Background BOP Prisons and Population BOP is a component of DOJ and is responsible for housing male and female federal inmates in a controlled, safe, and humane prison environment while also providing a safe workplace for employees. BOP operates 122 prisons across the United States. These prisons are characterized by five security levels: high, medium, low, minimum, and administrative. Table 1 below provides a description of each of these security levels and the number of prisons at each. According to BOP data, in fiscal year 2019, BOP housed 149,701 inmates in its prisons. During this same time, the BOP employed 32,525 employees, of which 15,664 were correctional officers with responsibility for the day-to-day supervision of the inmates. BOP Issuance of Pepper Spray at Prisons According to a July 2012 BOP memorandum, BOP was approved to conduct a pilot study on pepper spray. The goals of the pilot were to increase the safety of staff and inmates when responding to incidents involving violence and to prevent injury to staff and inmates due to an assault or serious resistance to staff control. BOP began issuing pepper spray at high security prisons in August 2012 as part of its pilot study. In February 2015, BOP issued a program memorandum requiring employees in high, medium, and administrative security prisons to carry pepper spray. Further, in September 2018, BOP issued a program statement that expanded pepper spray to employees in low security prisons. Figure 1 provides a more detailed time line of events on the use of pepper spray in BOP prisons, including requirements under the Eric Williams Correctional Officer Protection Act of 2015. BOP Policies for Issuing and Using Pepper Spray, Providing Training, and Reporting Incidents Pepper spray is a natural inflammatory agent that can cause coughing, tearing, and discharge of excessive mucous when deployed in the facial region. According to BOP training guidance and policy, pepper spray is to be used in incidents that require an immediate use of force (for example, an unplanned use of force because of an attack on staff or an inmate) or a calculated use of force in which employees have time to coordinate their response (for example, when an inmate refuses to vacate his or her cell). For calculated uses of force, employees are to consult medical personnel to determine if an inmate has a medical condition that will exempt the inmate from being pepper sprayed. BOP policy states that employees should receive initial training on pepper spray and annual refresher training. In training, employees are taught effective tactical communication for using pepper spray; use of force policy; how to use pepper spray; and the decontamination process, among other topics. According to BOP’s Use of Force and Application of Restraints policy, a prison’s warden may authorize the use of chemical agents, such as pepper spray, only under the following situations: (1) the inmate is armed or barricaded; or, (2) the inmate cannot be approached without danger to self or others; and (3) it is determined that a delay in bringing the situation under control would constitute a serious hazard to the inmate or others or would result in a major disturbance or serious property damage. Pepper spray, moreover, should only be used when all other reasonable efforts to resolve a situation have failed. This policy further states that staff shall appropriately document incidents involving the use of pepper spray using BOP’s Form 583—Use of Force Report. Form 583 contains fields to enter the date and time of the incident; inmates and staff involved; injuries; medical reports; a description of the incident; and other information, such as the existence of video of the incident. The form is to be completed by the lieutenant on duty at the time of the incident and sequentially forwarded to the captain, assistant warden, warden, and regional office for review. After a Form 583 is completed, the warden, associate warden, health services administrator, and captain at the prison, collectively, conduct an after-action review of the incident to determine if the pepper spray was used in accordance with policy. Results of the after-action review are documented on BOP’s Form 586—After Action Report. According to BOP headquarters officials, in addition to documenting the results of the after- action review, a completed Form 586 often includes recommendations on how to improve the response to such incidents in the future. Incident data captured on Forms 583 and 586 are maintained in BOP’s TRUINTEL database. Protective Equipment Worn and Tools Used by BOP Employees To enhance BOP employee safety, BOP provides its employees with a variety of protective equipment. BOP generally requires employees working within the secure prison perimeter to carry a radio, body alarm, pepper spray (as appropriate), and keys while on duty. These items are usually checked out from the control center using a chit—a small, brass, circular token inscribed with the BOP employee’s first initial and last name. As of March 2020, some employees also wear stab-resistant vests to help enhance their safety. Although BOP employees are furnished with protective equipment, their first line of defense to protect themselves against an inmate is expected to be their verbal communication with the inmate. BOP policy, training documents, and officials state that effective communication with inmates is essential to officer safety. Figure 2 depicts some of the protective equipment worn by BOP employees operating within the secure prison perimeter of prisons. Issuance of Pepper Spray for Prison Employees Is Broadly Reported as Effective, and Agency-wide Costs of Pepper Spray Are Not Clear BOP Pilot Study and Staff Indicate That Pepper Spray Has Been Effective in Enhancing Safety of BOP Employees BOP conducted a pilot study on the issuance of pepper spray from August 2012 through December 2013 at selected high-security prisons. To conduct its study, BOP compared injury sustained by staff and inmates data from immediate use of force incidents in which pepper spray was used to similar incidents in which pepper spray was not used. BOP found that pepper spray was effective in helping to reduce containment time—the amount of time it takes to bring an incident under control—and injury rates. Specifically, containment time of incidents decreased from an average of 4.3 minutes when pepper spray was not used to 2.7 minutes when it was used. This is a reduction of 1.6 minutes in containment time; pepper spray was used mostly in incidents involving two or more inmates, such as fights and assaults. When pepper spray was used, the rate at which staff received no injury increased by 9 percent compared to when pepper spray was not used. Further, the rate at which staff received minor and moderate injury declined by 60 and 76 percent, respectively, compared to when pepper spray was not used; and the inmate injury rate rose slightly, by 2.6 percent, primarily in minor injuries when pepper spray was used; however, BOP concluded this change was not statistically significant. All 90 of the BOP employees we spoke with from United States Penitentiary Atlanta, Federal Correctional Complex Coleman, and Federal Medical Center Devens indicated that pepper spray has been effective in enhancing safety as well as deterring incidents. Generally, these employees noted that pepper spray (1) reduces staff injuries because staff do not have to physically engage with inmates as often to break up incidents, (2) strongly deters incidents from occurring, and (3) allows employees to break up incidents more quickly than if they did not have pepper spray. Pepper spray is not as effective for a small percentage of inmates, such as those with mental illness or those who are under the influence of drugs or alcohol, according to some BOP employees. According to BOP data, in 2018, pepper spray was used in 1,680 incidents as follows: 993 incidents in high security prisons; 557 incidents in medium security prisons; 22 incidents in low security prisons; and 108 incidents in administrative security prisons. Some Allegations of Inappropriate Use of Pepper Spray Have Been Resolved, while Others Remain Under Investigation Officials from BOP’s Office for Internal Affairs stated that 179 allegations of inappropriate use of force incidents that involved pepper spray were reported from August 2012 through September 2018. Among these cases, BOP’s Office for Internal Affairs has investigated and closed 86. Among these 86 closed cases, investigators found that 21 involved an inappropriate use of pepper spray and were adjudicated in various ways (see table 2). The remaining 93 allegations were still being investigated as of January 2020. BOP-wide Costs for Pepper Spray Are Relatively Low, and Some Costs Are Commingled with Other Expenses According to BOP data, the total cost for pepper spray–specifically the cost to purchase pepper spray canisters and train employees in its use— was approximately $300,000 in fiscal year 2018, which was relatively small compared to BOP’s overall budget. BOP headquarters officials told us that because pepper spray cost information is maintained at the prison level, it would be overly burdensome for them to independently validate the data. Nonetheless, the cost information we received provides a general sense on the extent of costs. Canisters. Officials estimated that a canister of pepper spray costs $7 to $14. Canisters of pepper spray have a shelf-life of approximately 5 years and, according to a BOP headquarters official, are purchased in bulk. As a result, pepper spray does not necessarily need to be purchased on an annual basis. According to BOP officials, each BOP prison contracts with its own supplier rather than using a national contract across all of BOP. BOP headquarters officials told us that pepper spray costs vary across vendors and locations, among other factors. Each BOP prison is responsible for recording and tracking its own budget data on the cost of procuring, training, and issuing BOP employees pepper spray. According to BOP officials, this approach is intended to lower the costs of pepper spray, based on the premise that each prison is able to secure the best market price for pepper spray for its location and for the volume of canisters needed from the vendor. Training. Prison officials told us that pepper spray refresher training is combined with other employee training, making it difficult for them to provide us with specific cost for pepper spray training. All BOP staff are required to take initial and annual refresher training on the use of pepper spray. The initial training lasts about 4 hours, while the annual refresher training lasts about 2 hours. BOP Decided Not to Issue Pepper Spray at Minimum Security Prisons, but Has Not Conducted an Analysis to Support Its Decision BOP issued a program statement in September 2018, which states that pepper spray is not to be issued to employees working at minimum security prisons. However, the senior BOP officials we interviewed—none of whom said they were involved directly in the policy decision—told us they do not believe the explanatory documentation of the decision to not issue pepper spray to minimum security prisons exists. Officials stated that the decision was likely made for several reasons: inmates at minimum security prisons are usually nonviolent offenders, incidents at minimum security prisons are usually very minor and do not require the use of pepper spray, the concern that public perception of using pepper spray on inmates at minimum security prisons would not be positive, and canisters of pepper spray would expire before they would be used at minimum security prisons. BOP officials we spoke with also stated that inmates at minimum security prisons are less likely than inmates at other security level prisons to become involved in incidents because they do not want to be reassigned to a higher security prison. We found, nonetheless, that BOP’s TRUINTEL database shows that incidents do occur at these prisons— some of which have led to assaults, minor injuries and death. Based on our analysis of BOP incident data from TRUINTEL, we found that in 2018 there were 47 reported incidents in the seven BOP minimum security prisons. These incidents included assaults on staff and other inmates; sexual harassment; and fighting, among others. Five of the incidents resulted in minor injuries to 10 BOP employees, and 18 incidents resulted in minor injuries to inmates. Further, one incident led to an inmate fatality. Additionally, during our site visits, 56 out of 73 officials across various security levels stated that deployment of pepper spray should be expanded to minimum security prisons because it would give employees an additional tool to protect their safety. BOP headquarters officials told us they believe the agency’s decision to not issue pepper spray to minimum security prisons remains appropriate. Regarding the 47 incidents that occurred at minimum security prisons in 2018, officials stated that many of the confrontational incidents occurring at these prisons can be handled using verbal commands. While a decision to not issue pepper spray at minimum security prisons may be justified based on an analysis of relevant information, BOP officials could not provide documentation of such analysis to support its decision. This analysis could include assessing available incident data at minimum security prisons and determining whether any of the incidents could have been prevented or handled more effectively if the officer on duty was carrying pepper spray. Additionally, BOP employee perspectives on issuing pepper spray at minimum security prisons is another possible source of relevant information that could be included in an analysis to inform BOP’s decision. BOP issued policies in 2015 and 2018 that stated that while the preferred method of resolving issues with inmates is through a verbal intervention, there are instances where other means will be required to restore order. In addition, the policies state that the safety of staff, inmate(s), or others in any dangerous encounter is paramount and that the use of force— including use of pepper spray—may be needed to ensure safety. According to Standards for Internal Control in the Federal Government, management should use quality information to make informed decisions and to evaluate the entity’s performance in achieving key objectives and addressing risks—in this case, the possible safety risks to BOP employees and inmates. By conducting an analysis on available BOP data on incidents that have occurred at minimum security prisons, employee perspectives on the value of having pepper spray at such prisons, and other relevant data, such as cost data, as appropriate, BOP would have useful data with which to inform its decision on whether or not to authorize pepper spray for employees at minimum security prisons. BOP Reported a Number of Challenges to Ensuring Officer Safety and Is Taking Steps to Help Mitigate Them BOP Officials at Selected Prisons Reported Challenges, including Understaffing and Inmate Drug Use, That Affect BOP Employee Safety Four BOP headquarters officials, 18 wardens and their executive staff, and 10 union officials rated the potential impact of 15 selected factors (see app. I) on the safety of BOP employees in prisons. BOP officials rated the following five factors as having the most significant impact on BOP employee safety in prisons: (1) corrections officer understaffing, (2) disruptive inmate behavior due to illegal drugs, (3) inmate use of unauthorized communication devices, (4) inmate gangs, and (5) insufficient corrections training. See figure 3 for a diagram of the top five factors identified across the different groups of BOP officials who responded to the structured questions. Across all three groups, corrections officer understaffing was rated among the top five factors. No other factor was equally represented. For at least two groups, inmate use of unauthorized communication devices, disruptive inmate behavior due to illegal drugs, and insufficient information-sharing among managers and staff were rated among the top five factors. When asked to identify any additional challenges beyond the selected factors we included, BOP officials we interviewed stated they were not aware of other challenges. BOP Headquarters and Prison-Level Officials Are Taking Steps to Address Reported Challenges BOP officials told us that they are taking steps to mitigate some of the challenges officials we interviewed indicated are impacting employee safety in prisons. Officials identified the following: Corrections officer understaffing. Corrections officer understaffing refers to the staffing level—usually measured by the inmate-to-staff ratio—being too low to adequately prevent violence and maintain a safe prison. Among the BOP headquarters officials, wardens and their executive staff, and union officials we interviewed, two underlying reasons generally cited for understaffing conditions were hiring freezes and difficulty recruiting new correctional officers due to low starting salaries. According to the BOP Director’s testimony before the Senate Judiciary Committee in November 2019, building adequate staffing at BOP prisons is one of her highest priorities. The Director stated that BOP established 10-percent recruitment, relocation, and retention incentives for hard-to-fill positions; established a higher entry pay scale for experienced new correctional established a 5-percent nationwide retention incentive for retirement- used 3,000 temporary positions to help ensure seamless succession planning by avoiding the lag to hire someone to fill a position. We issued a report in December 2017 on BOP’s use of retention incentives. At that time, we found that BOP had taken steps to determine workforce needs and how to fill those needs but had not strategically planned for and evaluated its use of retention incentives. We recommended that BOP include in its strategic human capital operating plan (1) human capital goals; and (2) strategies on how human capital flexibilities, including retention incentives, will be used to achieve these goals. We also recommended that BOP evaluate the effectiveness of its use of retention incentives to determine whether the incentives have helped achieve BOP’s human capital goals or if adjustments in retention incentives are needed. DOJ concurred, and BOP implemented our first recommendation by drafting a human capital plan with goals and strategies for how retention incentives could be used to meet those goals. To implement our second recommendation, BOP conducted an analysis of its use of retention incentives and their effect on retaining BOP employees. Disruptive inmate behavior due to illegal drugs. According to BOP officials, some inmates obtain illegal synthetic drugs by mail. These drugs are sprayed onto inmate mail and other documents before being sent to the inmate in prison. Inmates burn the mail to get high off of the synthetic drug. In addition to the threat to the inmate population posed by inmates who are behaving under the influence of the drugs, entry of these drugs can expose staff—including those handling the mail—-to hazardous chemicals. In an effort to stop illegal drugs from entering prisons by this method, according to BOP officials we spoke with and the BOP Director in her November 2019 testimony, some prisons are photocopying mail before it is delivered to inmates. For example, officials at one prison we visited told us they photocopy inmates’ mail. Further, a BOP headquarters official stated that BOP is piloting various mail-scanning technologies aimed at reducing the number of drugs entering prisons. Inmates’ use of unauthorized communication devices. According to BOP officials and the BOP Director’s testimony, inmates’ possession of cell phones is a major problem. BOP officials stated that, in an effort to stop the unauthorized use of cell phones, some prison officials are using specialized equipment to detect cell phone usage and are exploring options to use cell phone jammers. We reported in September 2011 that BOP and selected state officials told us that cell phones were a major security concern because they allow inmates to hold unmonitored conversations, for example, to sell drugs or harass individuals. We recommended that BOP’s Director formulate evaluation plans for cell phone detection technology to aid decision-making, require BOP staff to use these plans, and enhance regional collaboration with states. DOJ concurred with our recommendations, and BOP addressed them by developing policy and testing procedures to improve their ability to evaluate new technology. BOP also established plans to enhance collaborative information-sharing with state and local agencies on combating cell phone smuggling and use. Conclusions Working in a federal prison presents inherent risks. Since 2018, BOP has authorized the use of pepper spray at all prison security levels with the exception of minimum security prisons. BOP’s issuance of pepper spray was supported by evidentiary information—that is, its pilot study indicated that pepper spray was an effective tool for enhancing staff safety. Notably, BOP’s current policy on pepper spray allowance does not extend to minimum security prisons. While BOP was not able to provide us with a documented analysis behind the nonissuance to minimum security prisons, the officials we interviewed made several arguments in support of the decision. While their arguments may hold merit, we found evidence based on our limited analysis that appears to question their underlying decision. To the extent that officials are operating under assumptions not fully examined, BOP is missing a potential opportunity to enhance the safety of its correctional officers. We believe that our concerns are amplified by our finding that a majority of BOP frontline employees want pepper spray expanded to minimum security prisons. Similar to the decision to issue pepper spray to other levels was based on pilot information, BOP has an opportunity to bring—either for or against issuance—a better case forward. Analyzing available data on incidents that have occurred at minimum security prisons, such as determining whether any of them could have been prevented or handled more effectively with pepper spray, and considering BOP employees’ perspectives, BOP could inform its decision whether to authorize pepper spray for employees at these prisons. Recommendation for Executive Action We are making the following recommendation to BOP: The Director of BOP should conduct an analysis, using available incident and cost data, and other information as appropriate, to determine if the current decision to not issue pepper spray to minimum security prisons should remain in effect. (Recommendation 1) Agency Comments We provided a draft of this product to DOJ, including BOP, for review and comment. DOJ concurred with our recommendation and told us they had no comments on the draft report. DOJ did provide technical comments, which we incorporated as appropriate. We are sending copies of this report to the appropriate congressional committees, the Attorney General, the BOP Director, and other interested parties. In addition, the report will be 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) 512-8777 or goodwing@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 III. Appendix I: BOP Employee and Officer Safety Structured Questions Throughout our audit work, we asked Bureau of Prisons (BOP) officials with whom we interviewed at the headquarters and selected prisons about factors that impact the safety of BOP employees, as well as efforts, if any, they had made to mitigate those factors. We specifically targeted three groups of BOP personnel—BOP headquarters, wardens and their executive staff, and union officials—to rate the impact of 15 selected factors on employee safety at the groups and by prison security level. We then analyzed their responses and identified the top five factors that these BOP officials identified as having an impact on employee safety. We received responses from four BOP headquarters officials, 18 wardens and their executive staff, and 10 union officials. Officials were provided the structured questions (see below) in advance of the site visit, and the team recorded their responses during the interview. We held one interview with four Bureau of Prisons (BOP) headquarters officials, nine interviews with 18 wardens and their executive staff, and seven interviews with 10 union officials about 15 selected factors that impact the safety of BOP employees, using a structured questions set (see app. I). These officials’ responses, which are broken down by group and security level, are presented in the figures below. Appendix III: GAO Contact and Staff Acknowledgments GAO Contact Staff Acknowledgments In addition to the contact named above, Brett Fallavollita (Assistant Director), Sonja S. Ware (Analyst-in-Charge), Anthony DeFrank, and Emily Martin made key contributions to this report. Willie Commons III, Elizabeth Dretsch, Eric Hauswirth, and Susan Hsu also contributed to this work.


Background Zika Transmission and Effects Zika is spread to people primarily through the bite of an infected mosquito but can also be transmitted from mother to child during pregnancy or from person to person through sexual contact or blood transfusion. 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. Zika is also linked to other problems such as Guillain-Barré syndrome, an uncommon condition of the nervous system. 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 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. 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. 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. U.S. Response to Zika Overseas In February 2016, the President submitted a request to Congress for 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. 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. USAID and State Obligated Almost All Funding Available for the Zika Response but Did Not Report Funding by Country USAID and State Obligated Almost All Funding Available for the Zika Response and Disbursed Approximately Two-Thirds As of September 30, 2018, USAID and State had obligated about $385 million (99 percent) of the total $390 million available for the U.S. Zika response overseas and had disbursed approximately $264 million (68 percent). Specifically, USAID had obligated all of its funds available for the Zika response and disbursed about two-thirds, and State had obligated and disbursed more than three-quarters of its funding for Zika. 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. 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. USAID and State Track Zika Funding by Account and Activity As of September 30, 2018, USAID had obligated all funds available for the Zika response and had disbursed about two-thirds, from three accounts. USAID has two sources of funding for Zika response activities: $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 disbursements by account. USAID obligated all funding for Zika response activities within a year after it was repurposed or appropriated. 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. 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. 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. 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. 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. 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 Report Zika Funding by Country In their reporting to Congress on the uses of Zika funds, USAID and State included some country information but did not track or provide information on funding uses broken down on a country basis. In October 2016, 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. 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 Appropriations Act, 2016, the reports’ information on the use of the repurposed Ebola funds was also not broken down by country. 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. 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 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 Mosquito Control, Public Awareness, Capacity Building, and Research Activities As part of the U.S. Zika response overseas, USAID provided assistance to several countries in the Caribbean, Central America, and South America and conducted a variety of activities related to mosquito control, public awareness, capacity building, and research. 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. 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. 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, 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. 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 Reported Various Results from Selected Activities We reviewed status reports for six USAID activities that received among the highest amounts of funding, and each identified various results. Below, we describe the activities and examples of reported results. For 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 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. 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 Awareness Initiatives and Medical Evacuations In response to Zika, State conducted public awareness and communication initiatives, medical evacuations for overseas staff, and other activities. According to a State official, State conducted Zika-related 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. USAID Took Steps to Address Sustainability Challenge but Only Partially Mitigated Challenge to Timely Implementation USAID Implementing Partners Aligned Their Activities with Host Governments and Involved Local Communities to Address Sustainability Challenge Over the course of our fieldwork, USAID and implementing partner officials identified two key challenges to the implementation of Zika response activities. The first was the long-term sustainability of Zika response activities. The second was the timely implementation of Zika response activities in countries without bilateral USAID health programs. While USAID took steps to address the challenge related to sustainability, it only partially mitigated the challenge to timely implementation of Zika response activities in countries without bilateral USAID health programs. Agency and implementing partner officials identified the sustainability of Zika response efforts as a key challenge. While USAID did not intend to continue U.S. Zika response activities after the one-time emergency funding, sustainability was a consideration and posed a challenge due to the short implementation time frame, according to agency and implementing partner officials. One official further elaborated that Zika funding efforts occurred during the acute phase of the outbreak, which 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 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. USAID Only Partially Mitigated the Challenge to Timely Implementation in Some Countries Where It Did Not Have Health Programs Agency and implementing partner officials described timely implementation of activities in some countries without bilateral USAID health programs as a second key challenge. Twenty-two out of the 26 countries where USAID implemented its Zika response activities were countries without bilateral USAID health programs. USAID officials stated that, as a result, there were no USAID health program officials present in 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 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. 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 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. Conclusions The Zika virus quickly spread to dozens of countries in 2015 and 2016, 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. Recommendations for Executive Action We are making the following two recommendations to USAID: 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) Agency Comments and Our Evaluation We provided a draft of this report to USAID, State, and CDC for review and comment. USAID provided written comments, which we have 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. Appendix I: Objectives, Scope, and 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. 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. 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. We obtained additional funding and activity information from USAID covering a period beyond that included in the reports to Congress. 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 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. We also utilized information from data reliability assessments for two recent GAO reports that utilized funding data from the same USAID and State systems. 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 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. 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. Appendix II: Illustrative Examples of Results 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. Applying Science to Strengthen and Improve Systems Table 1 presents the progress on key indicators as of March 2018 reported to USAID by the Applying Science to Strengthen and Improve Systems activity. The aim of the activity was 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. International Federation of Red Cross and Red Crescent Societies Global Health Table 2 presents the progress on key indicators as of May 2018 reported to USAID by the International Federation of Red Cross and Red Crescent Societies Global Health activity. The activity aimed to reduce risks associated with Zika infection through promoting community involvement, sharing lessons learned, and improving practices. United Nations International Children’s Emergency Fund Table 3 presents the progress on key indicators as of March 2018 reported to USAID by the United Nations International Children’s Emergency Fund activity. The activity aimed to promote the adoption of prevention behaviors among at-risk populations through actions targeting multiple levels of their environment: individual, interpersonal, community, institutional, and national policy levels. Save the Children Community Action on Zika Table 4 presents the progress on key indicators as of September 2017 reported to USAID by the Save the Children Community Action on Zika project. The goal of the project was to reduce Zika transmission and minimize the risk of Zika-related microcephaly and other neurological disorders among the most vulnerable through community-based prevention strategies. Population Services International Table 5 presents the progress on an illustrative selection of key indicators, by objective, as of March 2018 reported to USAID by the 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. Zika AIRS Project (ZAP) Table 6 presents illustrative examples of accomplishments as of March 2018 reported to USAID by the Zika AIRS Project (ZAP). This was a 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. Appendix III: Comments from the U.S. Agency for International Development Appendix IV: GAO Contact and Staff Acknowledgments GAO Contact Staff Acknowledgments In addition to the contact named above, Joyee Dasgupta (Assistant Director), Marc Castellano (Analyst-in-Charge), Diana Blumenfeld, Alana Miller, Fatima Sharif, David Dayton, Francisco Enriquez, Christopher Keblitis, Amber Sinclair, and K. Nicole Willems made key contributions to this report.