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30–041 PDF 2006

S. HRG. 109–604

PREPARING FOR PANDEMIC FLU

HEARING

BEFORE THE

SPECIAL COMMITTEE ON AGING 

UNITED STATES SENATE

ONE HUNDRED NINTH CONGRESS

SECOND SESSION

WASHINGTON, DC

MAY 25, 2006

Serial No. 109–24

Printed for the use of the Special Committee on Aging

(

SPECIAL COMMITTEE ON AGING 

GORDON SMITH, Oregon, Chairman 

RICHARD SHELBY, Alabama 

SUSAN COLLINS, Maine 

JAMES M. TALENT, Missouri 

ELIZABETH DOLE, North Carolina 

MEL MARTINEZ, Florida 

LARRY E. CRAIG, Idaho 

RICK SANTORUM, Pennsylvania 

CONRAD BURNS, Montana 

LAMAR ALEXANDER, Tennessee 

JIM DEMINT, South Carolina 

HERB KOHL, Wisconsin 

JAMES M. JEFFORDS, Vermont 

RON WYDEN, Oregon 

BLANCHE L. LINCOLN, Arkansas 

EVAN BAYH, Indiana 

THOMAS R. CARPER, Delaware 

BILL NELSON, Florida 

HILLARY RODHAM CLINTON, New York 

KEN SALAZAR, Colorado 

CATHERINE FINLEY, Staff Director 

JULIE COHEN, Ranking Member Staff Director 

(II) 

C O N T E N T S 

Page 

Opening Statement of Senator Gordon Smith ....................................................... 1

Opening Statement of Senator Herb Kohl ............................................................. 3

PANEL I 

Hon. Michael O. Leavitt, Secretary, U.S. Department of Health and Human 

Services, Washington, DC ................................................................................... 4

PANEL II 

Nancy Donegan, director of Infection Control, Washington Hospital Center, 

Washington, DC; on behalf of the National Hospital Association .................... 27

J. Steven Cline, DDS, MPH, chief, Epidemiology Section, Division of Public 

Health, North Carolina Department of Health and Human Services, 

Raleigh, NC .......................................................................................................... 42

APPENDIX 

Prepared Statement of Senator Hillary Rodham Clinton .................................... 55

(III) 

(1)

PREPARING FOR PANDEMIC FLU 

THURSDAY, MAY 25, 2006 

U.S. SENATE, SPECIAL COMMITTEE ON AGING, Washington, DC. 

The Committee met, pursuant to notice, at 10 a.m., in room 

SD–G50, Dirksen Senate Office Building, Hon. Gordon H. Smith 

(chairman of the committee) presiding. 

Present: Senators Smith, Kohl and Carper. 

OPENING STATEMENT OF SENATOR GORDON SMITH, 

CHAIRMAN 

The CHAIRMAN. Good morning, ladies and gentlemen. We welcome you to this hearing of the Senate Special Committee on 

Aging, and our hearing today is ‘‘Preparing for Pandemic Flu.’’ 

We have heard a great deal in the last several years about emergency planning and response. The tragedies of September 11 and 

Hurricanes Katrina and Rita showed us all just how vulnerable we 

can be to both man-made and natural disasters. Applying the lessons we learned from the past, we move forward with preparing to 

address the potential threats of tomorrow. While much may still be 

unknown about those threats, more and more indicators suggest 

that we may soon face a pandemic outbreak of a new influenza 

virus. 

One does not have to look far back into history to see how devastating a severe pandemic flu can be to our society. In 1918, Spanish flu killed an estimated 2 percent of the world’s population, 

mainly the young and the healthy. The milder Hong Kong flu outbreak in 1968 killed 34,000 in the U.S. alone, and caused between 

$71 and $166 billion in economic losses. 

We have been fortunate not to experience a catastrophic flu outbreak for many decades, but the emergence of the highly aggressive 

avian flu virus in the late 1990’s has generated a sense of urgency 

among the world’s public health officials. 

Just this week, a case of human-to-human transmission of the 

avian flu virus was reported in Indonesia. Reports such as these 

suggest that the next severe influenza outbreak could be looming 

on the horizon. In response to this threat, the United States has 

undertaken a significant effort to prepare for the next pandemic. 

Just recently, the Homeland Security Council released a lengthy 

pandemic influenza implementation plan. This report provides 

broad directives for all sectors of our society to follow in order to 

effectively prepare for the next flu outbreak. 

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I commend the efforts of the administration to put forward a 

comprehensive framework for pandemic flu preparedness, but it is 

clear we have much yet to do. Biotechnology and pharmaceutical 

companies continue to search for a safe and effective pandemic flu 

vaccine. Hospitals and other facilities are developing plans to ensure they have the necessary supplies and staff to handle a significant influx of patients. 

As we move forward with this important work, it is essential 

that we keep the special needs of older Americans in mind. They 

may be more vulnerable to an infection due to preexisting health 

conditions or weakened immune systems. The more outreach we 

can do to the elderly in our communities before an outbreak occurs, 

the better protected they will be. 

I hope we can use today’s hearing to delve more deeply into what 

needs to be accomplished to safeguard all Americans from the 

harms of a pandemic, but especially those most vulnerable, such as 

the elderly, the disabled, the chronically ill and children. 

I am very pleased to have my friend and our Secretary, Secretary 

Leavitt, with us here today, and I look forward to your testimony, 

Mike. 

The witnesses we have assembled represent many of the key parties that will be involved in the initial response to a flu pandemic. 

If we have learned anything from the past, it is that all levels of 

public and private sectors must coordinate their efforts to successfully respond to an emergency. 

While much is still unknown about the nature of the next influenza outbreak, we must press forward with implementing a comprehensive response effort. As Benjamin Franklin once said, an 

ounce of prevention is worth a pound of cure. That was true then 

and it still true, and it is certainly true as we look toward this horrible potential event. 

In light of today’s discussion of pandemic flu preparedness, I am 

pleased to join one of my Senate colleagues, Senator Evan Bayh of 

Indiana, in filing the All Hazards Public Health Emergency and 

Bioterrorism Preparedness and Response Act. This important legislation will help State and local communities better respond to the 

unique public health threats they might face, and creates new tools 

to encourage much-needed public health workforce development. I 

hope the Response Act will help guide Congress’ discussion of how 

future public health planning and response efforts can better safeguard the health and well-being of our citizens. 

So with that, I will turn to my friend and my colleague, Senator 

Kohl of Wisconsin.

3

OPENING STATEMENT OF SENATOR HERBERT KOHL 

Senator KOHL. Thank you, Mr. Chairman, for holding this hearing. 

Experts no longer ask if such a pandemic could occur. Rather, 

they question when it will occur. Earlier this month, the White 

House unveiled its plan for responding to a flu pandemic. This plan 

is a constructive first step with at least many serious questions unanswered, like which Federal agencies and officials will take the 

lead in responding to an outbreak emergency. 

I am concerned that we are not prepared to care for the complex 

needs of our Nation’s seniors, in particular. The elderly are among 

our most vulnerable members of society and they are far too often 

overlooked or even ignored in emergency preparedness plans. 

Hurricane Katrina illustrated how we failed the seniors who 

need us most. Last week, we chaired a hearing in this Committee 

where we heard that 71 percent of those who died during Katrina 

were over the age of 60. We need to learn the lesson of those 

deaths and make sure that any strategy to prepare for pandemic 

flu incorporates the unique needs of seniors. 

We need to do a better job in telling older people what supplies 

and plans they need to have in place in the event of a national 

emergency like pandemic flu. As a start, my office has developed 

a tip sheet, and HHS and DJS should follow with pamphlets, public announcements and specific direction for seniors and the agencies that serve them. 

We also must direct States and local governments to include in 

all planning, training of first responders and practice exercises for 

national emergencies. Communities need plans to locate and help 

seniors who live at home if a flu pandemic occurs. 

Federal, State and local governments are making progress in 

preparing for potential outbreak, but I believe we need to do more. 

Even if we are spared from a flu pandemic, the work that we do 

today will serve us all well in the event of any national emergency. 

We look forward to hearing from our panels today about the direction our Nation should follow and what it will take to deal with 

pandemic flu, including steps we must take to care for our seniors. 

Again, Mr. Chairman, I thank you for this hearing and we look 

forward to hearing from our witnesses. 

The CHAIRMAN. Mr. Secretary, thank you for being here, and 

your staff and others. We appreciate all that you and your Department have done. We have seen you a lot on TV, and you obviously 

know the subject well.

4

STATEMENT OF HON. MICHAEL O. LEAVITT, SECRETARY, U.S. 

DEPARTMENT OF HEALTH AND HUMAN SERVICES, WASHINGTON, DC 

Secretary LEAVITT. Senator, thank you for holding the hearing. 

It is an important subject. 

Pandemics happen. They are part of the biologic world. They are 

a biologic fact of life. They are part of the microbial world of viruses and bacteria that are constantly mutating, constantly finding 

ways to survive in more and more hosts. 

The history of pandemics isn’t so much the history of public 

health as it is humankind. As you pointed out, we have periodically 

throughout history had pandemics. You can go all the way back to 

the city of Athens in 430 B.C. and see the evidence of 25 percent 

of that great city’s population being wiped out by a pandemic disease. It not only changed the city’s health, but it changed their future. It affected their politics, it affected their prosperity. It 

changed the city in an irretrievable way. 

That has been true almost entirely every century. We would see 

evidence of two or three of these. The 14th century may be the 

best-known—Black Death. Twenty-five million people across Europe died. Again, it did not just affect the health; it affected the 

culture and it affected the politics and the prosperity of that entire 

region. 

You mentioned the fact that we have had 10 pandemics in the 

last 300 years. We have also had three of them in the last 100. You 

mentioned 1968 and 1957. They were what the scientists refer to 

as relatively small events by pandemic scale. They were highly efficient viruses; that is to say they spread quickly, but they were not 

particularly virulent. Not many people died. 

1918 that you also referenced, on the other hand, was both efficient—it spread fast—and it was virulent. Lots of people died, and 

that, of course, is the type of event that we need to be prepared 

for. We hope and pray it will not occur, but that is the level at 

which we need to prepare. 

We are today concerned properly, in my judgment. Scientists fear 

that the H5N1 virus that is spreading across the world on the 

backs of wild migratory birds could, in fact, be the spark of the 

next pandemic. No one knows with certainty, but the warning signs 

are there. We are seeing the capacity for this virus to jump the species barrier, clearly going from birds to people. We are also now 

seeing, and have throughout the history of this virus, very limited 

and highly inefficient transmission between people. You mentioned 

the circumstance in Indonesia. I am happy to respond during the 

questions if you would like to know more about that. 

We are concerned not only because it is widespread; we are concerned because of its genetic similarity to the 1918 virus. It is clear 

by the course of events over the last several years that this is a 

aggressive killer once it gets into people, and so there is reason for 

us to be concerned. For that reason, the President has asked that 

we mobilize the country. 

I have been moving throughout the country, having summits in 

every State, including Wisconsin and Oregon; in fact, almost every 

State now. Tomorrow, I will be in New Hampshire. It will be our 

51st summit. We are doing summits in both the territories and in 

5

the States. These have been rallying events. More than 20,000 public leaders from the health community, from local political leaders, 

from schools, from businesses have come for the purpose of being 

able to begin community planning. 

It is part of a comprehensive plan. There is no single action that 

prepares a community for this kind of an event. It requires our 

working on vaccines, on anti-virals, developing stockpiles, on having community preparedness. At the very foundation of preparedness, however, is a prepared community. The fundamental message 

of our summits has been this, that any community that fails to prepare, with the expectation that the Federal Government or even 

the State government can get to every community and rescue them 

at the last moment, will be sadly and tragically, mistaken not because any of us lack a will or because we lack a sufficient wallet, 

but because there is no way that a government can get to 5,000 

communities at the same time. 

That is one of the peculiar and very important distinctions of a 

pandemic. It is highly local. It happens everywhere at the same 

time, but it is a highly local event. The truth is we are overdue for 

a pandemic. 

The CHAIRMAN. Mike, to that point, could I ask you a question, 

because it really is what is on my mind? It is local. Obviously, even 

hurricanes are somewhat local, and 9/11 was local, but are there 

lessons from those response efforts that local communities are 

drawing lessons from that specifically related to the flu pandemic? 

Secretary LEAVITT. Senator, in your statement you mentioned 

some of the disasters we have endured as a Nation. There are 

many lessons to be learned. One of the lessons is that you have to 

think about the unthinkable because it happens. Another important lesson in my mind is that what you do before an emergency 

is far more important than what happens after in terms of being 

able to prevent injury and damage. 

But perhaps the most important will be the difference between 

a pandemic and any other natural disaster. Katrina was a devastating weather disaster. It covered Louisiana, Mississippi and a 

piece of Alabama, but at least it was constrained to that area. A 

pandemic would not be. 

In Katrina, we had people literally come from all over the country to help. That could not occur in a pandemic because people 

would be in their hometowns looking after their families, their community, in a way that would prohibit it. 

We also learned, I think, that most emergency events, if you will, 

like a hurricane or a bioterrorism event, are constrained as to time. 

The event occurs and then we move into recovery. That is not the 

case with a pandemic. It goes on for more than a year in waves. 

So life has to go on, so our preparation for a pandemic is different. 

The CHAIRMAN. I am sorry to interrupt you. 

Secretary LEAVITT. No, that is fine. I would just say that we are 

overdue, and we are not as well prepared as we need to be. We are 

better prepared today than we were yesterday. We will be better 

prepared tomorrow than we are today. It is a continuum of preparedness. 

No one knows whether this current virus will be the spark of a 

pandemic. We do know that pandemics happen and that we need 

6

to be better prepared. Everything we do on a pandemic helps us 

become a safer and a healthier community. Whether it is for a pandemic or whether it is a bioterrorism event, the preparation essentially is the same. 

The CHAIRMAN. Does that conclude your testimony? 

Secretary LEAVITT. That concludes my statement, yes. 

The CHAIRMAN. Do you think local communities are taking this 

seriously? I know you are and I know the Department is because 

I have seen evidence of it everywhere on news shows and reporting 

that is going on. But is this just sort of, well, that is what happened in the bubonic plague era, not ours? 

Secretary LEAVITT. Well, I think we are clearly moving from the 

buzz phase to the business phase. There are lots of communities, 

many companies, many schools and colleges and communities, and 

so forth, that are beginning to take action. Regrettably, there are 

those who haven’t yet, and that is where we need to focus. 

The thing about a pandemic and preparedness is that it requires 

everyone to prepare. This isn’t just something we can delegate to 

our local government. Every business needs to have a plan. Every 

college needs a plan, every school needs a plan. Every day care center, every residential facility or long-term care facility for the elderly needs a plan. Every hospital needs a plan. Every family needs 

a plan. This is something on which there is a shared responsibility 

throughout society. 

The CHAIRMAN. Isn’t it true that where we have had these recent 

outbreaks in Indonesia just this week, and I believe Romania 

where there have been deaths, there is literally human handling of 

birds, specifically plucking the feathers, wringing the necks and 

eviscerating them in a very hand-held fashion? 

Secretary LEAVITT. You are making an important point. I have 

said if you are a bird, it is a pandemic. If you are a human, it isn’t. 

This is clearly a bird disease at this point. The worry is that it will 

mutate, and there are steps of progress that viruses make and one 

of those steps is to go from bird to human, and then the next step 

is to go from human to human, and the next step is to go from 

human to human in a sustained and efficient way. 

We have done a very good job in this country of sensitizing people to the human-to-human worry. What we have not done as good 

job in is making certain that we underline the words ‘‘sustainable 

and efficient.’’ We have seen human-to-human transmission in a 

very inefficient and highly unusual way. 

We saw it in Hong Kong in 1997. We have seen it in Thailand 

last year, and now we have seen it, or at least there is some suspicion we may be seeing it in this case in Indonesia. In each of 

those cases, it can be found in an index case. The first case generally started with a bird. What we are finding in Indonesia is that 

there was, in fact, the index case of a woman who was, in fact, handling birds and became sick in a way very similar to that which 

others have. 

The investigators have found that those who then later contracted it were in very close proximity to a severely ill woman, and 

they were sleeping in quarters that are described as essentially a 

closet. While it has not been demonstrated, the best hypothesis we 

have at this moment is that because of their intimate and close 

7

contact with the highly sick patient, they may have, in fact, contracted it as well. There is nothing inconsistent about that over 

what we saw in Thailand or in Hong Kong in 1997. 

We continue to watch that very closely. I am happy to report to 

you that we have some of the best scientists in the world on this 

subject who are literally on the scene and who are literally examining those people and doing the kind of investigation that needs 

to be done. 

The CHAIRMAN. Mr. Secretary, it probably needs to be said as an 

assurance to the elderly who often tune in to this hearing that 

there is a reason why we haven’t had these sporadic outbreaks in 

the United States, in Europe and the more Westernized parts of 

Asia, and that is that the eviscerating operations in this country 

run to very high sanitary and mechanized kinds of procedures. I 

suspect you have seen the turkey plants in Utah. I have seen the 

chicken ones in Arkansas. It is amazing. It is not a business I 

would want to be in, but it is very clean and sanitary. 

Is it important to remind the American people what is being 

done to protect the fowl and the consumption of bird products in 

this country? 

Secretary LEAVITT. It is. It is important not only to remember 

that, first of all, it is a bird disease, not a broadly based human 

disease. Second of all, we have not seen an H5N1-positive bird in 

the United States yet, and we have certainly not seen it in a 

human being. 

It would not be a big surprise to us to see a wild bird with the 

virus on board, simply because they are wild and they fly through 

natural flyways all over the world. When that occurs, it will not be 

a crisis. It would not be a big surprise at some point to see it in 

a domestic flock, but your point is an important one. We manage 

those flocks with great care. The Department of Agriculture has 

seen these kinds of high-pathogenic viruses before. They know 

what to do. 

Perhaps the final point that must be made is that poultry when 

properly cooked is safe. Cooking kills the virus, and there is not a 

reason for people to reduce, for example, their consumption of poultry out of worry because of avian influenza. 

The CHAIRMAN. One of the other concerns I have, Mr. Secretary, 

really relates to where we are as a Nation in terms of vaccines. As 

you know better than anyone, we don’t do many vaccines in this 

country anymore. We have literally litigated them abroad. 

Secretary LEAVITT. Well, that may be among the most important 

problems that our preparedness has brought focus to. The good 

news is we believe there is the capacity to develop a vaccine that 

could provide an immune response to this virus. The bad news is 

we do not have the capacity domestically to produce a sufficient 

supply for every person in the United States to have a vaccine. 

That is part of what the President has put forward, an ambitious 

effort to change that. 

Some of that is because the vaccine business has become a lousy 

business in our country. Over the last 25 years, most of the vaccine 

manufacturers have gone out of business or have discontinued that 

work. The Congress was, I think, insightful in appropriating $3.3 

8

billion. Two weeks ago, I spent $1 billion of it on vaccine manufacturing technology research that is being done. 

We have a plan that, within 3 to 5 years, we will change that. 

Our ambition is to have the capacity to not only isolate a virus, but 

then to be able to produce a sufficient supply of vaccines for every 

person within the United States who chooses to have one. 

The CHAIRMAN. Within the United States? 

Secretary LEAVITT. Within the United States. 

The CHAIRMAN. That is an important thing to achieve, frankly, 

because if we actually had a pandemic and all the manufacturers 

in Europe have the same problem, they are not likely to want to 

send it here; they are going to use it there. 

Secretary LEAVITT. That is an important insight and one that we 

acknowledge. Consequently, part of our criteria has been to assure 

that any new manufacturing capacity that we partner to develop 

is done domestically. 

The CHAIRMAN. Senator Kohl. 

Senator KOHL. Thank you. 

Just to follow up a little bit more on that, Mr. Secretary, what 

sense of urgency is there to develop our capacity for this vaccine? 

You know, if it is coming on board 5 or 10 or 15 years from now, 

then we are just having a nice conversation today. 

Secretary LEAVITT. When I first began focusing on this problem, 

it appeared that, first of all, there was no additional capacity coming online. Second of all, the plan to get to what is known as cellbased technology, which is the big hope in being able to manufacture it more quickly, appeared to be somewhere between 8 and 10 

years away. 

I have met with all of the manufacturing organizations, with 

NIH, with the scientists. The President has, as well, and we have 

asked them to help us find every way possible to accelerate the development of this technology, and for that reason we are partnering 

and the $1 billion of contracts that I released on May 4 are a very 

good and important indication of that. The 3 to 5 years that I have 

spoken of is an ambitious, and I might say very aggressive approach, and will have substantially reduced the amount of time 

that it would have taken had we not taken that action. 

Senator KOHL. If we have a pandemic this year or next year, is 

it fair to conclude that we will not have what we need to have by 

way of vaccinations? 

Secretary LEAVITT. Let me go a step further than that, Senator. 

Pandemics, as I indicated in my opening statement, generally last 

about a year to a year-and-a-half, and they come in waves of between 6 and 8 weeks. It takes about 6 months from the time we 

have isolated the virus that caused the pandemic to create a safe 

vaccine and to manufacture it. 

Best case: What that tells me, and I am sure you, is that during 

the first 6 months of a pandemic we will be without a vaccine no 

matter what. The business of creating vaccines is really about 

being able to have it for the second and the third wave. 

What you have stated is correct. We would not have sufficient 

supply of vaccines for the first wave even after we have been able 

to develop this capacity because you really can’t stockpile in large 

measure vaccines because the virus you are ultimately going to be 

9

preparing the vaccine for may be substantially different than the 

one that you have been preparing for. 

Now, we are stockpiling significant stockpiles of vaccines. We 

have 8 million doses of the best of an isolate we created in Vietnam. That would produce some level of immune response, but it 

would be far from perfect and we are basically working as we go. 

What that means it that when you start dealing with a pandemic, 

you have got to have a comprehensive approach, and we are working intensively right now to develop social distancing and public 

health tools that communities can use in order to limit or to contain viruses as they happen in their communities. 

Senator KOHL. You said that local communities to a large extent 

will be on their own during a flu pandemic and shouldn’t expect a 

great deal of help from the Federal Government. What assistance 

should State and local communities expect from the Federal Government in the event of a pandemic? 

Secretary LEAVITT. Thank you, Senator. There is a very important role for the Federal Government and we are going to play it, 

but it is important to define it. An example of one of our roles is 

the international monitoring that we have just reflected with respect to Indonesia. We are building a network of laboratory capacity and having personnel on the ground all over the world so that 

if this begins to happen anywhere, we have a knowledge of it at 

the earliest possible moment. 

That gives us the capacity to respond and prepare. It also would 

give us a head start or a jump start in the development of vaccines, 

for example. So international monitoring and national monitoring 

are a role that only the Federal Government can play, and we will 

play it. 

Vaccine development—again, it would be unreasonable that any 

one community or a State, even, would develop a vaccine. Therefore, the Federal Government has taken responsibility for the development of vaccines, and we are making substantial progress and 

I have reported partially on that. 

The third area would be in the development of stockpiles of antivirals and other matters. Now, I have been very careful and direct 

in telling the States that our stockpiles will be insufficient to cover 

every community, but at least it gives them a start on something 

that they can begin to build. 

A fourth area in my mind is State and local preparedness. We 

have begun to create checklists and to hold exercises and to push 

hard for local communities to realize that they simply cannot ignore this and expect that the State government or the Federal Government overall will resolve it. 

These checklists that I have—this is one on long-term care facilities, for example. You mentioned that in your statement. Those 

checklists and the exercises that we do reveal our weaknesses. We 

can never be afraid to see our weaknesses because that is how we 

get stronger, and that is one of the roles of the Federal Government. 

Another role that we are playing is to work on how to communicate on this. This is a tough subject to deal with. The problem 

is anything you say in advance of a pandemic seems alarmist. On 

the other hand, everything you would do to get ready for it when 

10

it starts is inadequate. So we are working to teach State and local 

governments and businesses and schools how to talk about this in 

ways that inform, but will not inflame, and ways that will help 

people to prepare, but not to panic. Those are all roles that the 

Federal Government can and must play, and we are doing everything possible to assure we do our responsibility well. 

Senator KOHL. Earlier this week, the Washington Post reported 

on a study at Baylor College of Medicine that shows that people 

older than 65 may need as much as four times the standard level 

of flu vaccine for effective protection. Are you taking that into consideration as you build our stockpile of flu vaccine? 

Secretary LEAVITT. That is a very important piece of information 

and we are taking that very seriously, and it gives me an opportunity really to talk about one of the side benefits of all of this pandemic preparedness. 

We have had inadequate annual flu vaccine for many years now. 

Every year, we go through a period of are we going to have enough, 

are we not going to have enough. We have had a lot of producers 

offshore or out of the United States that have had problems and 

it is an ongoing problem that we have to solve. 

One of the benefits of creating new vaccine manufacturing capacity is that we can take that annual flu vaccine problem off the 

table forever because we will have to keep our pandemic vaccine 

capacity warm, if you will, and the best way to use it will be to 

make annual flu vaccine. That would give us now an opportunity 

to say, rather than use a one-size-fits-all method of application for 

the annual flu, we can begin to say, well, perhaps we have got to 

look at seniors. Maybe they don’t have a similar immune response, 

and if that is the case, we will now have flu vaccine that will allow 

us to provide it. 

Senator KOHL. Thank you very much, Mr. Secretary. 

The CHAIRMAN. Thank you, Mr. Secretary, for giving us insight 

for all the contingencies and make the preparations. 

Secretary LEAVITT. Thank you, Senator. 

[The prepared statement of Secretary Leavitt follows:]

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[Recess.] 

The CHAIRMAN. Thank you for your patience, ladies and gentlemen. 

Let me first begin with an introduction of our panel. We will first 

hear from Dr. Steve Cline. He is the Chief of Epidemiology for the 

State of North Carolina and he is overseeing the State’s pandemic 

flu preparation efforts. He will discuss the work which States like 

North Carolina are beginning to undertake with the new pandemic 

influenza preparedness funding that Congress recently appropriated, specifically highlighting plans for outreach to the elderly 

community. 

Then we will hear from Nancy Donegan. She is the director of 

Infection Control for the Washington Hospital Center. She is here 

today speaking on behalf of the American Hospital Association. The 

Washington Hospital Center was one of the primary facilities involved in the 2001 anthrax scare, so they have had firsthand experience in responding to a community-wide emergency event. Her facility has developed a communicable disease response plan and she 

will discuss the specific issues it addresses. 

We appreciate your both being with us today. Shall we go ladies 

first? 

STATEMENT OF NANCY DONEGAN, DIRECTOR OF INFECTION 

CONTROL, WASHINGTON HOSPITAL CENTER, WASHINGTON, 

DC; ON BEHALF OF THE AMERICAN HOSPITAL ASSOCIATION 

Ms. DONEGAN. Good morning. I am Nancy Donegan, the director 

of Infection Control at the Washington Hospital Center, a 900-bed, 

Level I trauma center which is part of the MedStar Health Corporation. On behalf of the American Hospital Association’s 4,800 

members, I appreciate this opportunity to appear before you today. 

Pandemic influenza is one of many possible emergencies that 

hospitals face. Hospitals maintain all-hazards plans for responding 

to a range of events, from natural disasters, to terrorist attacks, to 

pandemic outbreaks. Today, my testimony will highlight three 

issues: the capacity demands of pandemic influenza, the pandemic 

plan at the Washington Hospital Center, and AHA’s recommendations for the Federal Government’s role related to hospital preparedness. 

To prepare for emerging infectious diseases like avian influenza, 

hospitals must be ready to care for a large increase, or surge, in 

the numbers of acutely ill patients over a prolonged period of time. 

Surge capacity involves increasing hospital staffing and resources 

needed for patient care. 

Hospitals can increase their patient care capacity for relatively 

short periods of time by surging in place; that is, rapidly discharging appropriate patients, canceling elective procedures and increasing the number of staff. While surging in place can temporarily increase patient capacity, most hospitals will be overwhelmed if an event involves large numbers of ill over a prolonged 

period of time, such as in a pandemic, as supplies and staff are depleted. At the same time, hospitals will need to continue providing 

routine acute care, such as treating traumatic injuries and attacks 

and delivering babies. 

28

Over the last 5 years, hospitals receiving funds through the National Bioterrorism Hospital Preparedness Program have improved 

readiness. To date, hospitals have received about $2 billion. However, there is still a significant gap in readiness. In a sustained disaster such as a pandemic, hospitals would rapidly face a shortage 

of personnel and critical supplies such as ventilators, gloves, 

masks, gowns and drugs. The New York Times has reported that 

the national supply of ventilators, which would be critical for caring for patients in an influenza pandemic, falls far short of the estimated need. 

The Center for Biosecurity at the University of Pittsburgh Medical Center has estimated that the minimum cost of realistic readiness for a severe 1918-like pandemic are at least $1 million for an 

average size hospital. We believe that to have adequately prepared 

hospitals, a portion of Federal pandemic funding should be directly 

applicable to hospitals. 

The pandemic plan at the Washington Hospital Center follows 

the three pillars of the National Implementation Plan: one, preparedness and communication; two, surveillance and detection; 

three, response and containment. Our plan employs both high- and 

low-tech methods to communicate important just-in-time messages 

to staff and physicians. We have developed computerized and 

paper-based tools for reporting cases to the public health department and to hospital clinical areas. 

During a pandemic, all entry points into the hospital will need 

to screen patients based on epidemiologic definitions provided by 

the CDC. Hospitals will also need to screen all workers on a regular basis during a pandemic episode. In our plan, we have detailed methods to have workers self-monitor and self-report symptoms of respiratory infection. 

The best clinical response would include the use of effective vaccine or anti-viral therapy. Without effective vaccination, prophylaxis and therapy, infection control measures are the only strategies left to prevent transmission in the hospital. 

Infection control measures rely on patient isolation and personal 

protective equipment, along with engineering controls. The hospital 

has designed ER One, the Nation’s first all-risks-ready scalable 

emergency facility to handle mass-casualty events, including the 

ability to handle contagious patients. 

The AHA supports the Federal Government’s efforts to increase 

the stockpile of anti-viral drugs, increase research on non-egg vaccine production, and develop a prototype vaccine for avian influenza. In addition, an allocation plan for anti-viral drugs and vaccines must recognize the importance of hospital staff, physicians 

and emergency personnel. 

In conclusion, the National Pandemic Influenza Implementation 

Plan states, preparation requires infrastructure and capacity, a 

process that can take years. Hospitals do not have the means to 

create infrastructure or capacity with current funding. If the Nation is to be protected, hospitals will look to the Federal Government for greater resources to meet the anticipated burden. 

Mr. Chairman, thank you for the opportunity to testify. I look 

forward to answering any questions. 

[The prepared statement of Ms. Donegan follows:]

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The CHAIRMAN. Thank you, Nancy, and we will have questions. 

Steve, take it away. 

STATEMENT OF J. STEVEN CLINE, DDS, MPH, CHIEF, EPIDEMIOLOGY SECTION, DIVISION OF PUBLIC HEALTH, NORTH 

CAROLINA DEPARTMENT OF HEALTH AND HUMAN 

SERVICES, RALEIGH, NC 

Dr. CLINE. Thank you, Mr. Chairman and distinguished members of the Senate Special Committee on Aging. I am honored to 

be testifying here today before you on behalf of public health and 

the 8.7 million citizens of North Carolina, 2.4 of whom are over the 

age of 50, representing 28 percent of our population. In the next 

couple of decades, we expect that to increase to 35 percent of the 

North Carolina population over the age of 50. 

I am proud to be here. When I was explaining to my family that 

I was doing that, children have a way of keeping you humble. They 

said, why are you speaking to the Committee on Aging? Oh, Dad, 

it is because you are old. [Laughter.] 

Preparing for and responding to an influenza pandemic will be 

a monumental task that will affect all of us, young and old. The 

National Influenza Response Plan and the National Influenza Implementation Plan you heard Secretary Leavitt speak of places 

much of the responsibility to appropriately planning, preparing, detecting and responding on our Nation’s State and local health departments. Our citizens have expectations that we will get that 

right. 

This sense of urgency is further heightened by the amount of 

media attention pandemic flu is getting. We see daily death counts 

of human cases of bird flu as they move from Southeast Asia across 

Europe, and certainly on its way to the U.S. 

We have TV movies dramatizing fictional pandemics in this 

country, and newspaper stories almost daily, some saying we are 

not ready, some saying there is more transmission happening 

human-to-human, as in yesterday’s article. Of course, as we have 

already alluded to, we all watched the devastation of Katrina on 

the Gulf Coast and wonder is our community ready for such a big 

disaster. 

In my comments today, I would like to focus on three things: the 

progress that we have made in the area of preparedness; second, 

the challenges that we still face; and, third, how can Congress help 

keep us making progress. 

First, in the area of accomplishments, let me say thank you to 

Congress for the substantial Federal investment you have made in 

public health preparedness. States like North Carolina have done 

much to get ready, and as Secretary Leavitt said, we are much better prepared today than we were yesterday and we hope we will 

be better prepared tomorrow. I will mention briefly just some of our 

accomplishments in North Carolina and would be happy to answer 

questions about them following the testimony. 

As you heard, all emergencies start locally, so we have invested 

a substantial amount of money in our State in local public health 

preparedness in all 100 counties, in all 85 health departments serving those counties. We have built a health alert network system, 

43

a secure system for notifying our key partners when an emergency 

occurs. 

We have increased our capacity in our State Laboratory of Public 

Health, which will be a critical component to identifying, isolating 

and understanding the infection. We have built a hospital emergency department surveillance system that connects all 113 hospital emergency departments in North Carolina and reports every 

12 hours to the State Health Department. 

We have built public health regional strike teams and based 

them across the State so that they can respond wherever it 

emerges. We have built State medical assistance teams, which is 

a three-tiered system for scaling up medical surge capacity in our 

State. We have created public health epidemiologists in hospitals, 

borrowing from the concept of embedded journalists in the Iraq 

War, and put public health people inside hospitals, which has 

helped tremendously. We have also improved our interoperable 

communications, and training, training, training. 

In the area specifically of pandemic flu response, we have a very 

robust plan in North Carolina, the North Carolina Pandemic Flu 

Response Plan, first written in October 2004 and revised substantially this year. We have a broad-based pandemic flu planning committee which makes sure we are taking into account all of the citizens of North Carolina. In particular, we have a special populations 

work group that can focus on the unique needs of elderly, disabled, 

home-bound and other minority groups, particularly those who 

have English as a second language. We are developing a tool kit 

building upon the checklists that our Federal Government has and 

making those specific to North Carolina. 

There are challenges that are unique to being an older American 

and I would like to highlight just a couple of those. Older Americans, we have already acknowledged, are one of the fastest-growing 

segments of our population. They often have fragile health, which 

requires more services, not fewer. More services during a pandemic 

may create a problem. 

We are worried about reaching the non-institutionalized older 

adults. How do we find them? How do we know they are safe? How 

do we know they are healthy? We are working closely with community-based organizations who often are best at reaching those people, but will they be available and able to help us during an emergency? We have heard some discussion this morning already about 

the annual flu vaccine and the importance of providing good annual 

flu vaccine to all Americans, particularly our elderly. 

Where do we go from here? I have already mentioned the importance of funding. Sustained funding is the key component for us to 

continue making progress in preparedness. 

The second is to improve our adult immunizations. We heard 

Secretary Leavitt speak about hopefully improving the vaccine production system. That is important, but it is also important to improve the demand for that vaccine. Our people need to show up for 

those vaccines. Only about 48 percent of adults in our State get the 

annual flu vaccine. Also, the infrastructure to provide those vaccines needs to be improved. Vaccine production, we have already 

heard about. 

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Communications is another important component. The communications are tricky in a normal day. In a crisis and in an emergency, they will be even trickier. We will need strong leadership 

and clear messages if we hope to reach the public with the important information that they are going to need. 

In closing, I would like to say responding quickly and effectively 

to a pandemic flu will require extraordinary measures, in an atmosphere of fear, chaos and human tragedy. A strong, well-supported public health system is critical to saving lives and managing 

the crisis. The investments that have been made must continue if 

we expect to serve our citizens well. 

Thank you. I would be happy to answer questions. 

[The prepared statement of Dr. Cline follows:]

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The CHAIRMAN. Thank you, Steve. Forty percent of adults or seniors show up for flu shots in North Carolina? 

Dr. CLINE. No. Forty-eight percent in North Carolina get the annual flu vaccine. 

The CHAIRMAN. What if the other 52 percent showed up? Would 

you have it? 

Dr. CLINE. It is often an issue of timing and mal-distribution, not 

that we haven’t had enough vaccine. We have had seasons when 

we did not have enough vaccine, but most recently the vaccine arrived late. People think about getting their vaccine in October, November, December. January and February, which is still part of the 

annual season—often, that is not on their mind anymore and they 

don’t show up for those vaccines. 

The CHAIRMAN. Is it for want of information, or is part of it some 

choose not to have it? 

Dr. CLINE. I think some choose not to have it. I bet we have all 

heard of people who say I am worried the flu vaccine is going to 

give me the flu, which is false. Let me go on the record saying that. 

The CHAIRMAN. That is why I asked the question. I want to get 

that out. It is false. 

Dr. CLINE. But also I think people think if it is a vaccine toward 

the end of the season, it is not going to help them that season. That 

is also false. Flu can occur all year. In fact, we have flu all year, 

and whatever immunity you develop to that virus that year may 

help you, in fact, in any other flu virus attack. 

The CHAIRMAN. Steve, since this is the Committee on Aging, 

what is your State, and what should other States be doing to have 

some coordination with nursing homes and assisted living or people 

living independently, but who are still needy? 

Dr. CLINE. We have built something in our State called—the acronym is SMART, but it is the State Medical Assets Tracking System. What it does is allow us to know exactly how to contact every 

long-term facility, hospital, group home in our State that is licensed. We are able to put that in a geographic information system 

so we can map it. They are part of an electronic communications 

system so that we can easily communicate with them. Hopefully, 

working with them to develop their own facility plans, there will 

be a way for us to get good information to those residents. 

The CHAIRMAN. You are getting information to them to have a 

plan in case of an epidemic? 

Dr. CLINE. Yes. I would say probably the most important thing 

we are doing now, and I would suggest we should all be about, is 

engaging that group, that population, the facility employees, directors, staff, as well as the public. 

Dr. CLINE. Do you also have a relationship with area agencies on 

aging and with faith-based organizations that have their own networks? 

Dr. CLINE. We do. We work with them at the State level and 

their State representatives, but our real work is getting our local 

public health departments to work, and know those and build those 

relationships locally. 

The CHAIRMAN. Well, that is very commendable. 

Nancy, I wonder if Washington Hospital Center and other 

MedStar facilities have staff vaccination policies; in other words, 

50

getting the people who are working there and taking them coming 

in—how do you keep them healthy? 

Ms. DONEGAN. We do have a policy and we encourage flu vaccine 

very actively. It is not adequate that some of these biases and feelings that people have about flu vaccine have continued through 

time, despite, I would say, increasing campaigns to reach our 

health care workers to get a better vaccinated staff. 

Recently, the guidelines for influenza for next year introduced a 

new issue that encourages us to have declination statements from 

health care workers who refuse the vaccine. Although it hasn’t 

been implemented yet, I think it is a very good strategy as the 

bridge to probably some time when we will have mandatory vaccine 

for our workers. 

We hope that when there is a face-to-face decision with some 

face-to-face counseling rather than posters and education campaigns that people will make that choice. We approach the campaign with a little bit of information focused on protecting the employee, but I think we focus more and have our greater success 

when we focus on the patients they are talking of and their obligation to not be a conduit to expose their most vulnerable patients, 

and probably most effectively that, being in the public exposure, we 

want them to protect their babies at home and their elderly at 

home. That seems to be our greatest take right now, now that it 

is voluntary. 

The other thing that we are doing with that in preparation for 

pandemic flu is that we are trying to increase the dedication to vaccine that everyone in the hospital recognizes is their obligation, so 

that as we sometimes fall on a bad year, whether it is avian influenza or just a very bad non-avian influenza, we already will have 

the infrastructure; that this is a hospital where our workers get 

vaccinated. So the last couple of years, we are really trying to promote that with a much more aggressive stance. 

The CHAIRMAN. You mentioned in your testimony the need for 

Federal dollars coming directly to hospitals for these preparations. 

That is not happening now? 

Ms. DONEGAN. No. It seems as though most of the funding goes 

to public health and that we appeal to public health for distribution 

to hospitals, so that hospitals are really quite independent in their 

problem-solving, although they look to public health for reinforcement. 

The CHAIRMAN. Are public health agencies not sympathetic to 

hospitals? 

Dr. CLINE. I would like to answer that. She is correct. The HRSA 

funding for hospital preparedness comes to public health, and we 

think at least in our State that is a very good way to do it because 

we are actually able to work at a State level and coordinate all of 

the needs—hospitals, emergency medical services, homeland security grant dollars and public health dollars—and then apply it 

where it is appropriate. 

The CHAIRMAN. But if you see the need, you are going to be 

there. She is saying the need is there, or at least it could be. Are 

you sensitive to that, Steve? 

Dr. CLINE. Well, all of that money is going out to hospitals, correct, yes. 

51

The CHAIRMAN. I know we are spending a lot of money. It just 

seems like there is never enough, but that is true in almost any 

category of the appropriations that goes on here. Senator Kohl is 

in charge of appropriations, so we will look to him to figure out 

how to get the right amounts. 

The question I have, Nancy, is as to partnerships that Washington Hospital may have with other medical facilities in the area. 

Are there regulatory issues that are an impediment to using one 

another’s backups or anything you need us to be aware of that we 

should——

Ms. DONEGAN. No. I think that the hospital community has 

worked together one institution with the other quite well through 

time. We refer to each other, we refer to each other’s services, and 

many of our workers work in multiple institutions. 

Clearly, after September 11 and after the anthrax attacks, that 

communication linkage became much more formalized. There are 

networks that are very formalized, and even some of the smallest 

threats that—you know, in this area, sometimes we have worries 

that will come up and we quickly go into a network kind of methodology where we have communication and reinforce that communication. 

Our hospital, the Washington Hospital Center, is part of a corporation, so we have a linkage with the corporation that is very formalized, and then one that is somewhat formalized with other hospitals in the region so that we have sharing. 

Our biggest problem, despite our sharing—our sharing is really 

more on the communication level, but in our area, and I think in 

many areas, we really have all of our beds full everyday. We have 

patients in our hallways. So the idea that we could take more patients from another location—we aren’t able to do it, nor are we 

able to send our patients to another facility. They are full, too. 

So the idea of surge capacity, I think, is limited. We have limited 

success in that, in that we can do sort of an immediate response. 

But once we have filled those beds and once we need to maintain 

an ever-increasing population of patients, we really max out and 

we run out of structure, and there isn’t a sister institution that can 

pick up our burden. We really sort of max out through the system. 

The CHAIRMAN. Just one last question. Are there any protocols 

existing between post-9/11 and Katrina from lessons learned there 

that would help all the medical facilities in this area? If there were 

actually someone who came down with avian flu here, is there a 

facility identified as the best one to take that individual, someone 

with a contagion of that nature? 

Ms. DONEGAN. I don’t know everyone’s readiness. Our hospital 

does work very much to be able to stand behind the statement that 

we are all-risk-ready. Clearly, we have quite elaborate plans for a 

pandemic, and we had those plans beginning before 9/11. We clearly ramped them up after anthrax and the idea of bioterrorism, and 

I think our greatest educator so far has been SARS, especially 

what happened with Toronto and their experience. We really used 

that as our model for readiness. 

So we would say we are very ready, but I suspect from talking 

to people in other hospitals that each hospital has amplified their 

readiness significantly. I don’t know if it is to the same degree as 

52

we have. Partly because of our location and partly because of our 

sort of unique make-up, I think we are really dedicated to this 

issue. But I think most hospitals have changed their point of view 

on this and have much more accelerated degrees of readiness than 

they had. 

The CHAIRMAN. Well, I am not even suggesting that the policy 

implicit in my question is a good one. I don’t know. 

Steve, should there be a facility designated or not, or should each 

one be prepared to deal with it on their own? 

Dr. CLINE. I think each one has to be prepared to deal with it 

on their own, and I think if we look at the smallpox experience 

when we were planning how we would deal with smallpox, no hospital wanted to stand up and say, OK, I will be the smallpox hospital. It really didn’t make sense until you knew more about where 

it was emerging and how it was happening. 

I think the best readiness is going to be to make sure each hospital has a plan and that all hospitals are talking to each other and 

public health, and we will make a good decision when that happens. 

The CHAIRMAN. Senator Kohl. 

Senator KOHL. It seems as though it would be a reasonable conclusion that, depending upon individuals such as yourselves all 

across this country, some communities are far more advanced in 

making preparations. Would it be reasonable to assume that other 

communities of equal size would be far less advanced? Because it 

is apparently being handled as a situation that needs to be dealt 

with on a State-to-State and local-to-local basis, would you estimate that to be the case? 

Ms. DONEGAN. I would suspect there is some variability. For the 

most part, the efforts that you take in preparing for these, there 

are not special teams; no one gets hired to be the pandemic coordinator. The efforts come from taking busy people in busy jobs and 

sort of peeling off a new layer of responsibility. So I would imagine 

there is significant variability in the amount that different institutions have been able to do and that it is quite a task, but I don’t 

know the measurement of that variability. 

Dr. CLINE. I would agree there is not really a good measurement 

of it. North Carolina is an urban and rural State, so we have small 

communities that we know are not as well prepared as some other 

parts of the State. What we are doing to compensate for that is to 

build some regional capacity that we hope can move into that area 

if it happens and while we are still working trying to get every 

community ready. 

Senator KOHL. In the event of a flu pandemic, isn’t it essential 

that we have sufficient quantities of vaccination, without which 

most other preparations are going to be totally inadequate? Is that 

a fair conclusion? 

Dr. CLINE. Well, I think we are preparing for the reality that for 

the first wave of the flu there will not be a vaccine that is highly 

effective. But after that, we are hoping that there will be a vaccine 

and there will be some control measures that our citizens have gotten used to. Vaccination is one of the marvels of modern medicine 

in terms of preventing disease. We certainly want to get there as 

fast as we can, but with the flu virus, which changes regularly, we 

53

are going to have to wait until it emerges and then develop the 

vaccine. 

Senator KOHL. How long does that take? In your judgment, how 

long will that take? 

Dr. CLINE. Well, I think Secretary Leavitt said 6 months. I think 

the annual cycle is closer to 9 months for when they develop and 

can manufacture enough to get it out to all the providers. As you 

heard, they are making efforts to reduce that cycle to where it is 

a shorter time, and if we can move to the newer cellular technology—right now, they use eggs for developing that vaccine—we 

hope that will shorten that time. 

Senator KOHL. Well, does this mean that if a flu pandemic 

breaks out, we are defenseless for several months? 

Dr. CLINE. I will let you answer, but it does mean that infection 

control is going to be the important factor. 

Senator KOHL. Is that right, Ms. Donegan? 

Ms. DONEGAN. That is exactly right. The SARS experience really 

is our best model for teaching us not only that hospitals can put 

in good practices without therapy and without vaccine, but that infection control can work. However, infection control efforts are very 

difficult to maintain because they are behavior-based and they are 

barrier-based. In a complicated hospital setting where the technology and the acuity of the patients demands sort of a focus on 

patient care, some of the burden of using masks and goggles and 

gowns—it is very hard to have personnel do that with the reliability that they need to do to make this a fail-safe plan. 

So with a vaccine, you can really protect the employee while they 

are doing their typical activities. Otherwise, you are left with this 

infection control behavior that is difficult and has an element to fatigue to it. The workers in Toronto needed quite a bit of reinforcement because of the fatigue factor from really doing infection control strategies completely. Clearly, as they do more work on a respiratory track—when they sort of do a more high-risk procedure, 

then we need to provide even more barrier for them to protect them 

during those procedures. 

So those elements work, but they need reinforcement, they need 

a lot of equipment. They really need us to protect our employees 

for issues like the fatigue factor and that we have a good stream 

of material for them. 

Dr. CLINE. I do think SARS was a success story for containment 

without treatments and vaccines in this country, but it was much 

smaller scale. North Carolina had one of only eight laboratory-confirmed cases of SARS in the United States. It involved three of our 

hospitals. At the time, we thought it was only being transmitted 

in the health care setting. So it was not in the community. Pandemic flu will be very different because it will be in the community 

and our public will be asking how do I protect myself and my family. Some of the extreme measures of mask and gown and barrier 

protection are not going to be available, or maybe not even effective 

in the community. 

Senator KOHL. What do you imagine will happen if the flu pandemic breaks out and communities all across our country know 

that it is here and about, but we don’t have a vaccine? What is 

54

going to be the individual reactions of families and entire communities? You have probably thought about that. What do you think? 

Dr. CLINE. We have thought about that and we have also asked 

our public what is their likely response. What we get is they will 

self-isolate. They will figure out how to take care of themselves and 

their family in their homes as much as possible for as long as possible to try to avoid being in a place that they are worried could 

transmit the flu. 

Senator KOHL. Does that mean they won’t go to work and won’t 

send their kids to school, just go out maybe to buy essentials at the 

store and go back home? 

Dr. CLINE. Exactly, exactly. 

Senator KOHL. Is that what is likely to happen across our country? 

Ms. DONEGAN. I think that is the view that we share, yes. 

Senator KOHL. You can imagine a situation where the entire 

country virtually shuts down if it is a truly national pandemic, a 

flu pandemic, because there is no vaccination available and the 

hope is isolation so that you are not contaminated. The only way 

you can do that is by staying isolated, meaning you don’t go to 

work and the kids don’t go to school. All the meetings that are 

scheduled are called off. Is that right? 

Ms. DONEGAN. I think so. I think the dim view is how much economic and social impact this will have by behaviors like you are 

talking about. Then the more rosy view I think we also learned 

from SARS is that we saw this adaptability of a population where 

they met many of their responsibilities in life. They put on masks 

and they kept their social distancing. Humans in large degree are 

adaptive, and so I don’t know to what extent—clearly, I would 

think there would be the extent that we are talking about with this 

enormous impact and dysfunction. Then I would imagine that we 

would also see examples of resiliency and some return with adaptation that comes on a personal level, is my view on that. 

Dr. CLINE. Yes, I agree with her. Obviously, though, if we all 

self-isolated, there are some things about our way of life that would 

stop and that we not really prepared to do. There is some critical 

infrastructure and critical business that gets done in this country 

that we really can’t afford for all of them to stay home. 

So we are beginning that dialog in North Carolina to say where 

do you draw that line. Has every business taken a look at what 

they need to do to maintain just the bare minimum of their work 

going and develop a plan for that? We are trying to help them with 

that and coordinate that so that those critical needs of food and 

power and shelter can continue. 

Senator KOHL. Thank you. Thank you, Mr. Chairman. 

The CHAIRMAN. Thank you, Senator Kohl. 

Nancy and Steve, we are grateful for your presence here today 

and your patience with the interruption of the roll call vote. You 

have contributed greatly to our understanding and we salute your 

preparations. 

With that, we are adjourned. 

[Whereupon, at 11:33 a.m., the Committee was adjourned.] 

(55)

A P P E N D I X 

PREPARED STATEMENT OF SENATOR HILLARY RODHAM CLINTON

Thank you, Chairman Smith and Senator Kohl, for calling this hearing today, and 

bringing attention to the issues of the elderly population in pandemic situations. 

In many of our discussions around pandemic influenza, we have been looking back 

at the events of 1918, when young, healthy individuals bore the brunt of illness and 

death. 

But when you consider the other pandemics of the 20th century—those that occurred in 1957 and 1969—the elderly were among those that were hardest hit by 

the virus. 

The pattern in the 1957 and 1969 pandemics mirrored those that we see every 

year during our seasonal flu epidemic, when we have over 36,000 deaths and more 

than 200,000 hospitalizations that are concentrated among elderly individuals, who 

are at greater risk of complications from the flu. 

As such, I think that we need to increase our preparedness for the special needs 

of senior citizens to ensure that they will be able to continue to access necessary 

medical and support services without interruption. 

But what is particularly worrisome to me, when thinking about our nation’s ability to help seniors get the vaccines and antivirals that will help them survive a pandemic, is the fact that we aren’t even prepared to deal with the seasonal influenza 

epidemic that we face—that we know with certainty that we will face every single 

year. 

Since 2000, we have had multiple shortages of seasonal flu vaccine. We all recall 

senior citizens lining up for hours to obtain flu vaccine, unscrupulous distributors 

attempting to sell scarce vaccine to the highest bidder, and millions of Americans 

delaying or deferring necessary flu shots. 

Because we don’t have a system through which to track vaccine, we can’t ensure 

the supplies that we do have reach the highest priority populations—including seniors and the chronically ill—who should get vaccinated as early as possible in any 

given flu season. 

I’ve introduced legislation with Senator Pat Roberts, the Influenza Vaccine Security Act, that would help us make some positive changes in our nation’s system for 

distributing, tracking and delivering seasonal flu vaccine. 

Our legislation would establish a tracking system through which we could better 

trace the distribution of vaccine from the factory to the provider and identify counties with high numbers of priority populations, including senior citizens. 

With such a system in place, we could easily determine in times of shortage where 

vaccine was most needed and facilitate distribution to those areas to help our elderly get the shots that they need. All of this could take place in a matter of hours, 

rather than days or weeks. 

It simply makes sense to establish an operational tracking system for vaccine distribution that can be used in both seasonal and pandemic events, rather than rely 

on untried mechanisms in an emergency situation where we will already be facing 

multiple obstacles to delivery of health care—in particular, life saving care for elderly populations. 

I look forward to working my colleagues on this committee to continue to raise 

awareness of the needs of senior citizens in pandemic and other emergency situations. Thank you.

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