medieval come to order good afternoon and thank you for being here this year your incomes as a dozen schools in new york city are closed due to the h one n one influenza outbreak this hearing also comes as new york city my home town suffers in the first h one n one fatality i would like to begin this hearing by offering my sincere condolences to the family of assistant principal mitchell wiener and also to the students faculty and staff of an immediate school three twenty eight to thirty eight with adequate preparation our nation's responds better to natural emergencies than any other country however the nih when one terror attack and hurricane katrina demonstrated the consequences of inadequate planning and preparation these events have also taught us that while national planning is required it is the state and local public health departments safety professionals and first responders who are the most critical to get help to those in immediate need today's hearing will look at the ability of state states like a typical natural disaster such as a hurricane or wildfire outbreaks of pandemic flu affects all regions of the country virtually at the same time making regional cooperation impossible also a pandemic it is necessary for public health teams to function twenty four seven and a three shift pattern for two and of several months these public health workers must can conduct surveillance of lab tests and treatments well coordinated school closings surges at hospitals and the storage and distribution of treatments and vaccines shift in national priorities and the impact of the current economic downturn have led to budget cuts and health departments across the country according to the national association of counties and city health officials fifty three percent of local health departments in the state of new york last staff in two thousand and eight and forty percent expect to make more layoffs this year while dealing with budget and workforce challenges new york has become a focal point of the current h one n one  outbreak nationally the public health workforce has been recently reduced by over seven thousand workers with more reductions expected over eighty five percent of local health departments reduced staff and two thousand and eight and forty six percent are expected to lay off more workers in two thousand and nine a recent and seemingly prophetic g a o report published on february twenty sixth two thousand and nine warns of the continued threat  pandemic as our national priorities moved from pandemic preparedness to the economy and other issues current events remind us that pandemic can strike at any time and with little warning our communities need to stay ready to respond to such a threat i'm hopeful that this hearing will shed light on exactly how prepared we are to respond to a pandemic at state and local level i'm also hopeful that our witnesses will help us discover what we will all what we all can do not just the federal government to make sure our communities are ready to handle what mother nature dishes out i want to thank all of the witnesses will appearing here today pandemic preparedness i also want to thank our witnesses are taking time out of their busy schedule to testify before the committee we recognize in order to prepare for a hearing like this it isn't just the work of those who will prepare but in fact of some of the most important people in our response local and state response units in the event of an outbreak of pandemic flu a coordinated response between the federal state and local authorities from the department of homeland security health and human services to public health departments hospitals and emergency response teams in the smallest of american towns will be key to ensure the health and safety of all americans the question of whether there will be an outbreak of pandemic flu somewhere in the world of a proportion similar to that of the early one thousand nine hundred is not an if but strategy for pandemic influenza in two thousand and five a comprehensive approach for preparing for detecting and responding to a potential pandemic the strategy established guidance for federal state and local preparedness and response additionally since two thousand and two over nine billion in grants has gone out to the states to strengthen hospital and public health preparedness this coordinated response strategy is in the midst of having its first test the outbreak of the h one n one or swine flu as comprehensive as our plans at the federal level might be absent proper coordination with state and local governments any type of emergency response will be lacking less than two months before the h one n one outbreak first appeared the g a o reported that more could be done to facilitate coordination between federal state and local governments and the private sector to prepare for a pandemic questions also remain about the adequacy of the strategic national stockpile me and how assets such as antiviral and respirators sees me in the stockpile are distributed to the states during an emergency today we have an opportunity to learn more about the gaps that may exist and what we can do to address them should an epidemic worsen should this epidemic worsen or before any health emergency additionally it's clear that we now have a number of financial problems at the federal state and local  inevitable that without a immediate requirement for a pandemic flu preparation that states and localities would begin trying to divert funds to other areas this could be done at perhaps the worst possible time even as we speak the national stockpiles in some areas are being depleted simply because they have reached their expiration only a week ago i had individuals involved in our anthrax preparedness in my office showing me a table of the expiration of anthrax and in fact that this material is being destroyed a small amount of it is going to our troops in iraq and we're thankful for that but jordi of it in all likelihood it will not be used unless health officials begin to find either ways to certify a longer time before expiration or they're dispersed to first responders who could in fact take advantage today of preparation for a possible anthrax outbreak this and many other areas are of importance to this committee because although there has been good work done since nine eleven to help america be the best it can be in the case of any kind of emergency including a manmade one budget cuts at the federal state and local level are in fact of great concern to us we have to know will we maintain our preparedness and even improve it and particularly our coordination or are we saving pennies now to not be able to save lives later thank you mr chairman for holding this hearing and i yield back thank you very much for your statement you'll find minister the gentleman from rhode island patrick kennedy thank you mr chairman welcome all of you i'd like to get into the response to potential pandemic  and the necessity to address the psychological response obviously back in the fort fifty's sixty's you know there was that civil preparedness everybody got under the desk everyone had a bomb out shelter there was a sense that we needed to get people prepared and then of  war world war three one thing that it did for people is it gave them a sense that they had some sense of control over their situation in light of these announcements for twenty four hour barrage from the media lot of people get anxious nervous because they don't know what they're supposed to do do you not think that it's necessary for us to you know even in the light of now that we have terrorists have people prepared in this country to have a plan of action in advance at their workplace at their school you know when they're traveling to  work when they're at home whatever the situation may be as to what the how to what to do things are that they need to follow in order to respond a given scenario and isn't it important that they practice that scenario and that we as a society encourage that kind of civil preparedness so that there isn't a i'm dances and the acting director of the coordinating office for terrorism prepared as an emergency response from the centers for disease control and prevention thank you for the opportunity to discuss the importance of state and local public health preparedness and response efforts and how we can further ou response to public health emergencies in the united states our nation's current response to the two thousand and nine novel h one n one influenza is a direct result of the investments and support from the congress for state and local public health preparedness and the hard work of federal state and local public health officials across the country this outbreak has placed huge demands on state and local public health departments to rapidly expand on the ground investigations and response activities and highlighted how necessary it is to have a trained workforce at the ready state and local public health departments are first responders to a wide variety of how threats many of which never make the evening news the many duties of public health departments include tracking the source spread and severity of how threats educating the public on how safeguard their how delivering medicines guidance and community interventions to lessen disease public health departments must have flexible and scal capacity to respond to all hazards both major events such as influenza pandemics and terrorist attacks also to more routine events including community outbreaks of infectious diseases chemical spills and natural disasters the primary federal support for emergency preparedness and response at the state and local public health department level is c d c s public health emergency preparedness cooperative agreement this cooperative agreement provides funding and scientific expertise in areas such as surveillance and health monitoring epidemiology laboratory testing countermeasure delivery incident management and emergency communications in addition public health departments receive supplemental funding for pandemic influenza preparedness from two thousand and six to two thousand and eight to support practical community based approaches to prevent or delay the spread of an influenza pandemic activities related to the supplemental funding include planning community summits to facilitate engagement across government agencies business and nonprofit organizations and exercises to test response capabilities such as providing anti viral drugs and vaccinating broad segments of the community these efforts paid off during the response to two thousand one hundred one and one influenza public health departments at the state and local levels have been working around the clock emergency operation centers have been activated and emergency plans put into place across the country public health officials started tracking possible cases of h one n one influenza tested a large number of specimens samples for the presence of the virus provided information to communities about how to slow the spread of the virus and educated the public about  precautionary measures they could take this education worked a national survey conducted by the harvard school of lakoff earlier this month found that two thirds of respondents report that they or someone in their household washed their hands or used hand sanitizer more frequently in response to reports about h one n one flu and over half say that they made preparations to stay at home if they or a family member became sick despite the great strides in preparedness and response work remains to be done more can be done to bolster the public health workforce which is the foundation of affective preparedness and response ongoing storage is exist in key occupations such as epidemiology laboratory science and public health nursing it is also a challenge to have enough public health workers at the ready to deliver medicines and medical supplies during an emergency the nation's systems for tracking disease can also be improved for example we do not have nationwide electronic systems to automatically manage and share data such as laboratory results that are vital for response efforts the path of the two thousand watt two thousand and nine h one n one outbreak may change we need to be prepared a possible resurgence of this virus in the fall potentially potentially in a more virulent form complicating matters other public health incidents that need our attention continue to rise food borne disease outbreaks floods wildfires soon the hurricane season will be here we must remain vigilant throughout this and subsequent outbreaks at no time in our nation's history have we been more prepared to face this kind of challenge nevertheless we more work remains to be done sis a few words about you as a deputy commissioner of public health for the state of new york he's in associate professor of epidemiology at the university at albany school of public health d thanks very much chairman towns congressman congressman ice and distinguished committee members thank you for the opportunity to testified today the events of the last month with the dramatic emergence of the h one n one swine influenza and the equally rapid public health response have proven the value of the investment we have made as a nation in health emergency preparedness planning in recent years in a short time we have learned a lot about h one n one but we still have a lot to learn last week it appeared that things were getting back to normal but the virus has continued to circulate in many communities and a number of schools as the chairman noted have been closed in new york city this week due to high rates of absenteeism from h one n one my testimony today i'll provide a little background about new york's response and addressed the committee's questions on april twenty new york governor david paterson directed the state health department to activate its emergency preparedness plan in response to the h one n one cases in new york state this plan was developed over a number of years of pandemic planning and involve the collaboration of programs across the healthy part meant other state governmental agencies and local public health departments including the new york city department of health in terms of the committee's question on the need for resources and the impact of the economic downturn to federal funds sources have played a critical role to the state in developing its current preparedness the c d c public health preparedness cooperative agreement which dr sausan mentioned and the d h h s hospital preparedness cooperative agreement these funds i would point out have been reduced by forty percent and twenty four percent respectively in the last five years in addition the state did receive pandemic influenza supplemental funds as dr sausan noted from two thousand and five to two thousand and eight but those funds have now also ceased new york city also receives the same direct funding new york state has provided sixty million dollars in the state budget to support state preparedness programming these funds have been used to purchase supplies and medications for the state's emergency stockpile including the supply for new york city we have purchased the maximum number of anti viral treatment courses allowed under the federal program and now have three point one million treatment courses of anti virals on hand we also as purchased other supplies such as seven thousand five hundred ventilator for patients with respiratory failure during a pandemic new york has made it a priority to fund local health departments which are key to the local response the boots on the ground if you will for local response we provided ninety six million dollars in state and federal funds over the last seven years to our local health departments funding to locals was viewed as so important at the state health department absorbed the entire cut in the c d c preparedness grant in recent years in order to keep the county funding whole however due to the current fiscal crisis county funding finally was reduced  almost forty percent for the remainder of the current contract cycle ironically this occurred on april first just before the h one n one hit many local health departments had to layoff preparedness staff at that point in this context the current discussion of the additional thirty three hundred  fifty million in one time federal funding to state health departments and locals to deal with h one n one is welcome news although they the exact number should be examined to be sure it's enough when we're clear on what we're being asked to do with it such funding will be critical for states to maintain and strengthen their public health response capabilities in the face of what will likely be an ongoing threat in particular state and local health departments are likely to play a key role in any mass vaccination efforts should an h one n one influenza vaccine be made such a vaccination program would be unprecedented in scope and give to given the size of the population to be vaccinated federal funds will be critical to these efforts but it is also critical for congress to look to restoration of the cuts i mentioned in the base public health and he th hospital preparedness programs respectively that states have sustained over the last five years one time funding cannot provide for ongoing infrastructure needed to address h one n one and future public health emergencies  conclusion some have suggested suggested that public health may have overreacted to these events because a severe pandemic has not yet materialized i want to assure you that each step of the way prudent steps were taken to prepare and protect the population in face in the face of uncertainty about the virus state health department scientists who have spent their careers working on influenza have commented to me that this h one n one virus represents the biggest shift in influenza viruses in their professional lifetimes while initial guidance for example to close schools following a single case may seem in retrospect have been overkill i would make the analogy to hurricane preparedness when a hurricane is bearing down on you you don't take the view that we can relax because it might veer off you have to assume the worst and prepare for it that is what the public health community has done in the past month with h one n one influenza we are much better prepared than we were even a few years ago however there are gaps in health preparedness infrastructure that can only be addressed by stable base funding to maintain that infrastructure i urge congress to consider city and county health officials welcome political that always helps good afternoon protecting and serving a population of four hundred seventy five thousand in kansas city missouri is a challenge we have one hundred forty three year history and tradition of protecting against contagious and communicable diseases approximately ten years ago in the spring of ninety nine i started asking where were we as a nation at the local public health department on these issues we've made a lot of progress but the old saying harder thing harder than preparing for a disaster is answering the question of why you didn't and so with  that i believe that our charge in looking at how we may need to reform some aspects of public health actually we can borrow a model from fire departments if you think about a fire an influenza fire burns through buildings influenza burns through people fire departments don't respond with the minimum they need to put out a fire they come in with extra trucks areas to put out that fire because you don't want to chase a fire they have surge capacity to respond to those types of events ninety nine percent of the time there are fires going on in our fire department ninety nine percent of the time our local health departments are being challenged with covering all their mandates right now so we don't have that surge capacity that we need to be able to respond as an example i really believe that if i think about our health department where we were back in one thousand nine hundred nine we were less than five percent prepared to manage a category three pandemic from influenza we've made tremendous progress  but i think we peaked back in about two thousand and six that in a sense we have a perfect storm going on with federal state and local funds being cut we don't have the people there to maintain our plans that were developed by the pandemic flu funding was critical for us develop relationships with our churches with our faith community in general with our schools with our business community but this exercise that we've been going through recently with this h one n one has really pointed out that the things that we put in place a few years ago those communities are now asking us to respond but the people aren't there anymore because the funding went away as an example i've got one hundred eighty six staff serving that almost half a million people but only twenty of them are really available for this kind of event they're either funded out of grants and that's an issue i think we need to look at or we could change the federal people under grants are expected to be cross trained and prepared for these kinds of issues whatever the funding source coming down that we would have them and be able to deploy them in these kinds of incidents we basically if we'd had to go any longer with this event we were at the point in the prepared to stop and reduce our number of restaurant inspections to stop some of our contact tracing for sexually transmitted diseases because we were running our staff at twelve fourteen hours a day half that time even over the weekend and that was all really voluntary because we don't pay them overtime so it really makes it  very difficult to manage our response was extremely effective we activated c d c was very helpful in communicating with us the national public health and information coalition was useful the things that we had were in place my fear is that we are losing ground and i had to really sum up i want to thank the other local health departments the state health department c d c for as a lot of responsibility and surround is also president elect of the association of ohio health commissioner and the former regional coordinator for public health preparedness and the northeast region of ohio thank you very much mr and members of the committee appreciate the time to talk to you today and i want to give you my perspective from greater cleveland what we know and what we still need to do and our experience over the last several weeks really has been a live exercise of our testing our capabilities in illuminating our gaps and challenges that we still have ahead of us as we really prepare for what is to come for the coming flu season the funding is very concerning to us as we acknowledge our capabilities which i'll talk a little bit about but also illuminates our challenges in greater cleveland we've been working hard for many years working with our partners throughout the  our ability to determine the distribution and determinants of disease or epidemiology capacity ability to communicate with the public which was very critical so that they had a trusted communication point during this event and working knowledge of  command structure that have been working with for many years in terms of our gaps we still have a lot of work to do around volunteer recruitment training and retention right now in the greater cleveland area we have about five thousand volunteers and we need closer to five hundred in our five county region we need about fifteen thousand volunteers that need to be trained they need to be oriented and they need to be made available very quickly to assist if we need to ramp up stay home from school to stay home from work to telecommute to the kids would then need to stay away from the mall so we're not in position of of passing the virus around vulnerable populations the poor and disabled are particularly at risk and local surveillance capacity to be able to identify early on when an outbreak may hit your community in my view public health is an essential partner and must be viewed as part of the national defense system acquiring stable and adequate funding for public health is absolutely critical if we're going to be available and reliable for the public in a way that they have a right to expect because of budget cuts we're particularly concerned and hopeful at the same time about the three fifty million dollars that was talked about in supplemental money that the house was gracious enough to put into the budget and we're hopeful that that will be part of the conference discussion in terms of personal preparedness that congressman kennedy spoke of we've suffered folks are paying attention right now so every family knows what to do we need resources now since as of august two thousand and nine pandemic flu funding will be zeroed out so it's our hope that we  learn or have the opportunity to continue these efforts and it really is about people it's people on the ground they're there to respond day in and day out to assure the public to limit the scope and repeating some of what's been said before i think i'll try to emphasize some points as the last intestate would be will be included in the record thank you a couple of points that i think are worth stressing as much as we'd like to believe this episode is over this episode is not over in the united states we still face a novel influenza that is spreading rapidly in this country it is in forty eight states as well as the district of columbia we have confirmed with laboratory fifty seven hundred individuals but there's probably more along the order of a hundred thousand americans who have been made ill so far and we frequently hear the comment that this is just like another seasonal influenza it simply is not the average age of the individual with this outbreak right now is nineteen the average age of an individual the intensive care unit with this illness is twenty three that is not a seasonal influenza seasonal influenza is also do not occur this time of year so this is a novel and new virus and we simply do not understand it yet we do not know what is going to happen in the fall and i would argue that if we're lucky this will come back in the fall if it goes away in the summer at the same level of violence but it would not be responsible for us to  not keep history in mind and recognize that in one thousand nine hundred eighteen that second wave was far more severe in one nine hundred fifty seven in japan and influenza came back with a second wave that was much more severe so history would mandate that we are prepared in the fall for what comes at us i do believe that we can be very proud of your committee can be very proud of the performance of the government and dr sauce and captain sausan and dr besser and all of health and human services in the federal government should be commended on the way this was organized so that the federal government state government and local governments came together as a single public health and city to respond to the american people the harvard survey is testament to that when eighty percent of the public reports that they are satisfied with the governmental response and eighty eight percent say that that they are satisfied with the information they've gotten i think we always go home it's not going to get any better than that but we still have many challenges and face to face now we did based on the investments congress made plan and exercise these plans over the past number of years and our response to date has been quite good as we all know plans do not survive the first contact and many assumptions in our plans were incorrect we assume that this virus would start overseas we would have a month to two months to figure out how transmissible this virus was and how severe it was well it didn't it began in north america so we had to activate plans without really understanding the transmissible how severe it was we don't fully understand that right now but we were able to adopt and modify what we were doing and i think provide a very good response as you heard the other witnesses testify there's a big difference between a three week response which we've just gone through and a full epidemic or pandemic response which may be six months or more we simply cannot sustain the level of response we have had in this nation to date as was mentioned we do not have the workforce we don't have the depth on the bench it is only humanly possible to work two to three shifts for so long with a workforce that has been cut by eleven thousand in the past year and likely will be cut by eleven thousand more at the local and state level it is not humanly possible to maintain this response and that is why we need your help we as i mentioned before we have seen significant cuts in state and local preparedness funding that comes through the c d c we have seen significant cuts in the hospital parents money which comes out of asper and h h s and in addition we have had no pandemic plan planning funding at the state local level since august of zero eight so what you're seeing is a response but there's no fuel in the tank and we're asking you please to assess the states in the locals to mount a response for what may come at us in the fall very quickly i'll give you one example of what we have to prepare for it we are likely to develop a p influenza vaccine this novel h one n one vaccine for the fall it likely will acquire two doses that is six hundred million vaccinations we may have to give in the fall on top of the usual eighty to one hundred million doses we do we give for seasonal influenza so we're talking about potentially seven hundred million vaccinations to give in the fall with a workforce that is diminished the complexity of that not only the cost of it but the complexity of administer americans in a timely fashion is tremendous the vaccine will roll off the production line at fifteen to twenty thousand doses a week it will be distributed by the federal government to the states on a per capita basis so it will be drivelling and over a number of months and we have to get on a priority list to protect the first responders the health care providers and others so as one example that is the level of complexity we face and that is a need we need resources for the fall and i'm happy to answer questions i apologize for going over time thank you thank you i mean just think all of you for your your testimony let me just say that that that is sort of frighten me you know when you think about it in terms of and then you saying  to achieve six hundred million doses right if i misspoke i apologize what what initially there will likely be able if that comes off of that scene is going produce we're not quite sure how large that will be after that fifteen to thank you realistically historically in a outbreak once we get past the first responders don't we always allocate our resources to less than the entire population including the plan you have for smallpox and i guess i'm leading up to the point we don't have enough smallpox vaccine to begin to do the entire population that's not even in the plan is it  stockpiled we do have sufficient smallpox vaccine for the entire population the challenges of administering that vaccine really where the the bottleneck and the most difficult challenges will lie but your broader point which is planning for catastrophic event ok let's take the anthrax for example how many how many doses do you have today in a stockpile and more importantly how many will you have five years from now with the current no order i'll have to get back to you on the specific numbers we have both antibiotic treatments for anthrax as well as vaccine for anthrax and strategy increasing vaccine as well as developments of a new generation  which means the system fails inevitably runs into limitations of resources and therefore prioritization and strategies to to do the best we can and address the  we can within the limitations of resources and back to the resources for just a second doctor so since we spend about twice as much as the europeans do on health care i'm going to assume that money alone doesn't fix the problem based on how we spend money on health care in america just the fact that we already spend more than the nations were being compared to isn't the most important thing for us to have is a plan to ensure that our first responders including all the health care professionals that will receive people are able to be continuously an ocular rated prepared or if we don't have something the first to receive in that sort of the crux to the most important crux of the plan is that we not lose those people which dr jurist and others have said are already in short supply clearly there are a number of priorities for how we respond most effectively and first line responders are one of those priority groups whether that's in the health care system whether that's in emergency response in their margins the management system i think the comments made earlier about vulnerable populations however reflect government responsibility to assure that those with the least access and the  ok and one follow up to something i said my opening comment since the anthrax stockpile is expiring and it has never been offered broadly to first responders do you have a plan to deal with making that available to first responders around the country including our health care professionals rather than destroy the stockpile which is currently in the plan there is ongoing discussions amongst the emergency responder community with the department of homeland security department of health and human services about the appropriateness suitability of this vaccine in that setting there have been advisory committees for immunization practices looking at and providing permissive guidance that without sufficient understanding of risk that there may be a point in time when risk is sufficient to warrant prevent acts anation of those populations so there is discussion about that there is the ability to make that vaccine available before it expires but that's active discussions going on right now well let me just ask one final follow up questions chairman if i may may aren't our health care professionals specifically doctors and nurses at our community centers around the country aren't they the most informed consent individuals and if you have a distribution request and it's a voluntary taking by those individuals remembering that our military it's not voluntary they get they know they get the shots where they like it and they you know they go to combat they're going to have it wouldn't that be a group that by definition the safeguards you're talking about protecting them from not having enough informed consent isn't this a group of people that we normally rely on to  and therefore if a doctor in place at the cleveland clinic or cagr a community hospital wants that medicine and believes and has the normal informed consent are they by definition the people that should be allowed to make that decision not have it micromanaged in washington thank you sir your vote and welcome my understanding is that the license vaccine is actually potentially commercially available the company has indicated that they have  capacity to produce and sell the vaccine additionally these questions are really about purchases that the federal government has made and is there a strategy for making that available to populations in need i'm not aware that the medical the health care community in a similar way as they were not terribly interested in smallpox vaccine is not indicated an interest in anthrax vaccine at the same time responder community here is mixed in terms of their perspective of whether that should be required or made available to them and their part of homeland security is establishing whether this is appropriate for their for their approved equipment list and therefore can be used the funds could be chairman that wasn't my question a question is before we throw this material away or actually spend money destroying it will we make it a voice available with ordinary you know if you will informed consent so that it not be literally thrown away well the alternative to go by is what the hospitals including the first responders in cleveland who asked me about this when i was there and that's that's an excellent question and the a c to fly yield to the gentleman from from rhode island you have a plan but without the resources you really have a plan you can't carry it out and i think that you know you need to just be honest about it and just sort of pointed out and let's see if we can get some help  and at the time we testified before the committee a couple weeks ago when we said we were requesting three hundred fifty million dollars for state and local preparedness that was a figure that's a very low figure that figure would be equivalent to what we have we asked for was basically a nother sum of money to continue the level of planning it prepared us we did it now frankly we made a mistake because that was before we knew how serious this was and how how serious the fall may be so the three hundred fifty million in the house right now is probably not nearly enough and it's a start to get us to revise our plans we also asked for some money to purchase anti virals and to get to mr iss point for health care workers  critical response or responders our national stockpile right now only has countermeasures masks and anti virals for treatment it does not have anti virals and masks for profile access for health care workers public health workers unable so we asked for money for that also so clearly we need more money as you say it is not appropriate to put first responders whether public health fire or ambulance squads in harm's way without protecting them and yet current national stockpile does not have anti virals for that prophylaxis so we really do need more money and i'm sorry we under asked that thank you very much and i yield to the gentleman from rhode island who had asked this question you might want to rephrase it now services committee for a yes we're going to be going into markup in the next couple weeks but this is frightening all i know is that i would be derelict my job as a member of congress as a member of that committee next fall if i'm sitting there in congress and we have this flow and it's by all accounts this flu is coming back and this scenario that you're you're painting for us is happening and i'm sitting there after having sat in this hearing and someone said why aren't you in that hearing did you hear what they told you and i did nothing about it and for one thing we have been told there are going to be any more supplemental so that this has to be part of this year's budget it's got to be part of this year's appropriations so we had better get to it and knowing that the glazed over look in you know appropriators eyes when you talk about more money for this and that if this if something isn't burning up you know things are going to get funded you've got to really as as you all of said seize the opportunity that we have right now in terms of the public's attention on this and really make the most of it because we're not going to have this opportunity til next fall and then it's going to be too late  we had better move now and i just want to underscore your urgency about this and say don't hold back and you're not stepping on anybody's toes  you're going to be derelict in your own responsibilities to the administration which you work for and to your own obligation to public health a few don't make some really aggressive and ambitious budgets and put them forward in spite of whatever higher ups because frankly i'm going to demand it i'm going to push for it as i know the chairman will be to get these answers the fact that you can't even vaccinate one third of your current population when you have a year to prepare for it terrifies me and we have just a few months to prepare for the h one n one this fall and we can even prepare to get a third of the yearly which is only a million and change and we're talking about six hundred million doses i mean the scale of this thing is enormous and i don't think we can even wrapped our heads around how big a challenge this is so we need to know the number the ratio of public health personnel to the population that is needed we need to know the ratio of   prophylactic quitman all of those things need to be sized up and again i ask you what do we have in terms of plans for the faith e mail for what i mean what are we doing to be able to message people when it comes to this modern society to be able to communicate with them so they're not just getting messages from  a twenty four hour news that often are inflammatory and are full of misrepresentations in terms of news how do we get facts out there and real information terms of what to do and where to go so people feel empowered and not fearful that's the key is what i want to ask you guys how do we make people feel empowered  here thank you thank you sir getting to your first point about having confidence in your government having confidence that you know what to do and therefore responding more effectively that's absolutely critical numbers th jerry shared about this event where we approached a very aggressively we did use twitter and widgets and other kinds of tools to reach the broadest population we could distributed from the federal level state and local  levels through practitioners as well as directly to the public communications just in time about what you can do and what you can expect and what we know what we don't know has been one of the successes of our response so far maintaining the pace of addressing the complexity those will be challenges in a in a larger scale event for sure so so yes we're responding to some of those communication challenges that end  power the public power business etc we've definitely come a long way with respect to engaging business engaging the faith community engaging the public and we have a lot more work to do i will point out that those plans that have been discussed here have been evaluated in quite a lot of detail twelve departments two offices of the white house participated in a joint review of the pandemic influenza plans and there's a volume of information on the  dot gov website on those evaluations importantly the kinds of activities that we've been talking about here lie in the lane of public hell where the strongest parts of those plans the weakest parts of those plans where the broader interagency intergovernmental coordination interdisciplinary coordination with the emergency response community at large with the service sectors etc so even the plans that we have reflected gaps and needs for more effort not just sustainment of where we were six years ago i just like to add that i agree completely public communication is critical we can't respond to a pandemic in this country without people understanding what their role is what they need to do and we've invested a lot of effort in new york and i know in the other states in in trying to do that we've also worked with our business and faith communities we've worked with businesses to develop continuity of operations plan so they can continue to operate in a pandemic particularly if you know people can can work from home that kind of thing that doesn't always work but to try and think through and i you know in a normal flu season we only vaccinate one hundred million people because there's not a demand out there for it i think we've gotten their attention as others have  said with this h one n one and that the challenge will be how to meet the demand that i suspect we will see if we did really roll out of that scene and try to offer to everybody that that will be the real challenge and you're right we need to have a detailed plan of how many people we need to do that we partly need to see when it's going to happen how quickly it will roll out will we really see fifty million doses a week coming out there's a lot of detail there to give you a precise answer but we need a lot more than we have right now kennedy i think you know the whole issue of this culture of preparedness getting folks to think about this red cross has worked on this for some time when people have a sense that nothing happens they think that you know public health is chicken little they're saying you know i think from our end this is a wake up call and we're hoping to now capitalize c d c has some great educational information that talks about you know clean hands save lives just a basic message is critical but but there's lots of fear and there's a tremendous amount of rumors that occur in the middle of this that everyone here has dealt with that need to be dispelled as quick as possible and that that individual preparedness in planning for families and understanding messaging  are i think essential the it's nice that there's now attention being paid to public health and understanding of the critical nature of what we do so i'm glad that this discussion is  being you bring up a very important point about communication and maintaining the credibility of government and what we saw in one thousand nine hundred because a lack of transparency if people did lose faith in the government and we saw some of the social fabric in this country neighbor caring for workforce and that is why we need to have that bench strength and those professionals those nurses laboratory and epidemiologists on board every day so we can surge with them part of that system of public health that we so clearly need are experts in communication and you mentioned on the h h s subcommittee very importantly the communication was done so well because we had experts working on how to communicate with the public who are monitoring the twitters the blogs the web newspaper articles television media where the direction was what are people thinking what are they reporting so we could on a daily basis adjust our messaging and on a daily terrible name and a very unfortunate name but they are undergoing significant cuts in the budget i believe it's nine million in the old nine budget and three million in the ten thousand and ten budget has a terrible name marketing we say what is that doing in public health what they are doing is understanding how to communicate expertly with the public and much of our success was due to that centers work so i ask you to take a hard look at that and maybe they could change their name we will get back to you with the challenge you put out to us on the ratios in regards to public health volunteer as a matter and i think that's critical to give you an example we have a full time public information officers that's paid out of  the time within five minutes if we don't get a call from the media in two days we check the battery or try to figure out what's going on because they're constantly having interaction with the media that allows us to change that message when the message is wrong at the six o'clock we can usually get it changed by the ten o'clock news because we have the interactions with the media that's present in all of our communities and we need that support but that person burned out in th dr if you were going to be somebody who wanted to plant a virus in five hundred people that would have the most impact on this country if you were going to  out a profession five hundred people maybe two or three professions and you guys looked at exactly who's got what group of people have the potential to spread the problem fastest and  so with respect to terrorism and biological terrorism there is an intergovernmental process of establishing risk and conducting a risk assessment that includes understanding of impact something that is really quite daunting i just think about what we can do as an oversight rather than just complain about what the executive branch is not doing enough what we can do to be proactive on it  became obvious that somebody at work with public health that last october that if there was ever five hundred people who could come in close proximity to a lot of people all over this country  that all meet at one location and go out into the country would be the members of congress i mean you talk about you know the vectors you know paid for with taxpayers money other group that's probably probably the only group that's probably more than duly elected representatives of the house and senate would be flight attendants and pilots i don't know there may be other professions but boy i'll that we may have this right through the summer there is a lot of attention to the virus domestically as well as abroad particularly in the southern hemisphere which is entering its typical question we're talking about what we can do if you had a f d a approved post exposure treatment that was genetically engineered to address eleven out of sixteen different strains if you had the ability to have an effective post exposure treatment or or had a vaccine that was multi strain in itself got also be putting pressure on that where when we talk about crisis along they need to change your procedures and we need to change our procedures to make sure that we don't like the british when they're fighting  zulus have everybody lined up in straight little rows while they're being wiped out because the regulations say that's what you have to do to get em all rather than get to change our procedures to make sure you have the assets that could be available to you not just because of monetary but because of regulatory obstructions dr your comment yes i think there's a very good example of where we could use assistance in this regard there is a shelf life extension program currently that's the de but if we could develop a shelf life extension program so they discarding hundreds of millions of dollars worth of anti virals that would be extremely valuable minimal cost and that is clearly an intergovernmental affair extending the expiration date so that process actually is available to states who have received from the federal supply to relive there's a process that has to be gone through but the shelf life extension program is a broader issue thank you sir one thing i'd like to start off by knowledge ing is that as surveillance and bio surveillance begins at the local and state level and what we are able to provide back to state and locals to help inform them is a broader bigger national picture that crosses jurisdictional boundaries so it's a partnership from from the ground up bio surveillance some of the efforts to to get earlier qs of vents that might be happening detect them and respond to them more quickly that narrower piece really had a relatively small role to play in the early development of this this outbreak because it was laboratory detected very early on and a major focus at the public health level to go out and investigate laboratory confirmed cases and better understand this this outbreak as the outbreak spread our ability to understand what is going on broad communities where the laboratory was only one small piece of the broader outbreak that information is becoming more valuable certainly the probably the most useful piece of focus that we made in bio surveillance  past few years is is how we integrate information from multiple different types of information streams and then present that to decision makers on a daily basis in briefings in slide sets and whatever else that we share broadly and we have had some success there as well so i think that the feedback on bio surveillance efforts is too early in this outbreak to tell you entirely and i think the focus on bio surveillance as syndrome of influenza like illness is to narrow the focus on to focus on health information technology and electronic laboratory information death certificate information and hospital or medical information is a place where at the newspapers i think if we start to move forward on a pandemic we're going to be stressing the system the current level so the area that we're dealing with sporadic activity in ohio and in the in the greater cleveland area adequately advance detection preparedness and response capacity to a level that would be necessary for a more severe virus to emerge we were back in two thousand and five somewhere around two point two to two point five million in terms of our funding level for the county and that involved both the city and county that allowed us to advance our plan i think i think substantially which means now we're losing people which means the to do other national issues can go a long way if we look at a situation where we're going to be having to vaccinate folks to a new virus also dealing with flu vaccination dealing with a potential escalation of severity in the fall that confluence of things right now we're not prepared to address and what about would you if there was an increase in the incidence would you have the infrastructure at this moment to be able to keep up with testing suspected of virus well that testing in ohio specifically ties back into some rapid detection work that's being done in the hospitals and contact occurs through the state health department and the i think mr chairman it would be interesting to state health department about their contact with us because if something is getting out of officers even though they're in physical contact they're wanding check in passports and come into physical contact on a regular basis with these folks and again they use the term medically unnecessary now meanwhile we've got other instructions from folks should cover their mouths wash their hands and avoid unnecessary travel to mexico so now i've got hundreds of the checkpoint and the mexican folks on the other side the mexican security officers all have these masks on but but we're being told it's medically unnecessary and meanwhile the world health organization has  of the national average and we're not letting our folks wear these masks because it might alarm the public and i'm just wondering where is the sense of that policy th appropriate whether it's ever appropriate for people to use protective equipment or not is is an issue i don't want to i don't want to touch on but whether it should be required or recommended is is the challenge that c d c has been  is that when in doubt we offer guidance which protects the worker when in doubt whether influenza can spread through airborne mechanism and we have a severe situation we err on the side of protecting the worker the challenge the w h o phases are not severity based and the challenge in this entire outbreak has been is this more severe than what we see in seasonal flu and therefore should we take more extreme measures than we typically take in seasonal flu as you know the border border patrol does not border agents do not wear masks during flu so that question of are they at risk of more severe illness than they would be under circumstances comparable has been the challenging most challenging part of this we continue to watch for evidence of severity for evidence of uniqueness and needs for protection and to offer guidance which is minimum permissive of that type of five pandemic which according the world health organization says phase five is a strong signal that a pandemic is imminent and that the time to finalize the organization communication and implementation of plan medication measures very short  common sense into the situation congressman i think your question is is a very valid one and it's an example the types of things we've been wrestling with for the last three weeks and while we haven't gotten sleep in the last three weeks there are many many examples of issues like this where we as dr sausan said we don't because the started in north america we didn't have the two months to figure out how this transmitted from one person to another was an aerosol was a droplet we didn't simply know that  it was was a border guard at risk or not at risk what did it take to actually transmit this we didn't know that how severe it was it didn't i mean it initially given was going to mexico we were very concerned it looked as if it wasn't severe but we still don't quite know that so we were in a situation of trying to make decisions in the face of tremendous uncertainty always balancing what is the prudent thing to do against what is the disruption to  society with regard to what we were two weeks ago i was in a committee in which we were being encouraged to close the border now in retrospect i think we would have said that probably wasn't the right thing to do but there certainly were people feeling strongly that well why wouldn't we do that so this is what we're struggling with and this is an indication of why we now need to go back given we've had these plans which have been obviously imperfect and we give you many other examples of imperfect situations and dedicate the time and the resources this summer to figure out what are we going to in the fall if this comes back bigger what are we going to in the fall this comes back more serious and we need to be prepared we need to address some of the issues of how do we look at e and you do say properly i think we're going to figure this out by the fall you know and i think everybody on the panel has you know we could have a tough tough situation in the fall meanwhile our border patrol people transit security officers cannot use masks it seems rather silly to me but you know we'll see how that goes mr chairman i have i have abused my time and i want to yield at this point and thank you very  much let me thank all of you for your testimony you know i appreciate your thoughts and insights and i appreciate the interest of all the members who attended the hearing today before we adjourned i would like to emphasize the continuing need for attention to be given to the issue of state and local and in the red as we have seen in recent weeks an outbreak strike at any time and potentially take a heavy toll we must be prepared in order to protect the lives of our citizens we don't wait for a house fire before we make sure that our fire department have fire engines and water hoses likewise we can not wait for a pandemic before we make sure our public health departments have trained responders and a mechanism in place  strengthen of america's public health system would provide federal support for improving public health agencies effectual disease and surveillance and reporting what kind of sustained support can the federal government provide given today's harsh economic circumstances and how can states and localities the federal government and other entities leverage the resources that we already have in order to increase our public health response committee records and without objection the committee stands as my ga