectives, Scope, and Methodology                                         29



Appendix II    Illustrative Examples of Results for
               Selected Zika Response Activities                                          32



Appendix III   Comments from the U.S. Agency for
               International Development                                                  40



Appendix IV    GAO Contact and Staff Acknowledgments                                      46



Tables
               Table 1: Indicators Reported to USAID by the Applying Science to
                       Strengthen and Improve Systems Activity, as of March
                       2018                                                               33
               Table 2: Indicators Reported to USAID by the International
                       Federation of Red Cross and Red Crescent Societies
                       Global Health Activity, as of May 2018                             34
               Table 3: Indicators Reported to USAID by the United Nations
                       International Children’s Emergency Fund Activity, as of
                       March 2018                                                         35
               Table 4: Indicators Reported to USAID by the Save the Children
                       Community Action on Zika Project, as of September 2017             36



               Page i                                 GAO-19-356 Emergency Assistance for Zika
          Table 5: Illustrative Selection of Indicators, by Objective, Reported
                  to USAID by the Population Services International Activity,
                  as of March 2018                                                    38
          Table 6: Illustrative Examples of Accomplishments Reported to
                  USAID by the Zika AIRS Project (ZAP), as of March 2018              39

Figures
          Figure 1: Timeline of Zika Outbreak and the U.S. Zika Response
                   Overseas, 2015–2018                                                 5
          Figure 2: Zika Incidence Rates in Latin America and the
                   Caribbean, 2015–2017                                                7
          Figure 3: U.S. Agency for International Development (USAID) and
                   Department of State (State) Zika Response
                   Appropriations, Obligations, and Disbursements, as of
                   September 30, 2018                                                 10
          Figure 4: U.S. Agency for International Development (USAID)
                   Obligations and Disbursements by Account for Zika
                   Response Activities, as of September 30, 2018                      11
          Figure 5: Department of State (State) Obligations and
                   Disbursements by Account for Zika Response Activities,
                   as of September 30, 2018                                           13
          Figure 6: A Worker for a U.S. Agency for International
                   Development Implementing Partner Puts Mosquito
                   Larvicide in a Wash Basin in a House in Honduras                   17
          Figure 7: School Children Participate in a Learning Activity Aimed
                   at Promoting Awareness of Zika Risks and Prevention in
                   Trinidad                                                           18
          Figure 8: The World Mosquito Program Breeds Mosquitoes
                   Harboring Bacteria to Test the Feasibility of Hindering
                   Transmission of the Zika Virus                                     19




          Page ii                                 GAO-19-356 Emergency Assistance for Zika
Abbreviations

ASSIST                     Applying Science to Strengthen and Improve
                           Systems
CAZ                        Community Action on Zika
CDC                        Centers for Disease Control and Prevention
State                      Department of State
UNICEF                     United Nations Children’s Fund
USAID                      U.S. Agency for International Development
WHO                        World Health Organization
ZAP                        Zika AIRS Project




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Page iii                                        GAO-19-356 Emergency Assistance for Zika
                       Letter




441 G St. N.W.
Washington, DC 20548




                       May 13, 2019

                       The Honorable Lindsey Graham
                       Chairman
                       The Honorable Patrick Leahy
                       Ranking Member
                       Committee on Appropriations
                       Subcommittee on State, Foreign Operations, and Related Programs
                       United States Senate

                       The Honorable Nita Lowey
                       Chairwoman
                       The Honorable Hal Rogers
                       Ranking Member
                       Committee on Appropriations
                       Subcommittee on State, Foreign Operations, and Related Programs
                       House of Representatives

                       Zika is a virus that is primarily transmitted through mosquito bites and
                       causes symptoms that include fever, rash, conjunctivitis, and joint and
                       muscle pain, though many infected individuals do not have symptoms or
                       only experience mild symptoms. The Zika infection in pregnant women
                       has been linked to adverse pregnancy and birth outcomes: The virus can
                       be passed to the fetus and cause microcephaly and other severe brain
                       defects and may be associated with miscarriage and stillbirth, according
                       to the Centers for Disease Control and Prevention (CDC). 1 The Zika virus
                       is also linked to other problems such as Guillain-Barré syndrome, an
                       uncommon condition of the nervous system. In the Western Hemisphere,
                       the first cases of locally transmitted Zika virus disease were confirmed in
                       Brazil in May 2015. The World Health Organization (WHO) declared the
                       Zika virus a public health emergency of international concern in February
                       2016. While WHO declared an end to the public health emergency in
                       November 2016, it subsequently reported that 48 countries and territories




                       1
                        Microcephaly is a rare birth defect that causes a baby’s head to be smaller than expected
                       and not fully developed, which can lead to impaired thought processes, delayed
                       development of motor skills, and other adverse outcomes.




                       Page 1                                         GAO-19-356 Emergency Assistance for Zika
in the Western Hemisphere reported evidence of ongoing Zika
transmission, as of March 2017. 2

To address the epidemic, according to U.S. Agency for International
Development (USAID) documentation, $215 million of fiscal year 2015
supplemental Economic Support Fund funding initially appropriated to
respond to the Ebola virus was repurposed for the U.S. Zika response
overseas. The Zika Response and Preparedness Appropriations Act,
2016, also provided over $175 million in supplemental funding to USAID
and the Department of State (State) through the end of fiscal year 2017 to
support the U.S. Zika response efforts overseas. 3 The act required
USAID and State to submit a consolidated report to Congress on the
anticipated uses of the funds appropriated in the act on a country and
project basis and to submit updates every 60 days until September 30,
2017. 4 The act also included a provision for us to review the status of
USAID and State actions to respond to Zika. This report examines (1) the
status of USAID and State funding for the U.S. Zika response overseas,
(2) activities supported by these funds, and (3) challenges, if any, to
implementing Zika response activities and actions taken to address any
challenges.

To examine the status of USAID and State funding for the U.S. Zika
response overseas, we reviewed obligations and disbursements that the
agencies reported as supporting international Zika response activities, as
of September 30, 2018. We also reviewed USAID and State’s
consolidated reports to the Senate and House Committees on
Appropriations mandated by the Zika Response and Preparedness
Appropriations Act, 2016, and interviewed agency officials to discuss the
status of the agencies’ obligations and disbursements for Zika response
activities. We determined that the data we used were sufficiently reliable
for the purposes of determining the status of USAID and State funding for
the U.S. Zika response overseas. We assessed USAID’s tracking of


2
 In March 2019, CDC downgraded its international travel warning for Zika, which had
recommended that pregnant women not travel to Zika-affected countries in Latin America.
The March 2019 travel warning recommended that pregnant women consult a health care
provider before traveling to Zika-affected countries in Latin America.
3
 Pub. L. No. 114-223, Div. B, Zika Response and Preparedness Appropriations Act, 2016,
(Sept. 29, 2016).
4
The agencies submitted their initial report on October 28, 2016.




Page 2                                         GAO-19-356 Emergency Assistance for Zika
funding data against federal internal control standards related to using
quality information. 5

To examine activities that USAID and State implemented in response to
Zika overseas, we conducted fieldwork, analyzed agency documents, and
interviewed officials. We examined the status and progress of Zika
response activities. We conducted fieldwork in a nongeneralizable sample
of countries: Barbados, Colombia, Dominican Republic, Guatemala,
Honduras, Peru, and Trinidad and Tobago. We selected these countries
based on criteria including, among others, geographic diversity to include
the Caribbean, Central America, and South America and the presence of
activities under way that accounted for a significant portion of total USAID
and State Zika funding. During our fieldwork, we interviewed agency
officials, host government officials, implementing partners, health care
workers, community volunteers, and researchers to get their perspectives
on the progress of Zika response activities. We analyzed agency
documents describing the plans and goals of activities. We also analyzed
progress reports of a sample of six activities to provide illustrative
examples of results from these activities as reported by implementing
partners. For this sample, we selected activities that had among the
highest amounts of funding and that together represented a range of
countries, lines of effort, and types of implementing partners. Our sample
is not generalizable to all activities.

To examine challenges, if any, to implementing Zika response activities
and actions taken to address any challenges, we interviewed USAID
officials, USAID implementing partners, and host government officials,
and we analyzed progress reports from selected USAID-funded Zika
response activities. We analyzed the information collected in the
interviews and document reviews to identify the themes, or key
challenges and responses to those challenges. We assessed USAID’s
infectious disease response plan against relevant federal internal control
standards. 6 See appendix I for more information on our objectives, scope,
and methodology.

We conducted this performance audit from December 2017 to May 2019
in accordance with generally accepted government auditing standards.

5
 GAO, Standards for Internal Control in the Federal Government, GAO-14-704G
(Washington, D.C.: September 2014).
6
GAO-14-704G.




Page 3                                      GAO-19-356 Emergency Assistance for Zika
                        Those standards require that we plan and perform the audit to obtain
                        sufficient, appropriate evidence to provide a reasonable basis for our
                        findings and conclusions based on our audit objectives. We believe that
                        the evidence obtained provides a reasonable basis for our findings and
                        conclusions based on our audit objectives.



Background
Zika Transmission and   Zika is spread to people primarily through the bite of an infected mosquito
Effects                 but can also be transmitted from mother to child during pregnancy or from
                        person to person through sexual contact or blood transfusion. 7 The
                        disease can cause symptoms that include fever, rash, conjunctivitis (“pink
                        eye” where the eyes appear red or pink), and joint and muscle pain.
                        Although most people with Zika have only mild symptoms or none at all,
                        Zika in pregnant women has been linked to adverse pregnancy
                        outcomes, such as miscarriage and stillbirth, and severe birth defects.
                        Zika can be passed to the fetus and cause a birth defect of the brain
                        called microcephaly and other severe brain defects, according to CDC. 8
                        Zika is also linked to other problems such as Guillain-Barré syndrome, an
                        uncommon condition of the nervous system. 9 Although at present no
                        vaccine has been approved by the U.S. Food and Drug Administration to
                        prevent Zika, several vaccines are in different phases of development.


The Zika Epidemic       Zika was first identified in the Zika Forest in Uganda in 1947 and caused
                        only sporadic human disease until 2007. In 2007, Zika was detected in
                        Yap State, Federated States of Micronesia, and subsequent outbreaks
                        occurred in Southeast Asia and the Western Pacific. In 2014, Zika spread
                        east across the Pacific Ocean to French Polynesia, then to Easter Island.
                        In May 2015, Brazil documented the first case of locally acquired Zika

                        7
                         The Aedes aegypti is reportedly the primary mosquito spreading the Zika virus, while the
                        Aedes albopictus mosquito, which shares many of the same traits as Aedes aegypti, also
                        has the ability to spread the virus.
                        8
                          Babies with microcephaly can have a range of other health problems, depending on the
                        severity of their condition. These health problems can range from mild to severe, may be
                        life-threatening in some cases, and are often lifelong issues.
                        9
                         Guillain-Barré syndrome is a rare disorder in which the body’s immune system attacks
                        the nervous system outside the brain and spinal cord, causing muscle weakness and in
                        some cases paralysis, although most people recover.




                        Page 4                                         GAO-19-356 Emergency Assistance for Zika
                                        transmission in the Americas. See figure 1 for a timeline of the Zika
                                        outbreak and the U.S. Zika response overseas. According to WHO, in
                                        November 2015, Suriname, El Salvador, Guatemala, Mexico, Paraguay,
                                        and Venezuela reported cases of locally acquired Zika, followed by
                                        Panama, Honduras, French Guiana, Martinique, and Puerto Rico in
                                        December 2015. Zika continued to spread throughout the region, and on
                                        February 1, 2016, WHO declared that the recent association of Zika with
                                        clusters of microcephaly and other neurological disorders constituted a
                                        public health emergency of international concern. In November 2016,
                                        WHO declared an end of the public health emergency of international
                                        concern regarding microcephaly, other neurological disorders, and Zika.
                                        However, WHO announced that Zika and the associated health outcomes
                                        remained a significant public health challenge requiring intense action.

Figure 1: Timeline of Zika Outbreak and the U.S. Zika Response Overseas, 2015–2018




                                        Page 5                                       GAO-19-356 Emergency Assistance for Zika
Zika spread to multiple countries throughout the globe but primarily
affected countries in Latin America and the Caribbean region. According
to WHO, as of March 2017, transmission of the Zika virus was occurring
in 79 countries or territories, most of which are located in the Western
Hemisphere. 10 According to WHO, from 2015 to 2017, there were
approximately 583,000 suspected and 223,000 confirmed cases of Zika
virus transmission in the Western Hemisphere. See figure 2 for the
cumulative Zika incidence rates in each country in Latin America and the
Caribbean from 2015 to 2017.




10
   Of the 79 countries or territories, 61 (including 47 in the Western Hemisphere) were
classified by WHO in the most severe category: areas with new introduction or
reintroduction with ongoing transmission of Zika. The other 18 countries or territories
(including one in the Western Hemisphere) were classified by WHO in a less severe
category: areas with either evidence of virus circulation before 2015 or ongoing
transmission that was no longer in the new or reintroduction phase, but where there was
no evidence of interruption.




Page 6                                         GAO-19-356 Emergency Assistance for Zika
Figure 2: Zika Incidence Rates in Latin America and the Caribbean, 2015–2017




                                         Page 7                                GAO-19-356 Emergency Assistance for Zika
                        Notes: The incidence rate is the number of reported suspected and confirmed locally acquired Zika
                        cases in a country or territory per 100,000 population from 2015 through 2017. The cases were those
                        reported to the World Health Organization through the countries’ ministry of health websites as of
                        January 4, 2018.




U.S. Response to Zika   In February 2016, the President submitted a request to Congress for
Overseas                emergency funding to enhance ongoing U.S. efforts to prepare for and
                        respond to Zika, including a request for funding for USAID and State to
                        respond to the outbreak overseas. In addition, in April 2016, USAID and
                        State notified Congress of their intent to repurpose $215 million of fiscal
                        year 2015 supplemental Economic Support Fund Ebola funding for the
                        U.S. Zika response overseas, which included $78 million for CDC
                        international Zika activities. 11 In September 2016, Congress appropriated
                        about $175.1 million in supplemental funding to USAID and State in the
                        Zika Response and Preparedness Appropriations Act, 2016, for the U.S.
                        Zika response overseas. USAID activities initially began in five
                        countries—Haiti, Honduras, Guatemala, El Salvador, and Dominican
                        Republic—based on an assessment of their Zika risk and limited host
                        government capacity to prevent the spread and respond to the impact of
                        the virus. USAID ultimately supported activities in 26 countries in the Latin
                        America and Caribbean region.




                        11
                          According to State documentation, the funds, which were provided by the Department of
                        State, Foreign Operations, and Related Programs Appropriations Act, 2015, Pub. L. No.
                        113-235, Div. J, (Dec. 16, 2014), were repurposed pursuant to section 7058(c) of the act.




                        Page 8                                              GAO-19-356 Emergency Assistance for Zika
USAID and State
Obligated Almost All
Funding Available for
the Zika Response
but Did Not Report
Funding by Country
USAID and State             As of September 30, 2018, USAID and State had obligated about $385
Obligated Almost All        million (99 percent) of the total $390 million available for the U.S. Zika
                            response overseas and had disbursed approximately $264 million (68
Funding Available for the
                            percent). Specifically, USAID had obligated all of its funds available for
Zika Response and           the Zika response and disbursed about two-thirds, and State had
Disbursed Approximately     obligated and disbursed more than three-quarters of its funding for Zika.
Two-Thirds                  USAID and State had disbursed a higher proportion of the repurposed
                            Ebola funds than the funds appropriated in the Zika Response and
                            Preparedness Appropriations Act, 2016. 12 See figure 3 for USAID and
                            State Zika response funding appropriations, obligations, and
                            disbursements as of September 30, 2018. Of the $215 million in
                            repurposed Ebola funds, USAID and State had obligated $215 million
                            (100 percent) and had disbursed almost $201 million (93 percent) as of
                            September 30, 2018. Of the approximately $175 million appropriated in
                            the Zika Response and Preparedness Appropriations Act, 2016, USAID
                            and State had obligated about $170 million (about 97 percent) and had
                            disbursed about $63 million (36 percent) as of September 30, 2018.




                            12
                              USAID and State have two sources of funding for Zika response activities: $215 million
                            in fiscal year 2015 supplemental Economic Support Fund Ebola funding that was
                            repurposed to the Zika response and about $175 million through a supplemental
                            appropriation provided under the Zika Response and Preparedness Appropriations Act,
                            2016, for a total of $390 million.




                            Page 9                                         GAO-19-356 Emergency Assistance for Zika
                          Figure 3: U.S. Agency for International Development (USAID) and Department of
                          State (State) Zika Response Appropriations, Obligations, and Disbursements, as of
                          September 30, 2018




                          Notes: USAID and State have two sources of funding for Zika response activities: $215 million in
                          fiscal year 2015 supplemental Economic Support Fund Ebola funding that was repurposed for the
                          Zika response and about $175 million through a supplemental appropriation provided under the Zika
                          Response and Preparedness Appropriations Act, 2016, for a total of $390 million.




USAID and State Track     As of September 30, 2018, USAID had obligated all funds available for
Zika Funding by Account   the Zika response and had disbursed about two-thirds, from three
                          accounts. USAID has two sources of funding for Zika response activities:
and Activity
                          $211 million of fiscal year 2015 supplemental Economic Support Fund
                          Ebola funding repurposed for the Zika response and about $155.5 million
                          provided in the Zika Response and Preparedness Appropriations Act,
                          2016—including $145.5 million and $10.0 million through the Global
                          Health Programs and Operating Expenses accounts, respectively—for a
                          total of $366.5 million. As of September 30, 2018, USAID had obligated
                          approximately $366.5 million (100 percent) and had disbursed
                          approximately $245 million (67 percent), from the Economic Support
                          Fund, Global Health Programs, and Operating Expenses appropriations
                          accounts. See figure 4 for USAID Zika response funding obligations and



                          Page 10                                             GAO-19-356 Emergency Assistance for Zika
disbursements by account. USAID obligated all funding for Zika response
activities within a year after it was repurposed or appropriated. 13 As of
September 30, 2018, USAID had disbursed a higher proportion of
repurposed fiscal year 2015 supplemental Economic Support Fund Ebola
funding (93 percent) compared with Global Health Programs and
Operating Expenses funding (28 percent and 72 percent, respectively),
which was appropriated in the Zika Response and Preparedness
Appropriations Act, 2016, in September 2016.

Figure 4: U.S. Agency for International Development (USAID) Obligations and
Disbursements by Account for Zika Response Activities, as of September 30, 2018




Note: USAID has two sources of funding for Zika response activities: $211 million of fiscal year 2015
supplemental Economic Support Fund Ebola funding that was repurposed for the Zika response and
about $155.5 million provided in the Zika Response and Preparedness Appropriations Act, 2016,
through the Global Health Programs and Operating Expenses accounts, for a total of $366.5 million.




13
  By November 2016, USAID had obligated all $211 million of the repurposed fiscal year
2015 Ebola funds. By September 2017, USAID had obligated all $155.5 million of the
USAID Zika funds appropriated in September 2016.




Page 11                                               GAO-19-356 Emergency Assistance for Zika
The $211 million in Economic Support Fund obligations supported 56
USAID activities, as well as a $78 million interagency transfer to CDC.
The $145.5 million in Global Health Programs obligations supported 25
activities and program support. 14 Obligations for USAID-supported
activities ranged from $12,000 to $37 million and included support for
activities such as the procurement of insect repellent to assist pregnant
women in avoiding Zika infection and strengthening the ability of civil
society and community networks to disseminate information related to
Zika. CDC supported 25 activities that ranged from $276,000 to $13.6
million, including activities such as collecting and analyzing public health
data, conducting epidemiological studies to better understand the
prevalence of Zika and related risk factors, building laboratory capacity,
and providing training to conduct Zika virus testing.

As of September 30, 2018, State had obligated and disbursed more than
three-quarters of funding available for the Zika response, from two
accounts. State has two sources of funding for Zika response activities:
$4 million from a fiscal year 2015 supplemental Economic Support Fund
appropriation for the Ebola response that was repurposed for the Zika
response and about $19.6 million provided in the Zika Response and
Preparedness Appropriations Act, 2016, the majority of which was
provided through the Diplomatic and Consular Programs account, for a
total of about $23.6 million. 15 As of September 30, 2018, State had
obligated and disbursed about $18.3 million (almost 78 percent) from the
Economic Support Fund and Diplomatic and Consular Programs
accounts. See figure 5 for State Zika response funding obligations and
disbursements by account.


14
  As of September 30, 2018, USAID had also obligated almost $10 million from the
Operating Expenses account to support activities. For example, Operating Expenses
funds covered some expenses related to the procurement of mosquito repellents and
condoms for Zika prevention. The funds were also used to help build and strengthen
USAID staff capacity to effectively plan, implement, and monitor malaria and vector-borne
disease control in countries where USAID operates.
15
  Under the Zika Response and Preparedness Appropriations Act, 2016, State was
provided almost $14.6 million through the Diplomatic and Consular Programs account, $4
million through the Emergencies in Diplomatic and Consular Services account, and $1
million through the Repatriation Loans Program account, for a total of almost $19.6 million.
In September 2017, State notified Congress of its intent to transfer the $4 million from the
Emergencies in Diplomatic and Consular Services account and $870,000 from the
Repatriation Loans Program account to the Diplomatic and Consular Programs account,
to support an additional $4,870,000 in Zika-related public diplomacy initiatives to be
conducted by the Bureau of Oceans and International Environmental and Scientific Affairs.




Page 12                                         GAO-19-356 Emergency Assistance for Zika
Figure 5: Department of State (State) Obligations and Disbursements by Account
for Zika Response Activities, as of September 30, 2018




Notes: State has two sources of funding for Zika response activities: $4 million of fiscal year 2015
supplemental Economic Support Fund Ebola funding that was repurposed for the Zika response, and
about $19.5 million under the Diplomatic and Consular Programs account and $130,000 under the
Repatriation Loans Program account provided in the Zika Response and Preparedness
Appropriations Act, 2016, for a total of $23.6 million. State has not made any obligations or
disbursements under the Repatriation Loans Program account, and therefore this account does not
appear in the figure above.



Under the Zika Response and Preparedness Appropriations Act, 2016,
State was provided almost $14.6 million through the Diplomatic and
Consular Programs account, $4 million through the Emergencies in
Diplomatic and Consular Services account, and $1 million through the
Repatriation Loans Program account, for a total of almost $19.6 million. In
September 2017, State notified Congress of its intent to transfer the $4
million from the Emergencies in Diplomatic and Consular Services
account and $870,000 from the Repatriation Loans Program account to
the Diplomatic and Consular Programs account. These transfers resulted
in a total of $19.5 million available under the Diplomatic and Consular
Programs account and $130,000 under the Repatriation Loans Program
account.




Page 13                                              GAO-19-356 Emergency Assistance for Zika
                            The $4 million in Economic Support Fund obligations supported research
                            and development activities by the International Atomic Energy Agency to
                            control disease-carrying mosquito populations. The $14.3 million in
                            Diplomatic and Consular Programs obligations supported activities
                            including medical evacuations to protect the health of pregnant U.S.
                            government personnel and eligible family members, mosquito abatement
                            training and other measures to reduce Zika risk to overseas staff, as well
                            as public diplomacy efforts to further inform journalists and the public
                            about the U.S. response to Zika.


Agencies Did Not Track or   In their reporting to Congress on the uses of Zika funds, USAID and State
Report Zika Funding by      included some country information but did not track or provide information
                            on funding uses broken down on a country basis. In October 2016,
Country
                            USAID and State submitted a consolidated report to the appropriations
                            committees on the anticipated uses of funds made available to USAID
                            and State by the Zika Response and Preparedness Appropriations Act,
                            2016, in response to a reporting requirement in Section 203 of the act. 16
                            After the initial submission, the act required the agencies to update and
                            submit the report to the committees on appropriations every 60 days until
                            September 30, 2017. The initial report described ongoing Zika response
                            activities in five countries as well as planned activities in additional
                            countries. Subsequent reports listed specific countries where USAID and
                            State supported Zika response activities. However, USAID and State did
                            not provide information to Congress on the uses of funding appropriated
                            by the Zika Response and Preparedness Appropriations Act, 2016,
                            broken down by country. The reports also included obligation and
                            disbursement information for the fiscal year 2015 supplemental Economic
                            Support Fund Ebola funding that was repurposed for the international
                            Zika response; however, similar to the information provided regarding the
                            funds appropriated by the Zika Response and Preparedness




                            16
                              Pub. L. No. 114-223, Div. B, Zika Response and Preparedness Appropriations Act,
                            2016, § 203, (Sept. 29, 2016).




                            Page 14                                      GAO-19-356 Emergency Assistance for Zika
Appropriations Act, 2016, the reports’ information on the use of the
repurposed Ebola funds was also not broken down by country. 17

USAID officials told us that Zika activities were designed to be
implemented on a regional and multicountry basis. While over 95 percent
of all U.S. government funds available for the Zika response overseas
were obligated by USAID, and the agency had a number of financial
tracking systems in place, the agency did not take steps to record its
funding by country at the outset of Zika response programming.
Specifically, USAID officials noted that the contracts and grants the
agency had signed with its implementing partners did not include
provisions requiring partners to provide information to USAID that broke
down their use of funds by country. Consequently, USAID was unable to
track the uses of Zika funds on a country basis.

Federal internal control standards state that management should use and
communicate the necessary quality information both internally and
externally to achieve the entity’s objectives and address related risks. 18
According to USAID officials, tracking information on the uses of Zika
response funding broken down by country would be helpful in the future
for mission directors, chiefs of missions, and partner-country ministries of
health, some of whom have requested this information. Moreover, data on
USAID funding to address future infectious disease outbreaks if broken
down by uses in each country could provide additional useful information
to decision makers in assessing risks and planning responses. The ability
to compile funding by country when responding to future infectious
disease outbreaks would enable USAID to provide key decision makers,
including Congress and agency officials, with additional information to


17
  While USAID and State provided information about the repurposed Ebola funds in the
Zika reports, the reports indicated that the inclusion of that information was not required by
the Zika Response and Preparedness Appropriations Act, 2016, which specifically
required reporting on the use of funds made available by that act. The Zika reports noted
that information about the repurposed Ebola funds could also be found in the agencies’
Ebola reports; however, the information in the Ebola reports regarding the funds
repurposed for the Zika response also did not include a breakdown of the use of those
funds by country. The Ebola reports were created in response to a reporting requirement
in the Department of State, Foreign Operations, and Related Programs Appropriations
Act, 2015, which appropriated funds to USAID and State for necessary expenses to assist
countries affected by, or at risk of being affected by, the Ebola outbreak, among other
things. See Pub. L. No. 113-235, Div. J, Title IX, § 9004 (Dec. 16, 2014).
18
  GAO-14-704G.




Page 15                                          GAO-19-356 Emergency Assistance for Zika
                           better support spending oversight and inform budgetary and planning
                           decisions.



USAID and State
Supported a Broad
Range of Activities in
Response to Zika
USAID Supported            As part of the U.S. Zika response overseas, USAID provided assistance
Mosquito Control, Public   to several countries in the Caribbean, Central America, and South
                           America and conducted a variety of activities related to mosquito control,
Awareness, Capacity
                           public awareness, capacity building, and research.
Building, and Research
Activities
Mosquito Control           In support of mosquito control, USAID’s Zika AIRS Project (ZAP)
                           conducted activities that included

                           •   Entomological monitoring: collecting and reporting information on
                               the location and population of mosquitoes;
                           •   Larviciding: placing agents that kill mosquito eggs in likely breeding
                               sites, such as water receptacles;
                           •   Source reduction interventions: facilitating the removal or mitigation
                               of likely breeding sites, such as tires, pots, barrels, or anything that
                               may allow for standing water; and
                           •   Indoor residual spraying: spraying insecticide that has a lasting
                               effect in houses.
                           We observed mosquito control activities during our fieldwork. For
                           example, in Honduras we followed a team as they went house to house to
                           implement and facilitate mosquito control activities. They collected
                           information from mosquito egg traps, which serve as indicator of breeding
                           activity, and recorded it for monitoring purposes. They also examined the
                           premises for potential mosquito breeding sites, treated susceptible areas
                           such as wash basins with larvicide, and spoke with residents about
                           picking up trash and covering outdoor plant pots to reduce potential
                           breeding sites.




                           Page 16                                 GAO-19-356 Emergency Assistance for Zika
                   Figure 6: A Worker for a U.S. Agency for International Development Implementing
                   Partner Puts Mosquito Larvicide in a Wash Basin in a House in Honduras




Public Awareness   To support raising public awareness of the risk of Zika virus and to
                   promote behavior change to reduce the spread of the disease, USAID
                   implementing partners such as the Red Cross and CARE told us that they
                   collaborated with communities, local government, and schools to
                   communicate information about Zika. For example, in Trinidad, the Red
                   Cross conducted educational campaigns at schools to improve students’
                   awareness. During our fieldwork, we observed a session led by adult
                   volunteers during which children played games and engaged in
                   discussions designed to teach Zika prevention and response methods.
                   Implementing partners told us that the impact of such efforts extends
                   beyond those reached directly; for example, they said the children who
                   learned about Zika risks and prevention also conveyed the knowledge to
                   their families, who in turn may pass it on to friends or others in the
                   community.




                   Page 17                                    GAO-19-356 Emergency Assistance for Zika
                    Figure 7: School Children Participate in a Learning Activity Aimed at Promoting
                    Awareness of Zika Risks and Prevention in Trinidad




                    In Peru, CARE worked with schools to develop written education guides
                    for application in the classroom and conducted communication
                    campaigns. During our fieldwork, we went to schools and observed
                    students delivering oral presentations on Zika risks and prevention. In
                    addition, we witnessed other student activities, such as classroom
                    discussions and art projects focused on Zika, designed to demonstrate
                    understanding, raise awareness, and promote behavior change.

Capacity Building   To support capacity building, the Applying Science to Strengthen and
                    Improve Systems (ASSIST) activity, which USAID funding supported,
                    focused on improving Zika-related health services. Specific efforts
                    included conducting a baseline assessment of the quality of care,
                    improving clinical guidelines, training health care providers, and
                    implementing a quality improvement program. During our fieldwork in
                    Honduras, we visited a hospital and met with ASSIST-supported health
                    workers who told us that they applied new guidance in their practice, and
                    as a result, improved care in areas including counseling, screening,



                    Page 18                                     GAO-19-356 Emergency Assistance for Zika
           diagnosis, and follow-up of those affected by Zika. We also visited a
           hospital in Dominican Republic, where health care workers stated that
           they collaborated with ASSIST in responding to Zika by training staff and
           producing guidance materials. These activities raised awareness,
           increased prevention efforts, and improved care, according to health care
           workers.

Research   USAID supported research, training, and innovation activities through its
           “Grand Challenge” program as well as its interagency agreement with
           CDC. USAID launched a series of Grand Challenge efforts, providing $30
           million in grants to foster innovation on new methods and technologies to
           respond to Zika. One grant, for example, supported the World Mosquito
           Program’s research into the feasibility and effectiveness of infecting
           mosquitoes with bacteria to hinder transmission of the Zika virus. We
           visited the program’s operations in Colombia, met with scientists, and
           observed the breeding lab.

           Figure 8: The World Mosquito Program Breeds Mosquitoes Harboring Bacteria to
           Test the Feasibility of Hindering Transmission of the Zika Virus




           Page 19                                  GAO-19-356 Emergency Assistance for Zika
                           Program scientists told us that initial efforts have been promising and that
                           if more tests prove successful, the potential for reducing Zika
                           transmission could be significant. Another USAID Grand Challenge grant
                           supports research into the possible use of genetically modified yeast to
                           prevent mosquito eggs from hatching. We spoke with scientists, lab
                           technicians, and viewed facilities supported by this grant in Trinidad
                           during our field work. Scientists stated that yeast attracts mosquitoes and
                           is inexpensive, commonly available, and environmentally friendly. Testing
                           is ongoing, but if successful, the approach could help reduce populations
                           of mosquitoes in critical areas, according to the scientists.

                           The USAID–CDC interagency agreement identifies a range of activities
                           that involve technical assistance to help strengthen surveillance,
                           emergency operations and management, and epidemiological
                           investigations and research. One CDC activity, for example, focuses on
                           supporting public health surveillance and epidemiological studies to better
                           understand the prevalence and risk factors for severe health outcomes
                           related to Zika. Another activity aims to build laboratory capacity in areas
                           such as Zika diagnostic test production and distribution. In addition, the
                           objectives of CDC’s Field Epidemiology Training Program are to train
                           qualified professionals, build sustainable capacity for detecting and
                           responding to health threats, and develop in-country expertise so that
                           disease outbreaks can be detected locally and prevented from spreading.
                           In Dominican Republic, CDC officials told us that this program delivers 3
                           months of classroom and field project training, and that as of August
                           2018, four cohorts of approximately 80 students each had completed the
                           training. CDC officials told us that in addition to implementing various
                           activities, CDC’s Central America Regional Office in Guatemala played an
                           important role in facilitating U.S. government cooperation with Colombia,
                           which had the second largest outbreak of Zika after Brazil.


Implementing Partners      We reviewed status reports for six USAID activities that received among
Reported Various Results   the highest amounts of funding, and each identified various results.
                           Below, we describe the activities and examples of reported results. For
from Selected Activities
                           more information, see appendix II.

                           •   ASSIST: This activity sought to strengthen Zika-related health
                               services and systems in Latin America and the Caribbean with a focus
                               on pregnant women, newborns, and women of reproductive age.
                               ASSIST reported that it conducted virtual and in-person training,
                               courses, and workshops on Zika prevention, diagnosis, and care.
                               ASSIST also reported that 8,133 health care workers had been


                           Page 20                                 GAO-19-356 Emergency Assistance for Zika
    trained as of March 2017, and that its efforts had supported the
    development of Zika care protocols and guidelines with a new
    emphasis on clinical care and support for affected infants and
    families. ASSIST further reported that through March 2018, 75
    percent of children affected by Zika in Dominican Republic received
    specialized care at Hospital Infantil Robert Reid Cabral, an ASSIST-
    supported hospital in the capital, Santo Domingo.
•   Red Cross: This activity aimed to reduce risks associated with Zika
    infection through community involvement, sharing lessons learned,
    and improving practices. The Red Cross reported that its
    communication efforts reached approximately 3,000 students, 29
    communities, and almost 140,000 people via TV, radio, and social
    media engagement, providing them with information on risk and
    protection methods.
•   Zika AIRS Project (ZAP): This is a mosquito control activity focused
    on reducing Zika transmission in Latin America and the Caribbean.
    Specific activities supported by USAID funding included entomological
    monitoring, larviciding, source reduction interventions, and indoor
    residual spraying. ZAP reported that five countries (El Salvador,
    Guatemala, Haiti, Honduras, and Jamaica) implemented
    comprehensive mosquito control activities.
•   Population Services International: The purpose of this activity was
    to improve the capacity and raise awareness of people in countries
    affected by and at risk of Zika and other vector-borne diseases.
    Population Services International reported that through March 2018,
    35 health providers in Dominican Republic, El Salvador, and
    Guatemala had been trained in raising awareness about Zika
    prevention and the use of printed educational materials. In addition,
    1,006 pregnant women received counseling on Zika prevention, and
    967 received prevention kits containing condoms, mosquito repellent,
    and printed educational materials. Additionally, 227 pharmacy
    attendants from 195 pharmacies received information on Zika
    prevention.
•   Save the Children’s Community Action on Zika (CAZ): The goal of
    this project was to reduce Zika transmission and minimize the risk of
    Zika-related microcephaly and other neurological disorders. The
    project focused on helping the most vulnerable through community-
    based prevention strategies in Colombia, Dominican Republic, and
    three Central American countries. CAZ reported that it had reached
    approximately 65,000 students and trained 3,838 community agents
    and volunteers who supported efforts to strengthen the capacity to
    prevent Zika in 921 communities.



Page 21                                GAO-19-356 Emergency Assistance for Zika
                            •   United Nations Children’s Fund (UNICEF): This activity focused
                                primarily on four countries: Guatemala, El Salvador, Honduras, and
                                Dominican Republic. UNICEF worked to promote the adoption of
                                prevention behaviors among at-risk populations through actions to
                                raise awareness at multiple levels: individual, interpersonal,
                                community, institutional, and national policy levels. UNICEF reported
                                that these efforts reached more than 5.5 million people with key risk-
                                communication messages and more than 150,000 people through
                                coordinated social mobilization and person-to-person communication.
                                For example, in Guatemala, UNICEF worked with a local partner to
                                train young people and adolescents in schools and social groups to
                                lead prevention activities in their communities. Moreover, around
                                25,000 pregnant women benefited from counseling sessions on Zika-
                                prevention behaviors.


State Conducted Public      In response to Zika, State conducted public awareness and
Awareness Initiatives and   communication initiatives, medical evacuations for overseas staff, and
                            other activities. According to a State official, State conducted Zika-related
Medical Evacuations
                            public outreach to U.S. citizens abroad through social media and the
                            Smart Traveler Enrollment Program, a service that provides information
                            from U.S. embassies about local safety conditions. According to a State
                            official, State also implemented public diplomacy activities related to Zika
                            awareness and communication. For example, one activity aimed to raise
                            awareness of vector-borne diseases such as Zika and collect information
                            on insect breeding grounds. Another supported the addition of a science
                            envoy who focused specifically on Zika and mosquito-borne diseases. In
                            addition, according to a State official, State conducted Zika-related
                            medical evacuations as part of those normally offered to female staff who
                            became pregnant while serving abroad. State’s medical services division
                            also supported overseas posts by purchasing and distributing mosquito
                            repellent. State officials also told us that they coordinated Zika response
                            efforts internally and externally. For example, State participated in a U.S.
                            government interagency group led by CDC to exchange information on
                            Zika and coordinated with other agencies on the response effort.




                            Page 22                                  GAO-19-356 Emergency Assistance for Zika
                           Over the course of our fieldwork, USAID and implementing partner
USAID Took Steps to        officials identified two key challenges to the implementation of Zika
Address                    response activities. The first was the long-term sustainability of Zika
                           response activities. The second was the timely implementation of Zika
Sustainability             response activities in countries without bilateral USAID health programs.
Challenge but Only         While USAID took steps to address the challenge related to sustainability,
                           it only partially mitigated the challenge to timely implementation of Zika
Partially Mitigated        response activities in countries without bilateral USAID health programs.
Challenge to Timely
Implementation
USAID Implementing         Agency and implementing partner officials identified the sustainability of
Partners Aligned Their     Zika response efforts as a key challenge. While USAID did not intend to
                           continue U.S. Zika response activities after the one-time emergency
Activities with Host
                           funding, sustainability was a consideration and posed a challenge due to
Governments and            the short implementation time frame, according to agency and
Involved Local             implementing partner officials. One official further elaborated that Zika
Communities to Address     funding efforts occurred during the acute phase of the outbreak, which
Sustainability Challenge   made it difficult to focus on long-term needs. For example, an
                           implementing partner said that Zika-affected children require long-term
                           care that host country governments may not be able to support after U.S.
                           assistance ends. In addition, host country government officials, U.S.
                           government officials, and implementing partners said that some Zika
                           activities may not be sustainable after U.S. assistance is finished due to a
                           lack of funds and limited capacity to continue the work.

                           To address this challenge and support the long-term continuation of Zika
                           response activities, implementing partners aligned their activities with
                           those of host country governments and other organizations. Implementing
                           partners reported working with governments and other organizations to
                           incorporate Zika activities into their plans and practices so they could
                           continue over the long term. One implementing partner and the
                           Dominican Republic’s Ministry of Health, for example, planned mosquito
                           control efforts together, and a Ministry of Health official said they intend to
                           continue those control efforts after the end of Zika funding. Implementing
                           partners in various countries also stated that Zika activities brought
                           broader benefits to mosquito control, disability services, maternal health
                           care, surveillance efforts, and emergency preparedness, which facilitated
                           partners’ efforts to align their Zika response activities. For example, an
                           implementing partner reported using Zika funding to develop
                           organizational guidelines for treating Zika-affected children, which will be



                           Page 23                                   GAO-19-356 Emergency Assistance for Zika
used by the health care system in Dominican Republic to treat children
with related disabilities in the long term. According to some implementing
partners in countries we visited, they developed Zika protocols and
guidelines in response to new scientific information, trained government
and other personnel on the protocols, and worked with officials of host
country governments and other organizations to encourage adoption of
Zika activities. For example, according to an agency official, an
implementing partner in Peru developed a curriculum for epidemiologists
and trained them on how to detect and contain mosquito-borne diseases,
such as Zika. The agency official said that the implementing partner
shared the training curriculum and materials with Peru’s Ministry of Health
so it could continue the trainings after the end of Zika funding.

According to implementing partners, they also involved local communities
in activities to increase community ownership and address sustainability.
For example, an implementing partner official said they trained a cadre of
community volunteers in Guatemala and El Salvador on behavior change
practices so that they can continue activities after the end of Zika funding.
In addition, implementing partner officials said that engaging with
communities to learn about needs and resources is important to
continued community interest in activities. For example, an implementing
partner that works with communities on health priorities developed an
approach that includes a toolkit for identifying a community’s specific risks
for Zika and the efforts best suited to helping the community eradicate
mosquito breeding sites. In places affected by violence, some
implementing partners engaged with communities to better understand
how to prioritize community worker and volunteer safety to enable the
continuation of activities. For example, an implementing partner in
Guatemala engaged with local communities to understand areas they
recommended health workers avoid due to safety concerns.




Page 24                                 GAO-19-356 Emergency Assistance for Zika
USAID Only Partially         Agency and implementing partner officials described timely
Mitigated the Challenge to   implementation of activities in some countries without bilateral USAID
                             health programs as a second key challenge. 19 Twenty-two out of the 26
Timely Implementation in
                             countries where USAID implemented its Zika response activities were
Some Countries Where It      countries without bilateral USAID health programs. USAID officials stated
Did Not Have Health          that, as a result, there were no USAID health program officials present in
Programs                     these countries to build on relationships with host country health officials
                             and help facilitate the start of implementing partners’ activities during the
                             Zika response. USAID officials noted two reasons that working with host
                             country governments took time. First, some U.S. Zika response activities
                             started after a decline in Zika cases, when some host country
                             governments were no longer as focused on countering the disease.
                             Implementing partners responded to this situation by identifying related
                             health service improvements that could stem from implementing a Zika
                             response and were of interest to the host country governments. Second,
                             agency and implementing partner officials said that in some countries
                             without bilateral USAID health programs it also took time to identify the
                             appropriate points of contact and establish relationships—preliminary
                             steps needed to obtain approval from the host country government before
                             activities could get underway. According to USAID officials, these
                             relationships are critical to navigating bureaucratic systems and assist in
                             designing activities that meet the needs of host country governments and
                             communities, which are needed for timely implementation.

                             USAID took some steps to address the timely implementation challenge
                             in countries without bilateral health programs. For example, according to
                             USAID officials, USAID worked with multilateral partners that had a health
                             presence in those countries and relied on regional field-based Zika
                             coordinators to build relationships with in-country points of contact. As
                             noted above, however, agency officials indicated that Zika response
                             activities took additional time to deploy in some of the countries without
                             bilateral USAID health programs. Further, implementing partners reported
                             it took additional time to start up activities in those countries because of
                             the time it took to obtain approval for them from the ministries of health.
                             For example, one implementing partner reported that activity startup was
                             postponed for nearly 3 months until it received approval from the host

                             19
                               Over the last several years, USAID has transitioned out of providing assistance in the
                             health sector when it determines that a country can sustain health progress without
                             depending on foreign aid. For the purposes of this report, we refer to this transition as
                             “countries without bilateral health programs.”




                             Page 25                                          GAO-19-356 Emergency Assistance for Zika
country government. Another implementing partner said it was a
challenge to get information on Zika from the host country government or
establish dialogue until USAID officials became involved. USAID officials
also said that efforts to start and integrate Zika response activities in
countries with ongoing USAID health programs did not face a number of
the obstacles to timely implementation experienced in countries without
bilateral USAID health programs.

According to federal internal control standards, agencies should design
control activities, such as a plan, to achieve their objectives and address
related risks, such as the challenge related to timely implementation. 20 In
an effort to enhance its planning for outbreaks, USAID developed an
infectious disease response plan in July 2018 during the time frame of our
review. However, the plan does not provide specific guidance on how to
address the challenge of initiating emergency response activities in
countries without bilateral USAID health programs, such as by noting
particular practices that implementing partners and other officials can use
to address that challenge. For example, our fieldwork and interviews with
USAID officials indicate that the following may be helpful practices for
infectious disease response:

•     Immediately establish an in-country working group that includes
      implementing partners, host country government officials, and U.S.
      government officials to help initiate and coordinate outbreak response.
•     Communicate a current list of health ministry and other relevant
      government officials to implementing partners and other officials so
      they can quickly identify the appropriate points of contact.

According to USAID officials, USAID missions maintain regular contact
with host country governments, maintain contact lists, and participate in
coordination meetings. However, in the case of overseas Zika response,
some implementing partner officials in the field told us that they did not
initially know who to contact in the host country government. Likewise, a
host country government official told us that a working group on Zika
outbreak response was not established until after officials recognized that
implementing partner and host country government officials did not have
regular channels of communication. By taking steps to improve planning
for countries without bilateral USAID health programs—such as by adding
specific guidance for initiating emergency response activities in such

20
    GAO-14-704G.




Page 26                                   GAO-19-356 Emergency Assistance for Zika
                      countries to its July 2018 plan—USAID would be better positioned to
                      quickly build relationships with health ministry and other key government
                      officials in host countries and thus be better able to provide a timely
                      infectious disease response to future outbreaks.


                      The Zika virus quickly spread to dozens of countries in 2015 and 2016,
Conclusions           prompting WHO to declare the virus and associated health risks an
                      international public health emergency. As future infectious disease
                      outbreaks arise, Congress will be called on to fund overseas response
                      efforts, as it did with the Zika outbreak, and USAID is likely once again to
                      play a vital role in those efforts. Because USAID did not provide key
                      decision makers with information on how Zika funding was distributed
                      across the various countries where it conducted response activities,
                      decision makers lack visibility into a key aspect of the overall U.S. Zika
                      response overseas. The ability to compile this information by country
                      when responding to future infectious disease outbreaks would enable
                      USAID to provide key decision makers, including Congress and agency
                      officials, with additional information to better support spending oversight
                      and inform budgetary and planning decisions.

                      Further, while USAID took steps to address the challenge of sustaining
                      Zika response activities over the long term, it did not fully mitigate the
                      challenge of timely implementation of activities in countries without
                      bilateral USAID health programs. As a result, the agency’s response to
                      Zika took additional time in some countries without bilateral USAID health
                      programs. Infectious disease response planning that addresses countries
                      without bilateral USAID health programs would better position USAID to
                      quickly respond to infectious disease outbreaks, such as Zika, whenever
                      the need arises.


                      We are making the following two recommendations to USAID:
Recommendations for
Executive Action      •   The Administrator of USAID should take steps to ensure that, in
                          responding to future public health emergencies of international
                          concern, the agency is able to compile funding information broken
                          down by country. (Recommendation 1)
                      •   The Administrator of USAID should take steps to improve its
                          infectious disease response planning to address the challenge of
                          initiating response activities in countries without bilateral USAID
                          health programs in a timely manner. (Recommendation 2)



                      Page 27                                  GAO-19-356 Emergency Assistance for Zika
                     We provided a draft of this report to USAID, State, and CDC for review
Agency Comments      and comment. USAID provided written comments, which we have
and Our Evaluation   reproduced in appendix III. In its comments, USAID agreed with our
                     findings and recommendations and identified a number of actions it plans
                     to take in response. Specifically, USAID stated that in responding to
                     future public health emergencies of international concern, it plans to
                     compile and report on funding by country. USAID also outlined the steps
                     it plans to take to develop additional guidance for USAID officials in
                     countries without bilateral health programs. State and CDC did not
                     provide formal responses. CDC provided technical comments, which we
                     incorporated throughout the report, as appropriate.


                     We are sending copies of this report to the appropriate congressional
                     committees, the Administrator of USAID, the Secretaries of State and of
                     Health and Human Services, and to other interested parties. In addition,
                     the report is available at no charge on the GAO website at
                     http://www.gao.gov

                     If you or your staff have any questions about this report, please contact
                     me at (202) 512-3149 or gootnickd@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 key contributions to this
                     report are listed in appendix IV.




                     David B. Gootnick, Director
                     International Affairs and Trade




                     Page 28                                GAO-19-356 Emergency Assistance for Zika
Appendix I: Objectives, Scope, and
              Appendix I: Objectives, Scope, and
              Methodology



Methodology

              The Zika Response and Preparedness Appropriations Act, 2016, included
              a provision for us to review the status of U.S. Agency for International
              Development (USAID) and Department of State (State) actions to
              respond to Zika. 1 In this report, we examine (1) the status of USAID and
              State funding for the U.S. Zika response overseas, (2) activities
              supported by these funds, and (3) challenges, if any, to implementing
              Zika response activities and actions taken to address any challenges.

              To examine the status of funding for U.S. Zika response overseas, we
              reviewed USAID and State’s reports to the Senate and House
              Committees on Appropriations mandated by Section 203 of the Zika
              Response and Preparedness Appropriations Act, 2016. 2 We reviewed
              agency reporting submitted to Congress and discussed the reports with
              agency officials. We also reviewed USAID and State’s reports to the
              Senate and House Committees on Appropriations mandated by the
              Department of State, Foreign Operations, and Related Programs
              Appropriations Act, 2015. 3 We obtained additional funding and activity
              information from USAID covering a period beyond that included in the
              reports to Congress. 4 We reviewed the interagency agreement between
              USAID and the Centers for Disease Control and Prevention (CDC),
              outlining the CDC’s Zika response activities supported by $78 million in
              funds USAID obligated to CDC. We also obtained additional funding data
              from CDC and interviewed CDC officials to discuss the status of the
              agencies’ obligations and disbursements for Zika response activities. We
              analyzed USAID’s and State’s obligations and disbursements that the
              agencies reported as supporting the U.S. Zika response overseas, as of
              September 30, 2018. We analyzed agency obligations and disbursements
              1
               Pub. L. No. 114-223, Div. B, Zika Response and Preparedness Appropriations Act, 2016,
              §204, (Sept. 29, 2016).
              2
               On October 28, 2016, USAID and State submitted a consolidated report to the
              appropriations committees on the anticipated uses of funds appropriated in the Zika
              Response and Preparedness Appropriations Act, 2016, as required by the act. USAID and
              State also submitted periodic updates to this report.
              3
               While USAID and State provided information about repurposed Ebola funds in the Zika
              reports, the reports indicated that the inclusion of that information was not required by the
              Zika Response and Preparedness Appropriations Act, 2016, and noted that information
              about the repurposed Ebola funds could also be found in the agencies’ Ebola reports. We
              reviewed USAID and State’s Ebola reports submitted to Congress from April 2016 to
              September 2017 and discussed the contents of subsequent reports with agency officials.
              4
               USAID and State’s consolidated reports to Congress contained funding and activity
              information through September 30, 2017. We obtained additional data directly from USAID
              and State covering funding information through September 2018.




              Page 29                                          GAO-19-356 Emergency Assistance for Zika
Appendix I: Objectives, Scope, and
Methodology




across agency bureaus, funding accounts, and activities for the Zika
response.

Additionally, we interviewed officials from USAID and State to discuss the
agencies’ obligations and disbursements for Zika response activities. We
then reviewed the funding data and related documentation and consulted
with USAID and State officials on the accuracy and completeness of the
data. In the small number of instances where we identified potential
issues or inconsistencies in the data, we contacted relevant agency
officials and obtained information from them necessary to resolve the
discrepancies. We assessed USAID’s tracking of funding data against
federal internal control standards related to using quality information. 5 We
also utilized information from data reliability assessments for two recent
GAO reports that utilized funding data from the same USAID and State
systems. 6 We determined that the data we used were sufficiently reliable
for our purposes of examining USAID’s and State’s obligations and
disbursements of the funds.

To examine activities that USAID and State implemented in response to
Zika overseas, we conducted fieldwork, analyzed agency documents, and
interviewed officials. We examined the status and progress related to Zika
response activities. We conducted a teleconference with officials in Haiti
and El Salvador and conducted fieldwork in Barbados, Colombia,
Dominican Republic, Guatemala, Honduras, Peru, and Trinidad and
Tobago. We selected these countries based on the following criteria: (1)
geographic diversity to include the Caribbean, Central America, and
South America; (2) coverage of the main lines of effort (mosquito control,
public awareness, capacity building, and research); and (3) the presence
of activities under way that accounted for a significant portion of funding.
During our fieldwork, we interviewed agency officials who played a role in
Zika response activities, which included officials from State, USAID, and
CDC. We also interviewed host government officials, implementing
partners, health care workers, community volunteers, and researchers. In
addition, we visited offices, toured facilities, and observed operations. We

5
 GAO, Standards for Internal Control in the Federal Government, GAO-14-704G
(Washington, D.C.: September 2014).
6
 GAO, Ebola Recovery: USAID Has Initiated or Completed Most Projects, but a Complete
Project Inventory Is Still Needed for Evaluating Its Efforts, GAO-18-350 (Washington,
D.C.: Mar. 28, 2018) and Emergency Funding for Ebola Response: Some USAID
Reimbursements Did Not Comply with Legislative Requirements and Need to Be
Reversed, GAO-17-35 (Washington, D.C.: Nov. 2, 2016).




Page 30                                      GAO-19-356 Emergency Assistance for Zika
Appendix I: Objectives, Scope, and
Methodology




also attended a conference in Guatemala that addressed topics including
status, successes, challenges, and lessons learned related to USAID’s
Zika response. We reviewed agency documents describing the plans and
goals of activities. We also analyzed progress reports of six activities to
provide illustrative examples of results. We selected activities from those
with among with the highest amounts of funding and that together
represented approximately 33 percent of all USAID funding for Zika
response and a range of countries, lines of effort, and types of
implementing partners (such as nongovernmental organizations and
international organizations). The sample is not generalizable to all of
USAID’s Zika response activities.

To examine challenges, if any, to implementing Zika response activities
and actions taken to address any challenges, we interviewed U.S.
government officials, USAID implementing partners, and host government
officials, and we analyzed progress reports from selected USAID-funded
Zika response activities. We identified key challenges based on the
nature of the description and the degree to which a diversity of
interviewees and documents made mention of them. We reviewed USAID
policy, USAID’s infectious disease response plan, federal internal
controls, implementing partner progress reports, and interviews with
officials to determine what agencies did to address these challenges. We
assessed USAID’s infectious disease response plan against relevant
federal internal control standards. 7

We conducted this performance audit from December 2017 to May 2019
in accordance with generally accepted government auditing standards.
Those standards require that we plan and perform the audit to obtain
sufficient, appropriate, evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe that
the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives.




7
GAO-14-704G.




Page 31                                 GAO-19-356 Emergency Assistance for Zika
Appendix II: Illustrative Examples of Results
                      Appendix II: Illustrative Examples of Results
                      for Selected Zika Response Activities



for Selected Zika Response Activities

                      To provide illustrative examples of the results of Zika response activities
                      funded by the U.S. Agency for International Development (USAID), we
                      analyzed implementing partners’ progress reports for a sample of six
                      activities. We selected activities from those with among the highest
                      amounts of funding and that together represented approximately 33
                      percent of all USAID funding for Zika response and a range of countries,
                      lines of effort, and types of implementing partners (such as
                      nongovernmental organizations and international organizations).
                      Quantitative figures related to individual indicators listed below reflect the
                      targeted population of the activity. Start dates and funding information
                      provided below reflect the date of the report to Congress in which the
                      activity first appeared and the associated funds obligated. The sample is
                      not generalizable to all USAID’s Zika response activities.


                      Table 1 presents the progress on key indicators as of March 2018
Applying Science to   reported to USAID by the Applying Science to Strengthen and Improve
Strengthen and        Systems activity. The aim of the activity was to strengthen Zika-related
                      health services and systems in Latin America and the Caribbean with a
Improve Systems       focus on pregnant women, newborns, and women of reproductive age.




                      Page 32                                         GAO-19-356 Emergency Assistance for Zika
                                                                Appendix II: Illustrative Examples of Results
                                                                for Selected Zika Response Activities




                                                                Start Date: November 2016
                                                                USAID Funding Provided: $15,000,000

Table 1: Indicators Reported to USAID by the Applying Science to Strengthen and Improve Systems Activity, as of March 2018

 Key indicator                                                                                                                                                Number
 Number of health care providers who treat family planning users, pregnant women, and mothers of                                                                 3,351
 newborns who are trained to provide Zika counseling
 Number of affected individuals referred to psychosocial support services                                                                            Data not available
 Number of babies born with suspected or confirmed microcephaly or Congenital Syndrome associated with                                               Data not available
 Zika who are referred to appropriate clinical care services according to national norms
                                                                                                                                                          Percentage
 Percentage of pregnant women who are given condoms for Zika protection during antenatal care sessions                                                              79
 Percentage of pregnant women who receive counseling on prevention of Zika virus transmission during                                                                91
 antenatal care sessions
 Percentage of completion of counseling criteria during family planning, antenatal care, and postpartum                                                             87
 consultations, as set forth in the Zika Counseling Guide
 Percentage of women (pregnant women, mothers of newborns, women of reproductive age) who can                                                                       85
 identify both the risk of Zika sexual transmission and the use of condoms as a preventative measure
 Percentage of pregnant women who are screened properly for Zika signs and symptoms during antenatal                                                                83
 care sessions
 Percentage of newborns who are properly evaluated for microcephaly                                                                                                 77
 Percentage of infants with suspected or confirmed microcephaly or congenital syndrome associated with                                               Data not available
 Zika who receive appropriate clinical care according to age milestones in accordance with the national
 norms
 Percentage of affected individuals, including pregnant women with suspected Zika virus infection and                                                Data not available
 mothers of infants with microcephaly or congenital syndrome associated with Zika, who are attended to by a
 provider trained in psycho-emotional support during each visit to the health care facility
Source: GAO analysis of U.S. Agency for International Development (USAID) implementing partner progress report. | GAO-19-356




                                                                Table 2 presents the progress on key indicators as of May 2018 reported
International                                                   to USAID by the International Federation of Red Cross and Red Crescent
Federation of Red                                               Societies Global Health activity. The activity aimed to reduce risks
                                                                associated with Zika infection through promoting community involvement,
Cross and Red                                                   sharing lessons learned, and improving practices.
Crescent Societies
Global Health




                                                                Page 33                                                        GAO-19-356 Emergency Assistance for Zika
                                                                Appendix II: Illustrative Examples of Results
                                                                for Selected Zika Response Activities




                                                                Start Date: November 2016
                                                                USAID Funding Provided: $4,860,563

Table 2: Indicators Reported to USAID by the International Federation of Red Cross and Red Crescent Societies Global Health
Activity, as of May 2018

 Indicator                                                                                                                                                    Number
 Communities with improved information about risks                                                                                                                 67
 Communities accessing educational materials                                                                                                                       54
 Students reached via school activities including Zika clubs, awareness campaigns                                                                              14,123
 Individuals of reproductive age who identify preventative measures                                                                                             8,362
 Individuals of reproductive age who received messaging through TV, radio, and social media                                                                   109,570
 engagement
 Community clean-up campaigns                                                                                                                                      43
 Communities with reduced breeding sites                                                                                                                           24
 Households that have taken one action within the last month to prevent Zika infection                                                                          6,011
 Pregnant women in targeted facilities who receive Zika counseling or information                                                                               3,665
Source: GAO analysis of U.S. Agency for International Development (USAID) implementing partner progress report. | GAO-19-356




                                                                Table 3 presents the progress on key indicators as of March 2018
United Nations                                                  reported to USAID by the United Nations International Children’s
International                                                   Emergency Fund activity. The activity aimed to promote the adoption of
                                                                prevention behaviors among at-risk populations through actions targeting
Children’s Emergency                                            multiple levels of their environment: individual, interpersonal, community,
Fund                                                            institutional, and national policy levels.




                                                                Page 34                                                        GAO-19-356 Emergency Assistance for Zika
                                                                Appendix II: Illustrative Examples of Results
                                                                for Selected Zika Response Activities




                                                                Start Date: November 2016
                                                                USAID Funding Provided: $10,000,000

Table 3: Indicators Reported to USAID by the United Nations International Children’s Emergency Fund Activity, as of March
2018

 Indicator                                                                                                                                                    Number
 Number of pregnant women benefited with quality counselling sessions to prevent Zika virus infection                                                          24,475
 Number of territories (departments/municipalities) in the region reporting the implementation of plans                                                            45
 with Zika response components
 Number of target population reached with key risk communication messages through multiple                                                                  5,577,085
 communication channels
 Number of target population reached with social mobilization and interpersonal communication at Zika                                                         155,113
 virus prevention sessions
 Number of children and adolescents trained in Zika virus transmission, prevention measures, and                                                               50,479
 consequences
 Number of families with children affected by Zika Congenital Syndrome benefiting with nonclinical                                                                301
 care and support interventions
 Number of providers trained in family-focused early intervention services for young children affected                                                          1,661
 by Zika syndrome
Source: GAO analysis of U.S. Agency for International Development (USAID) implementing partner progress report. | GAO-19-356




                                                                Table 4 presents the progress on key indicators as of September 2017
Save the Children                                               reported to USAID by the Save the Children Community Action on Zika
Community Action on                                             project. The goal of the project was to reduce Zika transmission and
                                                                minimize the risk of Zika-related microcephaly and other neurological
Zika                                                            disorders among the most vulnerable through community-based
                                                                prevention strategies.




                                                                Page 35                                                        GAO-19-356 Emergency Assistance for Zika
                                            Appendix II: Illustrative Examples of Results
                                            for Selected Zika Response Activities




                                            Start Date: November 2016
                                            USAID Funding Provided: $5,061,957

Table 4: Indicators Reported to USAID by the Save the Children Community Action on Zika Project, as of September 2017

Indicator                                                                                                   Percentage or number
Percentage of women of reproductive age who report applying key Zika protective practices                                    48.70
Percentage of communities that show capacity for surveillance, prevention, and control of Zika virus                            47
disease and care and support of affected infants
Percentage of communities that show capacity for surveillance of Zika virus disease and vector                                  71
Percentage of communities that show capacity for prevention and control of Zika virus disease                                   48
Percentage of communities that show capacity for care and support of affected infants                                           52
Percentage of women of reproductive age who report implementing personal preventive measures to avoid                        15.80
Zika virus infection
Percentage women of reproductive age who recognize Zika risk, prevention, and transmission                                   49.90
Percentage and number of women of reproductive age reporting that condoms & other contraceptives are                         62.50
available at their local health facilities
Number of volunteers trained in community-based vector control                                                               4,331
Number of students informed about Zika prevention and control                                                               64,898
Number of community members participating in clean-up campaigns                                                             76,448
Number of target population provided with Zika key risk communication messages                                             342,082
Number of pregnant women informed on Zika                                                                                    2,870
Number of communities with community plans for the prevention and control of Zika                                              599
Number of communities with members actively participating in vector and/or case surveillance activities                        558
Number of children and adolescents participating as agents of social mobilization at community level                         7,103
Number of community volunteers with community-based surveillance reporting cases and suspected cases                         1,073
of Zika
Number of community volunteers with community-based surveillance reporting vector positive breeding                          2,612
sites
Number Zika events that involve families, schools, local governments, or community organizations                             2,346
                                                                                                                  Percentage and
                                                                                                           number of communities
Percentage and number of communities engaged in vector control activities                                                       62
                                                                                                                   568 communities
Percentage and number of schools which have implemented breeding site elimination campaigns with                               60
participation from school children                                                                                     252 schools
Percentage and number of communities which have implemented breeding site elimination campaigns                                 65
                                                                                                                   597 communities




                                            Page 36                                         GAO-19-356 Emergency Assistance for Zika
                                                                Appendix II: Illustrative Examples of Results
                                                                for Selected Zika Response Activities




 Indicator                                                                                                                                     Percentage or number
                                                                                                                                                     Percentage and
                                                                                                                                              number of communities
 Percentage and number of communities with a Zika risk communication strategy                                                                                      53
                                                                                                                                                      479 communities
 Percentage and number of communities with a Zika implementation plan                                                                                              62
                                                                                                                                                      569 communities
Source: GAO analysis of U.S. Agency for International Development (USAID) implementing partner progress report. | GAO-19-356




                                                                Table 5 presents the progress on an illustrative selection of key
Population Services                                             indicators, by objective, as of March 2018 reported to USAID by the
International                                                   Population Services International activity. The purpose of the activity was
                                                                to improve the capacity and raise awareness of people in countries
                                                                affected by and at risk of Zika and other vector-borne diseases.




                                                                Page 37                                                        GAO-19-356 Emergency Assistance for Zika
                                                                Appendix II: Illustrative Examples of Results
                                                                for Selected Zika Response Activities




                                                                Start Date: November 2016
                                                                USAID Funding Provided: $3,500,000

Table 5: Illustrative Selection of Indicators, by Objective, Reported to USAID by the Population Services International Activity,
as of March 2018

 Objective and illustrative indicator                                                                                                                             Number
 Objective 1.1: Increased use of personal safeguards, including the voluntary use of family planning and condoms to                                                     3,956
 prevent unintended pregnancy and sexual transmission of Zika among women of reproductive age, pregnant women,
 and their sexual partners
 Number of users who participated in online outreach for Zika prevention
 Objective 1.2: Developed body of evidence regarding target communities’ knowledge about Zika transmission and                                                          1,254
 prevention seeking behavior to strengthen social and behavior change communication messaging and program
 responses at the community, regional, and national levels
 Total sample of participants in study to measure recall and affinity for key messages from Zika campaign
 Objective 2.1: Increased provider knowledge about Zika and increased number of private health service providers who                                                    1,006
 incorporate Zika counseling into integrated sexual and reproductive health services
 Pregnant women who received counseling on Zika prevention
 Objective 2.2: Increased youth and adolescent knowledge about Zika and increased number of public educational                                                           145
 institutions that incorporate Zika counseling into integrated sexual and reproductive health services.
 Teachers and health ministry authorities participating in meeting in Honduras to share experiences from the first year
 of project implementation and learn updated information about Zika prevention
Source: GAO analysis of U.S. Agency for International Development (USAID) implementing partner progress report. | GAO-19-356

                                                                Note: Because the set of key indicators is long and varied for this activity, we list an illustrative
                                                                selection.




                                                                Table 6 presents illustrative examples of accomplishments as of March
Zika AIRS Project                                               2018 reported to USAID by the Zika AIRS Project (ZAP). This was a
(ZAP)                                                           mosquito control project focused on reducing Zika transmission in Latin
                                                                America and the Caribbean. Specific activities included entomological
                                                                monitoring, larviciding, source reduction interventions, and indoor residual
                                                                spraying.




                                                                Page 38                                                        GAO-19-356 Emergency Assistance for Zika
                                                                Appendix II: Illustrative Examples of Results
                                                                for Selected Zika Response Activities




                                                                Start Date: November 2016
                                                                USAID Funding Provided: $20,000,000

Table 6: Illustrative Examples of Accomplishments Reported to USAID by the Zika AIRS Project (ZAP), as of March 2018

ZAP country teams collaborated extensively with Ministry of Health counterparts in each country, not only in planning and
implementing ZAP activities, but also in exploring ways in which the project could support sustained efforts.
Five countries implemented comprehensive vector control activities, combining source reduction through environmental management
and routine larviciding with Bacillus thuringiensis israelensis.
Six countries conducted routine entomological monitoring, including adult mosquito collection, egg collection, and larvae/pupae
surveys.
New and innovative vector control methods were piloted in selected ZAP countries, including a pilot in Dominican Republic on the use
of lethal ovitraps as a method of both entomological monitoring and vector control.
ZAP has reinforced a focus on learning across the project during this reporting period, and cross-country learning through several
south-to-south technical assistance trips during which ZAP staff have shared best practices and innovations.
Source: GAO analysis of U.S. Agency for International Development (USAID) implementing partner progress report. | GAO-19-356

                                                                Note: Because accomplishments reported varied for this activity, we list an illustrative selection.




                                                                Page 39                                                        GAO-19-356 Emergency Assistance for Zika
Appendix III: Comments from the U.S.
              Appendix III: Comments from the U.S. Agency
              for International Development



Agency for International Development




              Page 40                                       GAO-19-356 Emergency Assistance for Zika
Appendix III: Comments from the U.S. Agency
for International Development




Page 41                                       GAO-19-356 Emergency Assistance for Zika
Appendix III: Comments from the U.S. Agency
for International Development




Page 42                                       GAO-19-356 Emergency Assistance for Zika
Appendix III: Comments from the U.S. Agency
for International Development




Page 43                                       GAO-19-356 Emergency Assistance for Zika
Appendix III: Comments from the U.S. Agency
for International Development




Page 44                                       GAO-19-356 Emergency Assistance for Zika
Appendix III: Comments from the U.S. Agency
for International Development




Page 45                                       GAO-19-356 Emergency Assistance for Zika
Appendix IV: GAO Contact and Staff
                  Appendix IV: GAO Contact and Staff
                  Acknowledgments



Acknowledgments


                  David B. Gootnick, (202) 512-3149 or gootnickd@gao.gov
GAO Contact
                  In addition to the contact named above, Joyee Dasgupta (Assistant
Staff             Director), Marc Castellano (Analyst-in-Charge), Diana Blumenfeld, Alana
Acknowledgments   Miller, Fatima Sharif, David Dayton, Francisco Enriquez, Christopher
                  Keblitis, Amber Sinclair, and K. Nicole Willems made key contributions to
                  this report.




(102433)
                  Page 46                                GAO-19-356 Emergency Assistance for Zika
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