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74–097 2012

PREPARING FOR THE 2009 

PANDEMIC FLU 

HEARING 

BEFORE THE

COMMITTEE ON ENERGY AND 

COMMERCE 

HOUSE OF REPRESENTATIVES 

ONE HUNDRED ELEVENTH CONGRESS 

FIRST SESSION 

SEPTEMBER 15, 2009 

Serial No. 111–64 

( 

Printed for the use of the Committee on Energy and Commerce 

energycommerce.house.gov 


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COMMITTEE ON ENERGY AND COMMERCE 

HENRY A. WAXMAN, California, Chairman 

JOHN D. DINGELL, Michigan 

Chairman Emeritus 

EDWARD J. MARKEY, Massachusetts 

RICK BOUCHER, Virginia 

FRANK PALLONE, JR., New Jersey 

BART GORDON, Tennessee 

BOBBY L. RUSH, Illinois 

ANNA G. ESHOO, California 

BART STUPAK, Michigan 

ELIOT L. ENGEL, New York 

GENE GREEN, Texas 

DIANA DEGETTE, Colorado 

Vice Chairman 

LOIS CAPPS, California 

MIKE DOYLE, Pennsylvania 

JANE HARMAN, California 

TOM ALLEN, Maine 

JAN SCHAKOWSKY, Illinois 

HILDA L. SOLIS, California 

CHARLES A. GONZALEZ, Texas 

JAY INSLEE, Washington 

TAMMY BALDWIN, Wisconsin 

MIKE ROSS, Arkansas 

ANTHONY D. WEINER, New York 

JIM MATHESON, Utah 

G.K. BUTTERFIELD, North Carolina 

CHARLIE MELANCON, Louisiana 

JOHN BARROW, Georgia 

BARON P. HILL, Indiana 

DORIS O. MATSUI, California 

DONNA M. CHRISTENSEN, Virgin Islands 

KATHY CASTOR, Florida 

JOHN P. SARBANES, Maryland 

CHRISTOPHER S. MURPHY, Connecticut 

ZACHARY T. SPACE, Ohio 

JERRY MCNERNEY, California 

BETTY SUTTON, Ohio 

BRUCE BRALEY, Iowa 

PETER WELCH, Vermont 

JOE BARTON, Texas 

Ranking Member 

RALPH M. HALL, Texas 

FRED UPTON, Michigan 

CLIFF STEARNS, Florida 

NATHAN DEAL, Georgia 

ED WHITFIELD, Kentucky 

JOHN SHIMKUS, Illinois 

JOHN B. SHADEGG, Arizona 

ROY BLUNT, Missouri 

STEVE BUYER, Indiana 

GEORGE RADANOVICH, California 

JOSEPH R. PITTS, Pennsylvania 

MARY BONO MACK, California 

GREG WALDEN, Oregon 

LEE TERRY, Nebraska 

MIKE ROGERS, Michigan 

SUE WILKINS MYRICK, North Carolina 

JOHN SULLIVAN, Oklahoma 

TIM MURPHY, Pennsylvania 

MICHAEL C. BURGESS, Texas 

MARSHA BLACKBURN, Tennessee 

PHIL GINGREY, Georgia 

STEVE SCALISE, Louisiana 

PARKER GRIFFITH, Alabama 

ROBERT E. LATTA, Ohio 

(II) 


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C O N T E N T S 

Page 

Hon. Henry Waxman, a Representative in Congress from the State of California, opening statement .................................................................................... 1 

Prepared statement .......................................................................................... 3 

Hon. Nathan Deal, a Representative in Congress from the State of Georgia, 

opening statement ................................................................................................ 8 

Hon. Frank Pallone, Jr., a Representative in Congress from the State of 

New Jersey, opening statement .......................................................................... 8 

Hon. Joe Barton, a Representative in Congress from the State of Texas, 

opening statement ................................................................................................ 9 

Hon. John D. Dingell, a Representative in Congress from the State of Michigan, opening statement ....................................................................................... 10 

Hon. Bart Stupak, a Representative in Congress from the State of Michigan, 

opening statement ................................................................................................ 12 

Hon. Greg Walden, a Representative in Congress from the State of Oregon, 

prepared statement .............................................................................................. 65 

Hon. Edward J. Markey, a Representative in Congress from the Commonwealth of Massachusetts, prepared statement .................................................. 71 

Hon. Anna G. Eshoo, a Representative in Congress from the State of California, prepared statement .................................................................................. 73 

Hon. Bruce L. Braley, a Representative in Congress from the State of Iowa, 

prepared statement .............................................................................................. 74 

WITNESSES

Kathleen Sebelius, Secretary, U.S. Department of Health and Human Services; Accompanied by Rear Admiral Anne Schuchat, MD, Assistant Surgeon 

General, United States Public Health Service, Director, National Center 

for Immunization and Respiratory Diseases ...................................................... 13 

Prepared statement .......................................................................................... 16 

Answers to submitted questions ...................................................................... 77 


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(1) 

PREPARING FOR THE 2009 PANDEMIC FLU 

TUESDAY, SEPTEMBER 15, 2009 

HOUSE OF REPRESENTATIVES, COMMITTEE ON ENERGY AND COMMERCE, Washington, DC. 

The committee met, pursuant to call, at 1:10 p.m., in Room 2123, 

Rayburn House Office Building, Hon. Henry A. Waxman [chairman 

of the committee] presiding. 

Present: Representatives Waxman, Dingell, Markey, Pallone, 

Eshoo, Stupak, Green, DeGette, Capps, Harman, Schakowsky, Inslee, Baldwin, Butterfield, Melancon, Barrow, Hill, Matsui, 

Christensen, Castor, Sarbanes, Murphy of Connecticut, Space, 

McNerney, Braley, Barton, Hall, Upton, Deal, Whitfield, Shimkus, 

Pitts, Walden, Murphy of Pennsylvania, Burgess, Blackburn, 

Gingrey, and Scalise. 

Staff Present: Karen Nelson, Deputy Committee Staff Director 

for Health; Ruth Katz, Chief Public Health Counsel; Sarah 

Despres, Counsel; Elana Leventhal, Policy Advisor; Stephen Cha, 

Professional Staff Member; Alvin Banks, Special Assistant; Jen 

Berenholz, Deputy Clerk; Mitchell, Smiley, Special Assistant; Ryan 

Long, Minority Chief Health Counsel; Chad Grant, Minority Legislative Analyst; and Aarti Shah, Minority Health Counsel. 

OPENING STATEMENT OF HON. HENRY A. WAXMAN, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF CALIFORNIA 

Mr. WAXMAN. The meeting will please come to order. 

Today’s hearing on the 2009 pandemic H1N1 flu is a continuation of this committee’s ongoing interest in learning more about 

and staying on top of this developing and continuing situation. The 

hearing builds on the work of Chairman Pallone’s Health Subcommittee, which held an initial hearing on the issue earlier this 

year. 

From then until now, one thing has become crystal clear, even 

as events continue to evolve. As a Nation, we must be prepared for 

whatever the H1N1 virus brings in its path, to fight it as best we 

can, and to ensure adequate and appropriate resources to treat 

those who fall seriously ill. 

We are especially pleased to have as our witness today the Secretary of Health and Human Services Kathleen Sebelius. Secretary 

Sebelius will share with us the government’s plan for addressing 

this enormous challenge. 

When the Health Subcommittee first met 6 months ago, there 

was much we did not know about H1N1 virus. We didn’t know how 


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dangerous the virus was. We didn’t know if there would be a vaccine available. We didn’t even know if the virus would return in 

the fall. Many of those questions have now been answered. 

We know this outbreak won’t be the false alarm of 1976, when 

the surge of swine flu cases never materialized. Indeed, we are already seeing a large increase in cases, a pattern that is likely to 

continue. The epidemic will undoubtedly lead to hospitalizations. 

Schools may close. Health care facilities may become overwhelmed. 

And almost certainly there will be some who will die. 

But there is also good news. This administration has carried on 

the efforts begun several years ago to prepare the country for the 

very situation we must now tackle. The plans developed appear to 

be unfolding appropriately, and experts tell us that, so far, the 

2009 H1N1 epidemic will not be anything like that which occurred 

in 1918, when an unusually dangerous flu virus devastated our Nation. 

More good news was reported just last week. We not only will 

have an effective vaccine in place; studies now indicate that the 

vaccine will probably require only a single dose rather than the two 

doses many had predicted. As a result, I hope Secretary Sebelius 

will report today that across the country we will have a good supply of vaccine, allowing us to avoid both the additional cost and the 

additional needle stick that a second dose would mean. 

I expect that we will hear more about this as well as other H1N1 

flu activities from Secretary Sebelius. I know all of us are also particularly interested in getting the Secretary’s perspective on not 

only the progress we are making in taking on this virus but also 

the difficulties we surely will face along the way. 

But as we make preparations and carry out detailed plans for 

dealing with this new virus, we must also take heed of the battle 

we confront annually against the seasonal flu. Each and every 

year, some 36,000 Americans, mostly among the elderly, die from 

this preventible disease. We can and should do much better than 

that, and I hope that Secretary Sebelius can also share with us the 

administration’s thinking on addressing this concern and, in particular, how that approach relates to its H1N1 strategy. 

With that, on behalf of the entire committee, I want to thank the 

Secretary for appearing before us today. We all look forward to 

hearing from you and to learning more about the H1N1 challenges 

that lie ahead. But before the Secretary will be recognized to make 

her statement, I want to call on several of the members of the committee to make opening statements. 

And we will start with Mr. Deal. 

[The prepared statement of Mr. Waxman follows:] 


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OPENING STATEMENT OF HON. NATHAN DEAL, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF GEORGIA 

Mr. DEAL. Thank you, Mr. Chairman. 

I want to thank you for holding this hearing on the examination 

of our Nation’s preparedness for the H1N1 flu virus as we approach 

the flu season. 

And I look forward to Secretary Sebelius’s testimony and welcome her to the hearing today. 

As I mentioned during the subcommittee hearing last April, the 

threat of a global influenza pandemic is one of the greatest public 

health threats that we face today. When speaking to scientists, researchers, health care providers, and other experts in the field, I 

truly believe that it is not a matter of if a flu pandemic hits but 

when. And I believe we have the responsibility to ensure the greatest public protection possible when the situation arises. We all recognize that is not a simple matter. 

Since the first reports of this novel strain of the influenza virus 

began to surface earlier this year, U.S. and international authorities have taken aggressive steps to mitigate the spread of the illness. This has taken the dedication and cooperation of all those involved, both public and private sectors, particularly as the infection 

rates have increased. 

As my home State of Georgia and other areas in the South have 

witnessed the easily transmittable H1N1 strain as it continues to 

spread, particularly as we have now begun school somewhat earlier 

than other parts of the country, we all recognize that this is a real 

threat. I have been in contact with my State’s agencies, and they 

are also coordinating, of course, with your offices at the Federal 

level, and also as you are coordinating with international groups 

during these months that will lie ahead as we try to deal with this 

problem. 

The current response to the H1N1 strain was coordinated in 

large part with plans which were developed to respond to a similar 

situation, the H5N1 avian flu. In 2006, Congress provided approximately $6 billion for pandemic planning and cross-agency collaboration. These earlier efforts and others focused on preparedness for 

emergencies have streamlined the response to this situation. While 

our efforts to combat H1N1 have been aggressive, we must continue to monitor the situation closely and be proactive, as we hopefully will be able to avoid this but regrettably know that it will 

probably increase in severity. 

Again, thank you, Secretary Sebelius, for being with us today. I 

look forward to your testimony. 

I yield back, Mr. Chairman. 

Mr. WAXMAN. Thank you, Mr. Deal. 

Mr. Pallone. 

OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE IN CONGRESS FROM THE STATE OF NEW JERSEY 

Mr. PALLONE. Thank you, Mr. Chairman. 

And thank you, Secretary, for being here today to give us an update on the H1N1 situation. 


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When the virus first hit, it was devastating. It caused sickness. 

It generated fear. It caused panic. And it caused many deaths, and 

there were many unknowns about the virus. We did not know how 

the disease would present itself over time, how well it would respond to the antiviral medications on the market today, or how 

quickly it would develop resistance to those drugs. And we didn’t 

know if and how quickly we would be able to develop and manufacture a vaccine. 

While we have learned more about the virus, and we have made 

progress on the vaccine, it has spread worldwide across continents 

and hemisphere. And now as a level six pandemic, the highest 

warning level there is, it has continued to spread in the U.S. during the summer months, which is unusual for the influenza, and 

that adds to the unknowns and reinforces the fact that we still 

have to take it seriously. 

In my State alone, 17 people have died since the beginning of the 

outbreak and over 570 have been hospitalized, and we have yet to 

see the disease at its strongest. In addition, the peak of this flu coincides with the normal flue season, which on its own can be extremely taxing on the health care delivery system. 

I am curious to hear how the Federal Government is tackling the 

fact that this flu tends to affect individuals under 50 years of age, 

unlike the seasonal flu that hits the elderly the hardest. The 

younger population does not deal with disease often and tends not 

to seek medical care as readily. 

There have been many questions about our Nation’s ability to respond to medical emergencies. Unfortunately, it is hard to justify 

spending money on programs that are in place in case something 

bad happens, especially since so many programs that are needed 

on a daily basis have been chronically underfunded, but as history 

has taught us, grand-scale disease outbreaks can be devastating. 

At a time when our economy is just beginning to mend and the 

number of uninsured is rising, we must now, more than ever, be 

prepared for such a situation, and we don’t want to add to the 

health insurance crisis, and we certainly don’t want to hinder the 

economic recovery. 

So I want to commend you and your team, Secretary, for the excellent work you have done on this issue. During the first wave of 

the virus, I know you and your staff were working around the clock 

to provide tests and test results States, to develop a vaccine, to 

educate State and local governments, and keep the public informed 

of the latest information on the virus and how best to protect themselves from becoming sick. So I want to thank you for that, and 

look forward to hearing more today about how the Federal Government is prepared for this next wave of H1N1. Thank you. 

Mr. WAXMAN. Thank you, Mr. Pallone. 

Mr. Barton. 

OPENING STATEMENT OF HON. JOE BARTON, A 

REPRESENTATIVE IN CONGRESS FROM THE STATE OF TEXAS 

Mr. BARTON. Thank you, Mr. Chairman. Thank you for holding 

this hearing. 

And thank you, Madam Secretary, for being here. 


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I want to say that this is a very important issue. Obviously, 

America and the world is worried about the pandemic flu. We had 

begun to discuss this this year back in April when we had a hearing on the H1N1 virus. I would like to review some of the recent 

history. 

Department of HHS has responded by declaring a public health 

emergency which has allowed the Food and Drug Administration to 

approve the use of approved antivirals and other measures. The 

Centers For Disease Control has responded by releasing antiviral 

drugs from the Strategic National Stockpile. To date, all 50 States 

have received their portion of that stockpile, which has been replenished through purchases. HHS is working with the Department of Homeland Security and is coordinating response efforts. 

Much of this work has been successful because we aren’t breaking new ground. This committee and the Federal Government had 

begun serious work back in 2004, so, in 2009, while we are not totally prepared, we are better prepared than we ever have been. 

There are still some issues that should be addressed, as outlined 

in the President’s Advisory Council on Science and Technology. It 

is my understanding that the administration is actively working to 

address these concerns, and I look forward to hearing from you, 

Madam Secretary, on those issues. 

I guess that is it, Mr. Chairman. I have another part of my statement, but it is on the overall health care reform, and I understand 

that you limited your statement to the pandemic flu. So, in the 

spirit of this hearing, I am going to do that. 

I want to take a point of personal privilege and say I appreciate 

all the good wishes that many of you have given me about my 

birthday. Today is my 60th birthday. And 30 didn’t bother me. 

Forty didn’t bother me. Fifty didn’t bother me, but 60 bothers me. 

But I am glad to be having it, and I am blessed to have a great 

family, great friends and I think to be on the greatest committee 

on the House of Representatives. 

So, with that, Mr. Chairman, I yield back. 

Mr. WAXMAN. Thank you, Mr. Barton. 

I, too, want to wish you a happy birthday, and tell you, you don’t 

look a day over 59. 

Mr. Dingell. 

OPENING STATEMENT OF HON. JOHN D. DINGELL, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF MICHIGAN 

Mr. DINGELL. Thank you, Mr. Chairman. The gentleman from 

Texas has spoiled my opening remarks. It was my intention to congratulate him as a fine young man who has performed well in his 

responsibilities, and to congratulate him on his 60th anniversary 

and hope that he reaches many more. I am sure that at the least 

I am the first on this committee to have the privilege and the 

pleasure to doing that. 

So, Mr. Barton, all of us on the committee do wish you a very, 

very happy birthday and many, many happy returns. 

Now, Mr. Chairman, I want to thank you for holding this important hearing. 


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And I want to welcome Secretary Sebelius and thank her for 

joining us this afternoon. 

Madam Secretary, you recall that your father was a member of 

this subcommittee, a very distinguished one, and I am sure that 

gives you good memories when you appear in this room. 

You have taken a proactive role in preparing our country for the 

upcoming H1N1 pandemic by implementing surveillance procedures to track an outbreak, mitigation measures to keep Americans 

healthy, a proper vaccination plan, and a communications strategy 

to disseminate information of importance. I want to commend you 

and look forward to hearing your update on the administration’s 

progress in planning for a potential outbreak. 

At the same time, I want to recall that on an earlier occasion, 

we made some fine mistakes in dealing with a health problem of 

this kind on a related virus which led to some splendid costs and 

some fine earnings for the legal profession. And I want to tell you, 

Madam Secretary, I am pleased that you have not fallen into any 

of the holes that your predecessors did on that one. 

In any event, we have held, as all know, a hearing earlier on 

H1N1 when there were only the first few people who were infected 

with the virus. It appears that the spread of the influenza virus 

that we are discussing did not let up during the summer as some 

had hoped, and experts predict an increased number of cases in the 

upcoming months. 

As of September 5, 2009, my own State of Michigan has already 

seen 3,419 confirmed or probable cases of H1N1. Further, 11 people, most with underlying health conditions, have died after contracting the virus. All 50 States have reported now that there are 

cases of the virus within their borders, and Nationwide about 600 

persons have died and 9,000 have been hospitalized. These figures 

highlight the need for the Congress and the administration to work 

together to prepare for the months ahead. 

Preventing the spread of H1N1 will require collective action not 

only from Federal, State, and local governments, but also from individuals as well. To address this, it is imperative that we prepare 

evidence-based programs for parents, children, and businesses, and 

also public health professionals, on what to expect as the Nation 

prepares for more flu cases than seen in the past few years. I want 

to applaud the administration and the Federal Government for 

stockpiling vaccines, masks, antiviral medications, ventilators, and 

other things necessary to address the potential upcoming problems. 

Influenza is unpredictable, and we must indeed be prepared for a 

wide variety of surprises. 

Today, Federal, State, and local officers are planning and executing multimedia outreach campaigns to arm Americans with the 

information they need to best keep themselves healthy or to address their problems once they become ill. This is imperative, because while we wait for H1N1 vaccine to become available, we 

must each play a part in slowing or reducing the spread of the 

virus with simple steps like handwashing and staying home when 

sick. 

Additionally, it is important for families and businesses to prepare their strategies for dealing with H1N1. I have created an 

H1N1 agenda for my own office, and urge other businesses here 


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and elsewhere to do the same. I look forward to working with you, 

Mr. Chairman, and the committee, and also with you, Madam Secretary, as we seek to mitigate the outbreak of H1N1. 

Thank you, Mr. Chairman. 

Mr. WAXMAN. Thank you, Mr. Dingell. 

Mr. Stupak. 

OPENING STATEMENT OF HON. BART STUPAK, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF MICHIGAN 

Mr. STUPAK. Thank you, Mr. Chairman, for holding this important hearing on the pandemic flu preparedness. 

Secretary Sebelius, welcome to the committee, and I look forward 

to hearing your testimony on the Department of Health and 

Human Services’ efforts to ensure Federal, State, and local public 

health officials are ready to prevent or respond to the spread of the 

H1N1 flu. 

When the H1N1 outbreak began in late April, Federal and State 

health officials acted quickly to deal with the outbreak. Among 

other things, antiviral drugs were released from the National 

Stockpile, and efforts were immediately undertaken to develop, 

manufacture, and to test a vaccine. Congress provided an emergency appropriation of $1.9 billion for a full response. An additional 

$5.8 billion was authorized contingent upon a Presidential request 

documenting the need for and the proposed use of the additional 

funds. I am interested in learning how much of this money is actually going to public health agencies. 

In our communities, particularly rural districts like the one I 

represent, our local public health agencies, hospitals, and clinics, 

shouldered the responsibility for responding to a public health crisis. It is vital they receive financial support from the Federal Government. 

H1N1 is unique from flu season. Unlike the seasonal flu, H1N1 

affects a different population; in particular, young people with children, younger adults, and pregnant women. From all indications I 

have read, the vaccines for H1N1 will not be ready until mid October. I am looking forward to hearing from you on what types of infrastructure HHS and CDC will have in place to distribute the vaccines in a timely fashion to pregnant women, people who live with 

or care for young children, health care and emergency services personnel, persons between the ages of six months and 24 years of 

age, and people between 25 and 64 who are at a higher risk from 

the H1N1 because of chronic health disorders like asthma. 

As chairman on the Subcommittee on Oversight and Investigations, this is an issue I will continue to monitor following today’s 

hearing. I look forward to your testimony and learning how well 

the Federal Government is coordinating with State and particularly local officials and as a Nation will respond and hopefully prevent widespread outbreak. 

Thank you, Mr. Chairman. I yield back the balance of my time. 

Mr. WAXMAN. Thank you, Mr. Stupak. 

By previous understanding with the minority, we said that the 

only ones who would be recognized for opening statements would 

be the chairman, the ranking member, Mr. Dingell, and then the 


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Chair and the ranking member of the Health and the Oversight 

Subcommittees. 

But, without objection, the record will be held open for any opening statements from any member that wishes to include them. I 

want to do this and move on because—Mr. Walden, are you ready 

for your opening statement? 

Mr. WALDEN. Mr. Chairman, I will submit it for the record, because I don’t want to take too much time away from the Secretary. 

I appreciate the opportunity to do that. I look forward to your comments on this, and I do hope you will be able to come back at some 

point because I am sure we have questions on the overarching 

health care bill. 

But I would just say that the flu is something we are all concerned about. I have a son who is a sophomore at Wake Forest 

University, which got swept pretty early on with the flu outbreak. 

He got it. I don’t know if it was the H1N1 and neither does he, but 

he has recovered, thankfully. But it is an issue all families are worried about. So I look forward to your testimony. 

Thank you, Mr. Chairman. 

[The prepared statement of Mr. Walden appears at the conclusion of the hearing.] 

Mr. WAXMAN. Madam Secretary, we are delighted to have you 

with us. Your full testimony has been submitted in advance and 

will be made part of the record, and we want to recognize you for 

your oral presentation to us. 

STATEMENT OF THE HONORABLE KATHLEEN SEBELIUS, SECRETARY, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES; ACCOMPANIED BY REAR ADMIRAL ANNE SCHUCHAT, 

MD, ASSISTANT SURGEON GENERAL, UNITED STATES PUBLIC HEALTH SERVICE, DIRECTOR, NATIONAL CENTER FOR 

IMMUNIZATION AND RESPIRATORY DISEASES 

Secretary SEBELIUS. Thank you very much, chairman Waxman, 

Ranking Member Barton, Mr. Deal, Mr. Pallone, Chairman Emeritus Dingell, Mr. Stupak, Mr. Walden, members of the committee. 

It is very good to be back before the Energy and Commerce Committee. And I appreciate the opportunity to give you an update on 

the public health challenges of the H1N1 influenza. 

Let me just start by saying the administration is taking these 

challenges very seriously. In fact, the night I was sworn in on April 

28, I went immediately to the situation room because this virus 

was just breaking out, and from day one, this has been very high 

on my radar screen. 

We are working in close partnership with virtually every part of 

the Federal Government, but also with Governors, mayors, tribal 

leaders, State and local health departments, emergency personnel, 

working with the medical community, the private sector, to actively 

prepare for the virus outbreaks that may develop over the next few 

months and to have some mitigation strategies in place in the 

meantime. 

Since the initial outbreak of the 2009 influenza, not only has a 

worldwide pandemic been declared, it has also presented itself as 

the dominant flu strain in the southern hemisphere during the 

winter flu season. Here in the U.S., we continued to see H1N1 flu 


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activity over the summer, which is unusual, and as a number of 

you have already noted, it has increased now that the fall is under 

way. We are anticipating further increases in flu cases as seasonal 

flu begins circulating among us. 

We have provided, Mr. Chairman, each of the members with an 

update that is at your seats with some more details on the current 

situation, including a situational update that is on, I think, the 

third page of your handout. Dr. Anne Schuchat from the Centers 

for Disease Control is with me today, and CDC gives us the these 

situational updates on a daily basis, and we wanted you to have 

the newest information. 

Although evidence to date shows that the virus has, fortunately, 

not changed to become more deadly, what we know is this influenza is unpredictable, and we need to monitor both the impact of 

the 2009 H1N1 and seasonal flu throughout the next several 

months. 

The virus is in fact in more people than we typically see with 

seasonal flu, including children, younger adults, and pregnant 

women, and slowing this spread of the virus is a responsibility 

shared by all of us. 

Chairman Emeritus Dingell already referenced there are some 

simple steps; handwashing, covering coughs and sneezes, and staying home when you are sick are important steps. The governmentwide web site, www.flu.gov, does have comprehensive information 

about what to do to avoid getting the flu. 

And I would suggest, Mr. Chairman, I know we have communicated this to the offices, but on that Web site, flu.gov, are widgets. If any Members of Congress want to put a widget on your own 

Web site so that your own constituents can monitor on a regular 

basis, see the latest basis CDC guidance, get regular information, 

we would strongly encourage you to do that. If I am speaking in 

techno speak, a 12-year-old can be hired easily and tell you what 

to do with a widget. My recommendation. 

Oh, I apologize, Ranking Member Barton, I should have started 

with a happy birthday. And you will find the 60s will treat you 

well. It is a good place to be. 

To date, the CDC has issued recommendations on how individuals, schools, child care settings, colleges and universities, large 

and small businesses can guard against the flu, as well as a recent 

guidance on the appropriate use of antiviral drugs. Again, all of 

those are on the Web site and can be downloaded and shared with 

constituency groups if you are going to have some meetings at 

home. Guidance on infection control and worker safety in health 

care settings is forthcoming in the next few days. 

As I announced this weekend, we plan to initiate our H1N1 vaccination program in October. Mid October is still the target for the 

large-scale campaign to get under way, but we anticipate having 

limited amounts of vaccine available a week or 10 days earlier. 

I am pleased to report that today the Food and Drug Administration has approved applications for vaccines for the 2009 H1N1 

virus from four of the manufacturers of the U.S.-licensed seasonal 

influenza vaccines. The vaccines for this virus are being produced 

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turing processes and facilities used for seasonal flu vaccines that 

are provided every year to protect millions against the flu. 

And in response, Mr. Chairman, to your point, seasonal flu vaccine is now available widely in cites around the country, and again, 

we are urging people strongly, particularly if they are in the target 

population for seasonal flu, to go ahead and get the seasonal flu 

vaccine right now. 

We recently, just last week, had good news from studies being 

done both by NIH and manufacturers that a single dose of the vaccine rapidly introduces a strong immune response in healthy 

adults. We think that age group could go down as low as age nine, 

but the clinical studies in children and pregnant women are still 

under way, so we don’t have the full data about whether children 

will need two doses or not. They do in seasonal flu, younger children. We are still waiting for those results to be back. 

And, Mr. Chairman, originally we thought that it would take up 

to 21 days for the immune response to be robust, and it is showing 

up in 8 to 10 days. That is very good news. So one dose, 8 to 10 

days for most of the population above age nine we think is a very 

positive step forward. The trials in pregnant women are under way, 

as I said, and in children, and our expectation is that the vaccine 

will be a good match in protecting against these populations as 

well. 

Once ready, the vaccine will be shipped through a central distribution system and available in up to 90,000 sites around the 

country. Every State was asked to develop a plan and identify the 

appropriate vaccination sites. Our contractor is shipping directly to 

those sites so there is not a glitch along the way. 

Two types of vaccine, a flu shot made from inactive aided virus 

and a nasal spray made from live weakened virus, will be available, free of charge, though some providers may charge an administration fee. And, again, Congress did authorize funds at the time 

of the supplemental bill to cover some of the costs, and the Department of Health and Human Services has expended on top of that 

about $1 billion in our funds to get that process started before the 

supplemental funding was available. 

CDC’s Advisory Committee on Immunization Practices, ACIP, 

recommended that initial doses of the H1N1 vaccine go to people 

at greatest risks of complications from the flu as well as those who 

have frequent contact with people at risk, and we are working with 

States, territories, tribes, local communities, as well as the private 

sector to help distribute and administer the new H1N1 vaccine. 

Thanks to Congress, we have allocated $1.44 billion for States and 

hospitals for planning and preparation. 

The Nation’s current preparedness is a direct result of the investments and support of the Congress and the hard work of the HHS 

agencies and States and local officials across the country, both recently, but certainly over the last several years. So we look forward 

to continuing to work with Congress in the weeks and months 

ahead. 

Again, Mr. Chairman, I thank you for the opportunity to participate in the conversation, and I look forward to taking your questions. 

[The prepared statement of Ms. Sebelius follows:] 


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Mr. WAXMAN. Thank you very much, Madam Secretary, for that 

update. 

There are many members here, because this is an important 

hearing, and I know you have to leave in a couple hours. In order 

to accommodate the members, what I am going to do, with Mr. 

Barton’s assent to ask each member to ask one question. We will 

put the timer on at 3 minutes. But we would appreciate it if members could ask just one question, but no more than 3 minutes. 

Mr. Barton, is that correct? 

Mr. BARTON. Yes. And I want to let the minority members know 

that I support this; in fact, it is my recommendation. There is a 

precedent for this. Other Cabinet Secretaries that have been before 

the panel, we have adopted this practice. I think it is fair, so that 

the junior members have an opportunity to ask a question as well 

as the senior members. 

Mr. WAXMAN. Thank you, Mr. Barton. 

I am going to start off the questions with a more junior member 

to me, Mr. Markey. 

Mr. MARKEY. I thank the chairman very much. We have been sitting next to each other for 33 years. 

And the 60s are great, too, Madam Secretary. 

You know, one of the real questions that people have is the safety of this drug, and there was a real concern going back to 1976 

and that swine flu epidemic and the diseases later associated with 

the distribution of that drug. So just so I can understand this, this 

drug has not yet been FDA approved; is that correct? 

Secretary SEBELIUS. It just was licensed today. 

Mr. MARKEY. It was licensed today. That is great news. And 

could you talk a little bit about what is different, what the difference is between this drug and the drug back in 1976 in terms 

of what the FDA and the agency believe will be the impact on 

Americans? 

Secretary SEBELIUS. Well, Mr. Markey, one of the first steps that 

the President took was to actually gather the experts from 1976 together and ask for advice about what went right and what went 

wrong. And we had an opportunity to meet with everybody from 

the then Secretary of Health Environment to the Surgeon General 

to some of the scientists who were involved, and they gave some 

very good advice. 

The principle difference may not have been in the manufacturing 

of the drug but the fact that the flu never spread, so that the outbreak that was initially identified among about 200 soldiers in Fort 

Dix never went anywhere. So a massive vaccination campaign was 

launched. About 40 million Americans were vaccinated, and yet 

there was no flu. Not in America, not anywhere. 

So we are in a very different situation today, where we know this 

virus is spreading. And this vaccination, vaccine, is actually being 

manufactured exactly like the seasonal flu vaccine. It is showing up 

in the same way, and it is using the same processes and procedures. 

So, in terms of the safety and efficacy, while there are clinical 

trials under way to determine the right dosage and really the efficacy of the vaccine, is it hitting the right target, there have been 

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cines. So we are assured by the scientists that lots of steps have 

been taken along the way to make sure that this will be a safe procedure. 

There has been more oversight than in 1976, better made somewhat differently, more oversight in testing and in quality. So we do 

not anticipate the same problem. And, as I say, if it were a different process than seasonal flu, we would have more concerns, but 

it has been similar. 

Mr. WAXMAN. Thank you, Mr. Markey. 

Mr. Barton. 

Mr. BARTON. Madam Secretary, I may have questions for the 

record, but my one question is something you may not be aware. 

I was briefed this morning by officials at Texas A&M, which is not 

in my district, but it is the school that I went to. They have developed, if I understood them correctly, a vaccine that is made from 

hydroponic tobacco that they can produce up to 100 million doses 

very quickly, if necessary. Are you familiar with that, by any 

chance? 

Secretary SEBELIUS. Mr. Barton, I don’t know about that vaccine. 

I do know that tobacco is one of the growing agents looked at as 

an alternative to the egg-based vaccines. But I don’t— 

Mr. BARTON. If I were to get the researchers to touch base with 

your staff, would you all be willing to be briefed about that program? 

Secretary SEBELIUS. Sure. 

Mr. BARTON. Thank you, Madam Secretary. Thank you. 

Mr. WAXMAN. Mr. Dingell had to leave. 

Mr. Pallone. 

Mr. PALLONE. Thank you. 

Madam Secretary, I am concerned about emergency room hospital capacity, that type of thing. There was this report that was 

issued last month by the President’s Council of Advisers on Science 

and Technology that said there could be as many as 1.8 million 

hospitalizations in the United States during the epidemic. And of 

this 1.8 million, up to 300,000 could require intensive care units. 

And those patients could occupy 50 to100 percent of all ICU beds 

in affected areas at the peak of the epidemic. 

Even without the epidemic, those ICUs nearly operate close to 

capacity in my district. So what, with regard to the Nation’s hospitals, I mean, do we have the surge capacity to meet this potential 

demand? And can you tell us what steps the Department is taking 

to help hospitals prepare for this surge in cases? 

Secretary SEBELIUS. Mr. Pallone, I think it is a very important 

question. 

Part of the planning effort that was launched well before this 

virus was identified was in building surge capacity for hospitals. 

And billions of dollars have been invested over the last number of 

years. In fact, I had a chance here in D.C. To visit their five regional center sites that have been developed to get even increased 

capacity, and one is here in Washington, D.C., and get a sense of 

what they are doing. So there have been recent dollars put forward, 

but also dollars over the years to have that planning go on for 

surge capacity. 


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We are concerned that we also try and get information to the 

public as rapidly and as clearly as possible. The worst of all worlds 

is to have everybody show up at the hospital or come through an 

emergency room door. The vast majority of individuals who get 

H1N1 so far are not terribly ill, do not require additional treatment, and certainly don’t require testing to see what kind of flu 

they have, so that we are trying to assure people the flu is the flu 

is the flu right now. CDC will continue to test through hospitals 

and other areas those who are getting seriously ill so we can monitor the cases. But the testing isn’t required. 

So we have resources to hospitals. We are helping with systems 

that will put in place additional medical capacity, everybody from 

the Medical Reserve Corps to additional personnel who we can help 

with assistance. So we don’t think at this point that the PCAST, 

the Presidential Advisors scenario, is the most likely scenario to 

happen. We have watched the southern hemisphere very closely 

and what they have done for surge capacity, and, again, we will 

learn a lot from them. But they had no critical emergencies that 

weren’t able to happen with shifting some space. 

So I think, at this point, we are doing everything we can to get 

people ready and provide for some alternative, but part of it is to 

diminish, hopefully, the strain on hospitals by encouraging people 

to go to the Web site, to learn more, to call the primary care provider and urge them to just take steps that they would with regular flu. 

Mr. WAXMAN. Thank you, Mr. Pallone. 

Mr. Deal. 

Mr. DEAL. Thank you. 

I would like to ask about the distribution of the vaccine when it 

becomes available. Will the distribution be sent to the States and 

the States determine where it will go to within their States? And 

will there be a determination of how much goes to each State, and 

what will be the factors that will be looked at in determining how 

many doses the State would be allocated? 

Secretary SEBELIUS. The distribution is based on a per-capita 

basis, and States absolutely develop their plans working with their 

emergency personnel, their local health departments, and others to 

determine the vaccination sites. 

So, again, the distribution contract is not going to go to one central site in a State as the traditional vaccine. It is going directly 

to the sites that have already been predetermined. States were 

asked to send plans to the CDC. Part of the resources provided by 

Congress helped with that planning effort. And the contract will be 

up to 90,000 sites that have already been determined. So it will be 

some traditional providers offices and health clinics and hospitals, 

but also a number of nontraditional sites. 

Mr. DEAL. Could I ask one brief question on that? That per-capita amount, is that determined by who the CDC thinks should be 

eligible for getting the vaccination, or just a general per-capita? 

Secretary SEBELIUS. No. It is a general per-capita amount in 

terms of how it rolls out. We will have enough vaccine available for 

everyone. There is enough on order. We are looking now at the reorders for the one dose versus two. There will be enough vaccine. 


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What we are concerned about is getting it to the priority populations as quickly as possible, and that is what we have asked the 

States to focus on, how to get pregnant women, children under the 

age of 24, caregivers of infants, health care workers, how to make 

sure that those folks get to the front of the line, if you will. 

Mr. WAXMAN. Thank you, Mr. Deal. 

Mr. Green. 

Mr. GREEN. Thank you, Madam Secretary. 

And I have read several articles in the media indicating the administration supports voluntary school-based vaccination to protect 

our children from the H1N1. And I am a cosponsor along with my 

colleague from Pennsylvania, Mr. Murphy, with a pilot program, 

H.R. 2596, which would allow HHS to perform a voluntary multiState demonstration project to test the feasibility of using the Nation’s elementary schools and secondary schools as influenza vaccination centers, in coordination with school nurses, school health 

programs and local health departments, community health providers, insurance companies, private and State insurance agencies 

and private insurance, and I am pleased that bill is part of H.R. 

3200. 

Would the administration support a voluntary, multi-State 

school-based seasonal influenza and H1N1 vaccination program 

such as was created in H.R. 2596? And let me say that that 

version, I know Senator Reid in the Senate is looking to do a national version of that particular provision. 

Secretary SEBELIUS. Well, Mr. Green, what we are going to have 

is a demonstration, national demonstration project of the bill you 

just suggested going on in the next couple of months. And certainly 

our leadership at the Centers for Disease Control feel strongly that 

if we are successful in using schools as partners in vaccination, 

that that may be a great way to enhance the vaccination take-up 

rate going forward for seasonal flu and other issues. I am old 

enough that I was part of the group with the early polio vaccine, 

and we got that vaccine at school. That was always a partner. 

And this effort, we have school districts who are very eager to 

be vaccination sites and are standing by to do that. So we will 

know a lot about your voluntary program, and we think it probably 

will be a very good idea. 

Mr. GREEN. And being part of the sugar cube generation also, 

that I think this important; again, it needs to be voluntary, but we 

can have a great deal of more coverage by dealing with our schools, 

our centers in our community. And we are talking about our children. 

Secretary SEBELIUS. Given the age group that this virus is targeting, we thought schools and actually daycare centers and others 

are very appropriate outreach sites to reach the population who we 

need to reach. And so, working closely with the Secretary of Education and his counterparts, superintendents, the Governors. And 

I think most Governors are very enthusiastic of having the schools 

be voluntary vaccination sites. 

Mr. GREEN. Thank you, Mr. Chairman. 

Mr. WAXMAN. Thank you, Mr. Green. 

Mr. Murphy. 


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Mr. MURPHY of Pennsylvania. Thank you, Mr. Chairman. It is a 

pleasure to have you here, Madam Secretary. And thank you for 

all the work you are doing on health care, too. 

As part of this, I am assuming that part of the analysis you give 

with regard to this virus, if it was unchecked and unabated, the 

impact it would have overall on America’s health care system, including the cost. One of the issues this committee is trying to grapple with, as you are, is the cost of health care in America. 

We have an impossible time getting information from the Congressional Budget Office on anything that has to do with prevention. Therefore, I am wondering if your office has gathered some information, analyzed that as this, for example, as these vaccinations 

are advanced out there earlier, what we are saving, and what is 

this overall savings that comes from, yes, the government is spending money to move these out there, but what is the impact on saving money and saving health care costs, and wondering if you have 

that information? If not, could you get it to us? 

Because this committee really would like to have some of that, 

if I could say so, Mr. Chairman. 

Secretary SEBELIUS. Mr. Murphy, I will certainly look to see 

what kind of cost effectiveness or strategies we have put together. 

I am not sure. I think we can tell you probably and gather it for 

you the cost of what happens with seasonal flu every year, the 

200,000 hospitalizations, the 36,000 deaths, you know, what the 

impact is. 

I would suggest, though, what we don’t have is then a huge sort 

of social cost. One of the projections, absent a vaccine, of this virus 

spreading even in a relatively mild case, which would be 200,000 

hospitalizations, 36,000 deaths, that is what seasonal flu looks like 

every year. But if you have a widespread part of the population 

who misses work, what the impact is then on businesses and trade, 

whether you can even do continuity of businesses if you have essential workers missing. 

Part of the issue about schools is what happens if half the teachers are sick, or how do people go to work if half the kids are sick. 

So I don’t know that we have added those costs, but we can try to 

put together some information for you about that. 

Mr. MURPHY of Pennsylvania. I would appreciate it, because it is 

a type of modeling which we just don’t have, not only in terms of 

scenarios of analysis, but now we have something very real that we 

anticipate could have an impact on workforce, education, as well as 

direct and indirect medical costs. And I would appreciate if you 

would get that to us. 

Thank you, Mr. Chairman. 

Mr. WAXMAN. Thank you very much, Mr. Murphy. 

I would call on Ms. Harman. 

Ms. HARMAN. Thank you, Mr. Chairman. Thank you for holding 

this hearing. And thanks to a very capable former governor and a 

very capable team for putting in place a plan to prepare, not scare, 

the public. I do want to commend you on the tone of this plan, 

which has I think overcome a lot of the original hysteria that met 

the early stories about the effect of this illness. So thank you very 

much. 


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My question, really, is taking this to the next level or perhaps 

to the next problem. Is this basic set of protocols we now have in 

place and the public pitch that we are making quite effectively 

about this strain of flu, will this be—could this be applicable to perhaps a pandemic that is more severe, a possible biological attack 

in our country, or other huge health challenges that might arise? 

And if this set of procedures and protocols and tone that we are 

using is not applicable, what steps can you take now to be sure it 

does—we are able to adapt it to future problems we don’t presently 

anticipate? 

Secretary SEBELIUS. Well, I think that is a great question. And 

no question about the fact that Congress, working with the prior 

administration, put in place steps really that have been executed 

over the last 6 or 7 years of not only resources that have amplified 

efforts within the Department of Health and Human Services, including in our own vaccine development, operation, enhancements 

to NIH and Centers for Disease Control and FDA, but certainly resources at the State and local level and a lot of planning. As a 

former Governor, we went through pandemic planning. I never 

dreamed I would be sort of here with a pandemic, but we called 

together efforts over the years. 

So I think, at a minimum, what is happening over the next several months will enhance our entire public health infrastructure. 

Having hospitals look at the spring where the gaps were, redouble 

efforts to get ready for the fall is enormously helpful how they direct resources. Looking at workforce issues, how to get vaccinations 

to people. A huge challenge, and it is an ongoing challenge, is just 

information, how to make sure folks can access timely, accurate information in a very transparent fashion, and walk that balance between complacency and panic but get people prepared and ready. 

So I don’t think there is any question that what we do over the 

next several months will significantly prepare us for whatever challenge is next. We know, whether that is a natural disaster or a 

manmade disaster, that that infrastructure strength, the communication strategies, working with the partnerships not only 

throughout government but in the private sector is enormously 

helpful and is exactly what you go through region by region. We 

just haven’t done it nationally really in 40 years. 

Mr. WAXMAN. Thank you, Ms. Harman. Mrs. Blackburn. 

Mrs. BLACKBURN. Thank you, Mr. Chairman. 

And, Madam Secretary, thank you for taking the time to come 

and talk with us today. I am pleased that you are here, and I don’t 

envy the task in front of you. I know it is going to be a rough flu 

season from what we are seeing and hearing already, and I do 

think the free flow of information is going to be an imperative as 

we try to handle this with our districts, with schools, with our public events that are taking place. 

You have testified before our committee twice. And the first time 

that you came, we were working on the health care reform bill, and 

now we are looking at what could end up being one of the, significant to our constituents, as the impact of that health care reform 

bill. This is a public health situation that we know is going to be 

in front of us to deal with this event. 


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Now, when you were here before and we talked about the issues 

dealing with health care, we talked a little bit about the TennCare 

situation. I asked you about some of the issues that were there. 

Your responses took a while to get to me. They were a single sentence, and that prompted another question, and I just received the 

response to those today. So I do thank you for getting those. But 

I do ask that, as we move forward, that knowing that this is going 

to be critical, that we have timely and accurate information, that 

we do have that free flow of exchange as this public health issue 

affects our districts, and maybe a little bit more timely than the 

response to the questions which was a little bit curt and inadequate and bordering on disrespectful. 

I do want to say thank you for the widgets. I appreciate that 

those are on your Web site and that we can link to those. And I 

do want to ask you, as we are talking about the supplies and the 

supplies being let to the States, and you mentioned those that are 

most vulnerable to the flu, are those that—the physicians and the 

caregivers that are going to administrator the flu shots, do they 

have a ranking or a priority system, or will the States work that 

out? Are they going to take seniors and pregnant women first? Or 

do you have—can you give us any guidance on what that protocol 

is going to be for who gets to go at the front of the line? 

Secretary SEBELIUS. Well, Congresswoman, we have not tried to 

determine for States the most proper way to get to their target populations. We thought that was a local and regional decision. We 

have done a lot of work with the provider community outreach directly to OB/GYNs, outreach to primary care docs, to health clinics 

with the health infrastructure. But States are submitting plans 

based on their own determination, region by region, area by area, 

how best to target their vulnerable populations, and that is where 

the vaccine will be distributed. 

Mrs. BLACKBURN. So our best response to those populations when 

they call our offices is, consult your local physician? 

Secretary SEBELIUS. In terms of where to get the vaccine? 

Mrs. BLACKBURN. And who gets priority? 

Secretary SEBELIUS. Well, their local physician won’t be determining who gets the priority. Again, the State health department 

has determined that, and that information should be available 

right now. There will be vaccine for everyone. It won’t roll off the 

production line simultaneously. So the State really has predetermined where the priorities areas are and what sites should get it. 

Mrs. BLACKBURN. Thank you, ma’am. 

Yield back. 

Mr. PALLONE [presiding]. The gentlewoman from Wisconsin, Ms. 

Baldwin. 

Ms. BALDWIN. Thank you, Mr. Chairman. 

Thank you, Secretary Sebelius, for your testimony. There were 

several very encouraging items of news in terms of the hope that 

one dose will be sufficient, that it will be getting the desired immune impacts within 8 to 10 days, and that you think you will 

have sufficient dosage for everyone starting with priority targets. 

I have a few questions, very short questions related to that vaccine issue, and then in follow-up will submit some written questions on strengthening our public health system, addressing workVerDate Mar 15 2010 02:52 Aug 18, 2012 Jkt 074097 PO 00000 Frm 00048 Fmt 6633 Sfmt 6633 E:\HR\OC\A097.XXX A097

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force shortage issues, and technology issues. But on the vaccine, 

three quick questions. 

Of the 195 million doses ordered, is the hope that you can reach 

everyone through use of the adjuvant that you have also ordered? 

And so tell me a little bit about the use of adjuvant during this season. 

Second, I know that we had shortage of seasonal flu vaccine I 

think back in 2004 when there was a closure of a production facility in the U.K. We did not have a lot of domestic manufacturing 

capacity at that point. I believe that has changed, but I wonder if 

you can tell me, of the five manufacturers that we are working 

with for these dosages, where their facilities are located domestically versus foreign. 

And then, I believe you announced in your testimony that four 

out of the five manufacturers have been approved today by the 

FDA. What is the status of the fifth? Is there any reason we should 

be worried? 

Secretary SEBELIUS. No adjuvant is currently anticipated to be 

used in the United States at all. There are some backup plans if 

things took a terrible turn for the worse. We have never used in 

any widespread area an adjuvantive vaccine, so the scientists 

strongly recommended that we not head down that path. And this 

time, the current purchases are likely to be enhanced to get to the 

point. What you have reported is the initial purchases. But as we 

see the take-up rate as we get the rest of the clinical trials, we will 

make the purchases based on what is anticipated the take-up rate 

is for 300 million potential users. As you know, 100 percent of the 

people will never get vaccinated for anything, unfortunately. We 

currently have five facilities. In the year that we ran out of vaccine 

there was one. I’m sorry. We were down to one. There were two but 

one was debilitated. 

I can’t tell you off the top of my head unfortunately exactly 

where they are. We will get you that information back. But what 

I was told yesterday by the vaccine committee is that we fully anticipate that all five will be licensed. There were some final steps 

needed to be taken in the final contract. 

Ms. BALDWIN. Just on the domestic production and vaccines 

being made in America, I remember a particularly telling hearing 

during the last administration where if we were having a particularly virulent pandemic, the presumption was that if we weren’t 

manufacturing it here in the U.S. it would not be available to us 

in the U.S., and I certainly hope that we are bolstering our domestic production of vaccine. 

Secretary SEBELIUS. What I am told is it is greatly enhanced and 

most of it is domestic. 

Ms. DEGETTE [presiding]. The gentleman from Georgia, Mr. 

Gingrey. 

Mr. GINGREY. Madam Chairman, thank you. Madam Secretary, 

thank you very much for being with us again. And let me just say 

at the outset that your efforts, along with those of Secretary Janet 

Napolitano when, way back, I guess, in June, July when you were 

getting confirmed I think you have done a great job. No question 

about it. I don’t think anybody could ever accuse you of being 

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priated toward this effort. And my only concern, back then, a little 

bit lesser now, was the issue of creating a pandemic of fear. And 

I mentioned that to you, and you have already addressed that in 

your testimony. But I want to ask you about, particularly about 

pregnant women because that was what I did in my previous life 

as an OB-GYN physician, and I have three adult daughters and a 

daughter-in-law and nine grandchildren, the daughter-in-law just 

had a baby 3 weeks ago. 

Secretary SEBELIUS. Congratulations. 

Mr. GINGREY. Thank you, Madam Secretary. Very concerned was 

she, though, about this issue of the swine flu and what should she 

do and that sort of thing, questions about what if she got it, what 

would be the risk to her, especially in the third trimester, as she 

was then. And what was the risk to the fetus. And I think that we 

need to get more information. I noticed on WebMD a recent printout from WebMD. July 29, 2009. It says pregnant women, even if 

they are healthy, are at high risk of hospitalization and death from 

H1N1, swine flu, the CDC reports. Now, I would like for you to answer that question. Are they, I mean, I know they are at increased 

risk over the general population and there are certain issues with 

decreased lung capacity and not as vigorous immune response because of their pregnancy. 

It does put them at higher risk than the general population of 

women. But are they at high risk of hospitalization and death? And 

I think the answer to that is probably no, but comment on that if 

you will. 

Secretary SEBELIUS. Congressman, what we saw in the spring is 

that pregnant women constitute about 1 percent of the population. 

They were 6 percent of the hospitalizations and deaths that occurred, a significantly out-of-kilter population, and with no underlying health condition other than the pregnancy. So we are not 

talking about somebody who had diabetes going into pregnancy or 

someone with chronic lung condition. 

Mr. GINGREY. They are definitely at higher risk than the general 

population, maybe as much as five times, a factor of five. 

Secretary SEBELIUS. Six would be the—so, in terms of the outreach, we have tried to be—and that was not only the U.S. data, 

that is showing up around the world. That, again, pregnancy seems 

to be, in and of itself, an underlying health condition that significantly enhances the risks. So, I know that for a lot of pregnant 

women, I certainly did this myself, was reluctant to take anything 

during the term of the pregnancy. But talking to a number of OBGYNs, looking at the data, talking to the scientists, there is a great 

belief that the risk of any sort of event occurring because of the 

vaccine far is outweighed by the risk that occurs without being vaccinated. And in your daughter’s case, a new mom, babies under 6 

months old are not recommended for the vaccine, so another of the 

target population is caregivers of infants 6 months and younger, to 

try and protect the infant. So you sort of have—— 

Mr. GINGREY. Madam Chair, I realize that my time—can I do a 

real quickie question? Maybe we can do a second round. I yield 

back. And thank you, Madam Secretary. 

Ms. DEGETTE. The gentlelady from California, Ms. Matsui is recognized. 


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Ms. MATSUI. Thank you, Madam Chair. And thank you, Madam 

Secretary, for being with us today again. In States and in cities 

across our country, local public health departments are really getting decimated by budget cuts. In my hometown of Sacramento, the 

public health department has already had to cut 17 percent of its 

budget this year alone. These cuts mean that in my district alone, 

the public health department will be losing three communicable 

disease specialists and two microbiologists from a public health lab. 

This is on top of losses in field nursing staff, bioterrorism preparedness workers and other people who work behind the scenes every 

day testing samples for H1N1 virus and other communicable diseases. Madam Secretary, the one bright spot in these statistics I 

just mentioned is that my local public Health Department will be 

able to retain at least some positions thanks to a one-time infusion 

of recovery package dollars. What other plans do we have at CDC 

or in the department at large, to help local public health departments cope with the huge responsibilities they are going to have 

soon? And also too, what is the plan if the virus mutates some time 

soon so we have a greater pandemic emergency? 

Secretary SEBELIUS. Well, Congresswoman, part of the planning 

effort has certainly been to recognize that the situation you are describing in California is nationwide, that public health agencies 

have been severely hampered by the budget cuts, so that the resources, the $1.4 billion which was pushed out, hopefully, will help 

enhance that. We have also reactivated the Commissioned Corps, 

the emergency group of retired medical providers and volunteers 

who came together after 9/11. They are now about 200,000 strong 

throughout the country, registered in every State and kind of put 

them on notice to help with the vaccination efforts and have them 

able to be called upon. We do have our Commissioned Corps of 

health workers who, again, can be brought in to supplement some 

of the State-based efforts. But every State, as they submitted plans 

to the CDC, recognizes that part of the challenge in dealing with 

this is a restricted core of personnel, of trained personnel. 

Again, we are not urging folks to continue with the testing protocol. That was important early on to determine, but right now we 

are just moving more to the vaccination and mitigation phases to 

try and just diminish the circulation of the flu. So some of the earlier activities hopefully will be shifted into the vaccination effort. 

Ms. MATSUI. Thank you 

Ms. DEGETTE. The gentleman from Louisiana, Mr. Scalise. 

Mr. SCALISE. Thank you Madam Chair. And Secretary Sebelius, 

appreciate you coming before us. And since all my colleagues asked 

the questions that I had regarding the H1N1 situation, concerning 

last week’s testimony, the President’s address to the joint session 

of Congress, there were some things that he had said regarding I 

guess the new developments on the health care debate. Since the 

bill that passed out of this committee, the Congressional Budget 

Office testified that it would add $239 billion to the debt, and that 

8 million illegal aliens would have access to the government plan. 

Since the President in his statements last week said that he 

wouldn’t sign a bill that would add to the deficit and wouldn’t allow 

illegals, would you support changes that would be necessary to 

make H.R. 3200, which passed out of this committee, comply with 


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those two initiatives that President Obama stated before the joint 

session to make sure that the bill doesn’t add to the deficit which, 

right now it would add, and then to make sure illegal aliens 

wouldn’t have access to the government plan, which CBO testified 

8 million would. 

Secretary SEBELIUS. Congressman, I am pleased to have any 

number of discussions on health reform. And you know it is a top 

priority of the administration, and I would be pleased to come back 

and do that. The chairman asked that this hearing be on H1N1, 

and I would like to defer to that. I don’t know— 

Mr. SCALISE. We have never had the opportunity to ask you, because your only testimony to us was at a time when you had acknowledged that you hadn’t looked at the details of the bill. So 

really, we are not going to have another opportunity that I know 

of to talk to you personally about the concerns we have that are 

in H.R. 3200. 

Ms. DEGETTE. Would the gentleman yield? 

Mr. SCALISE. I would yield, yes. 

Ms. DEGETTE. I would advise the gentleman on behalf of the 

chairman that he does intend to have further discussions and 

meetings and hearings, and the chairman really has asked the Secretary to come and be prepared today to talk about the H1N1 situation. And I think, you know, obviously, Members are allowed to 

ask any questions they like, but I think the Secretary’s really prepared on that topic today. And I can communicate to the chairman 

that he should have the Secretary back, and I know she is willing 

to come. 

Mr. SCALISE. And I appreciate that. The problem we have is that 

these discussions are ongoing every day. There could be a bill on 

the House floor. We don’t have any assurance that we are going to 

have a hearing before a vote occurs, and I would imagine that the 

Secretary is well-versed in these issues because I know you were 

in the joint session with us last week in the House Chamber when 

the President made those firm commitments. He said he would not 

sign a bill that added to the deficit by a dime. He said that he 

would not support illegals getting access to health care. And yet in 

the CBO testimony, the CBO sat here in the chair you are sitting 

in and said 8 million illegal aliens would have access to the government tape. And he said that it would add $239 billion to the deficit, 

so I am sure you understand those issues. 

You were there at the speech last week. I am sure you have some 

ideas of how we can fix that. We have got ideas of how we can fix 

those problems. But would you support the fixes that would be necessary to make the bill conform with what the President said before Congress. 

Secretary SEBELIUS. Congressman, as a recovering legislator, I 

am reluctant to sign off on any legislative language. I would happy 

to take a look at it to see if I could support it. I certainly support 

what the President stated going forward, that he, I mean, he will 

sign or not sign a bill. I think you can actually count on him. 

Mr. SCALISE. And you weren’t here, I know, but we presented 

some of those amendments here in committee. 

Secretary SEBELIUS. I have not heard the CBO’s testimony 


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Mr. SCALISE. To specifically fix those two problems. They were 

voted down by this committee. 

Secretary SEBELIUS. If you could send me that language I would 

be delighted to take a look at it. 

Mr. SCALISE. I would like to get the commitment from the acting 

Chair that we would be able to get the Secretary back before any 

vote is taken on the House floor. I think that is very important 

that we get these questions answered 

Ms. DEGETTE. The gentleman’s time has expired. I did give him 

extra time because of the colloquy. And I know the Chairman will 

work with the Secretary to make sure we can get her back here to 

answer any questions people may have. And with that, I will recognize the gentleman from Michigan, Mr. Stupak. 

Mr. STUPAK. Thank you, Ms. DeGette. As far as the last gentleman, section 246 of the bill makes it very clear illegal aliens are 

not available to get health care underneath H.R. 3200. And if you 

remember, since you sat through the markup with us, the Space 

amendment that SCHIP and Medicaid also made it illegal. That 

was unanimously adopted by the committee. But so be it. Let’s 

move on to H1N1. Currently, States are expected to purchase a 

portion of the needed vaccine to protect their citizens. But it includes a 25 percent subsidy from the Federal Government. And my 

concern is, a lot of our States are suffering right now because of 

the economic downturn and may not be able to meet their obligation because of limited resources or operational constraints. 

Is there some kind of a plan available under DHS to help some 

of these States like Michigan, California, others that are struggling? I don’t want anyone not to get it because of States budget 

concerns. 

Secretary SEBELIUS. Congressman, through the resources that 

Congress has provided and through the resources from the Department of Health and Human Services, the vaccine will be free, distributed to the States free. They are not expected to have a cost 

share. I think there has been a cost share associated with their 

purchases of anti virals which are in the stockpile but not with the 

vaccine. The vaccine is free, going to be distributed. There may be 

an administration fee by the provider, but there is no fee to get the 

vaccine 

Mr. STUPAK. What about the anti viral then? 

Secretary SEBELIUS. States have purchased anti virals over the 

years in a stockpile. Those are being pushed out as we speak, and 

the department is continuing to replenish that stockpile and, if 

needed, will supply those to States. 

Mr. STUPAK. Okay. So no State should have to worry about not 

being able to afford or obtain the anti viral. 

Secretary SEBELIUS. That is correct. That is what we are trying 

to do with the resources. 

Mr. STUPAK. Let me ask you right now. It is flu season now, traditional flu season and people are getting their shots. Is there some 

kind of waiting period they should have before they get their seasonal flu and the H1N1 flu shot? 

Secretary SEBELIUS. Well, again, since we don’t anticipate the 

real supply of H1N1 until October 15, we are saying to people get 

it now. It is my understanding that the clinical trials underway 


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right now are looking at whether or not there is any harm to simultaneously getting the flu shot, and as we get closer to October 

we will have that data available. 

Mr. STUPAK. Let me ask you this: I am from Northern Michigan 

and we share a border with Canada. We go back and forth daily 

and we are doing a lot of preparation on this side. Is there any special considerations being given to border communities on the southern border, northern border, and what are they doing in those 

countries, especially as we are moving back. It seems like we have 

got a much more robust program here in this country. I haven’t 

seen the same in Canada or especially Canada. 

Secretary SEBELIUS. The Department of Homeland Security 

looked carefully at that issue and the scientific advice during the 

spring, and it was determined that since there was already a robust outbreaking of H1N1 already within our borders, that border 

closings really would harm commerce potentially, but not really 

help with the disease outbreak. So there is no anticipation at this 

point to do anything with our northern and southern borders 

Mr. STUPAK. Well, I don’t want to see a border closing, but are 

you coordinating with our countries like Canada in particular to 

make sure that we are doing basically the same things, same education programs? 

Secretary SEBELIUS. There definitely has been a lot of national 

and international discussions and particularly with Canada and 

Mexico. That has been underway since the early spring and will 

continue. 

Ms. DEGETTE. The gentleman from Oregon, Mr. Walden. 

Mr. WALDEN. Thank you, Madam Chair. And I appreciate the 

Chair’s commitment to have the Secretary come back before the 

committee before we have a vote on the health care overhaul bill 

on the House floor. 

Ms. DEGETTE. I don’t have that power. But I am going to talk 

to the chairman who does have that power. 

Mr. WALDEN. But if you had that power you would give us that 

commitment I know. I appreciate that because a lot of us share 

that concern. I also wanted to draw attention of the Secretary to 

a letter, a bipartisan letter Mr. Rogers, Mr. Gonzalez and I and 

others sent to you recently regarding the 2010 fee schedule on 

Medicare as it relates to cardiologists and oncologists and proposed 

cuts that could be as high as 40 percent in some codes. 

If you haven’t gotten that, I don’t expect you to be on top of every 

letter that comes your direction, but if you could flag that one we 

would appreciate your response. I was reading a story in the paper, 

one of the papers coming out here yesterday from Oregon about the 

problem in the southern hemisphere related to H1N1 as it related 

to folks in the hospital trying to deal with those who were sick. 

And they raised the issue, in the story at least, that the hospital 

workers, the nurses. The doctors, others did not have a sufficient 

and early supply of masks and other protective equipment to prevent the spread within the hospital setting. 

Are you and your folks confident that in these environments 

where all of us who get sick are going to rush, that there is adequate whatever we call it, the materials, the masks, the protective 

equipment, the whatever, so that those we rely upon for our health 


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care will, in and of themselves, be healthy in the process and not 

at unnecessary risk? 

Secretary SEBELIUS. Congressman, that discussion is actively underway. And as I say, the guidance from the CDC is about to be 

issued. We—the scientists have not been in complete agreement 

about the right protocol, particularly with the use of respirators 

going forward, so the request went to the Institute of Medicine to 

do a sort of rapid response study. They came back with a protocol 

which I would suggest is the ideal case scenario, a respirator per 

provider for every patient seen. There are not adequate supplies to 

follow that protocol. 

Mr. WALDEN. So one new respirator for every patient? Every 

time you see a patient the doctor or nurse would have to put on 

a new respirator? 

Secretary SEBELIUS. That is what the IOM suggested. And the 

stockpiles in the country in the manufacturing capacity would not 

allow us to follow that protocol, so right now, we are working actively with OSHA and CDC and the health care providers to develop a protocol that actually is more in fitting with what the supply looks like, because IOM was told not to take into account what 

is available or what could be available over the next 6 months. Unfortunately, the reality is we have got to look at what is available. 

So that discussion is actively underway as we speak. 

Mr. WALDEN. And on that point, the Vice President had said at 

one point, and I think he probably regretted it, that he wouldn’t 

put his family on an airplane, et cetera. I was on an airplane yesterday and the person behind me was coughing, and I am convinced was taking no precautions about the emissions. I directed 

the air filter to flow backwards. What advice and counsel do you 

have for all of us about—I realize we ought to cover our mouths 

and all. But if you are on the other side of that, should we be wearing those kinds of protective face masks when the outbreak comes? 

Is it going to be helpful or is that just overboard? 

Secretary SEBELIUS. What I have been told by the scientists is 

that probably not; masks are really not—if you are in a caregiver 

capacity in a home situation, coming in close contact, it may provide some protection. But basically, no. And if this continues to 

present much like seasonal flu, you know, a number of people get 

hospitalized with seasonal flu every year, we don’t have that kind 

of rigid fitted mask protocol underway. So we are trying to balance 

safety and security. What is most alarming, and I think all of you 

would be great to help with, health care workers right now don’t 

get vaccinated. Less than 50 percent of health care workers ever 

get vaccinated for seasonal flu, even though they are a priority 

group for H1N1 we are afraid that take up rate may be the same. 

So I would say that is step one is to take advantage of the protection that is there with the vaccination, both with seasonal flu and 

then with the H1N1 vaccine because they are at the front of the 

line and we would hope that they would do that. 

Ms. DEGETTE. The gentlelady from the Virgin Islands, Mrs. 

Christensen. 

Mrs. CHRISTENSEN. Thank you, Madam Chair, and thank you, 

Madam Secretary, for being here with us again today. Individuals 

25 to 64, with underlying medical conditions such as asthma, diaVerDate Mar 15 2010 02:52 Aug 18, 2012 Jkt 074097 PO 00000 Frm 00055 Fmt 6633 Sfmt 6633 E:\HR\OC\A097.XXX A097

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betes and compromised immune systems are one of the target 

groups for the forthcoming vaccine. As you know, racial and ethnic 

minorities are disproportionately affected by all of these chronic 

diseases and more. Are your clinical trials, are the people in the 

clinical trials diverse? And what outreach is being, has been done 

that is culturally and linguistically appropriate to reach these 

sometimes hard to reach populations, often with poor public health 

infrastructure, to ensure that they get the adequate prevention 

treatment and so forth? 

Secretary SEBELIUS. The clinical trials, it is my understanding, 

are diverse, and we are aware of the concerns that have been 

raised in the past. Again, a lot of the trials underway are specifically about dosage because the clinical trials have been done for 

years on seasonal flu, which deal a lot with outcomes. The challenge of communication and outreach strategies is one that we are 

taking very seriously. So traditional media is being used, non traditional media, ethnic specific media, so translating everything on 

the Web site into Spanish, into Vietnamese automatically, and then 

other languages can be requested as needed, looking at a variety 

of media outreach that reach non traditional community, working 

with the faith-based and community outreach programs. 

Mrs. CHRISTENSEN. Okay, because a lot of these communities 

also are not connected. 

Secretary SEBELIUS. Right. So we are using the faith-based 

groups to connect. For the younger population it is an equal challenge. So Facebook and Twitter and ESPN has agreed to become 

a partner for the scrolls they put across college dorms. We have a 

PSA contest on YouTube in terms of trying to get to people. So we 

are really trying to maximize. And special outreach to minority 

providers and health clinics, knowing that they are likely to see a 

lot of folks with underlying health conditions who need to understand how serious the risk is for this virus where nobody has an 

immunity. 

Mrs. CHRISTENSEN. Thank you, Madam Chair. 

Ms. DEGETTE. Dr. Burgess. 

Mr. BURGESS. Thank you, Madam Chairman. Secretary Sebelius, 

I guess I should point out, for health care providers of my age, we 

were, most of us, in the midst of our training during the last swine 

flu outbreak during the Ford administration, and remember very 

vividly some of the problems encountered. So as information is 

gathered as to the safety of this vaccine, I think it is extremely important to get that out and get it disseminated. We had a big problem in Fort Worth, Texas, with the first round of this in the spring. 

The school district closed, and I would say, I think appropriately 

so, but they received a great deal of criticism. The school district 

across the Trinity River in Dallas did not close and obviously there 

were a lot of comparisons made between the decisions of the two 

school districts. 

Still, I think Superintendent Johnson did exactly as she should 

have when she was confronted with a large number of suspected 

cases, and could not get information back in a timely fashion from 

the CDC as far as recommendations. To prevent that type of difficulty from occurring again in the fall, I asked, and your department was kind to respond and we did a seminar on H1N1 in Fort 


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Worth this past August, and we had representatives not just from 

HHS but from DHS and CDC as well as the State and county 

health departments. The impression I got from that day’s discussion was that the decisions about closure or non closure of schools 

would be left up to the local authorities. 

But then seems like less than 48 hours later, the guidelines coming down that your Department would decide when schools should 

close. So I would just simply ask the question, who is going to be 

making these decisions? Is it the local folks? Is it you? Is it Secretary Duncan from the Education Department? Who is going to be 

making these decisions? Because it obviously impacts not just the 

school year of the kids, the learning curricula of the children, but 

in Texas, of course, we have, like many other States, we have a 

testing protocol under No Child Left Behind, and we don’t want to 

see our school districts unnecessarily penalized, but we don’t want 

to see our school districts take unnecessary risks with the children’s safety. 

Secretary SEBELIUS. School closure both in the spring and now, 

moving forward, are always a local decision. That is made at the 

local level. Having said that, the Centers for Disease Control has 

issued school guidance, and it is just that, guidance, what they are 

seeing from the science and what they would recommend. And at 

this point, the guidance is different than what was being discussed 

this spring, in part because we didn’t know how lethal the disease 

would be, and it was very unclear whether or not sending your 

child to school could, indeed, cause much more serious harm. Now, 

we have learned a lot over the spring and summer. I have learned 

a lot from the southern hemisphere, and so the guidance issued by 

the Centers for Disease Control and put forward by Secretary Duncan and others in outreach to schools across this country is really 

leaning towards keeping schools open, having protocols available in 

the school to deal with outbreaks, isolating kids, sending them 

home, trying to make sure that teachers and students are vaccinated, but keeping schools open. That could change. The flu could 

change. We are watching it very closely. But the school decision 

will continue to be made at the local level. 

Ms. DEGETTE. The gentlelady from Florida, Ms. Castor. 

Ms. CASTOR. Thank you, Madam Chair. And thank you, Madam 

Secretary, for all of your efforts in educating the country on H1N1. 

I am not unlike the millions of parents across the country that 

have been, we have been teaching our kids, you know, wash your 

hands all the time, cover your cough. We haven’t altered substantially the way we live our lives. So this Saturday we had a dozen 

9- and 10-year olds over for my 10-year old daughter’s birthday 

party. And they did not protest when I had them wash their hands 

before snacks, wash their hands again before cake, wash their 

hands again towards the end of the evening. But wouldn’t you 

know it, that one of my daughter’s friends got sick at the party. 

And her mother called me yesterday and, sure enough, it is H1N1. 

Now, of course she is staying home from school, and there are 

a number of kids out this week. But parents want to know, and 

your guidance is very good. The CDC guidance is very good. But 

the question I hear a lot from neighbors and other parents, you 

know, how long does the child have to stay out of school? And this 


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guidance, it says that a person who has it can infect others up to 

5 to 7 days after getting sick. But it also says that it is okay to 

go back to school 24 hours after the fever is gone. So what is the 

most consistent answer I can give to parents of a child that has 

just come down with H1N1? 

Secretary SEBELIUS. I think the scientists are saying 24 hours 

after the fever is gone, without any medication to lessen the fever. 

And the problem is that for the kind of average, maybe five to 7 

days, a lot of kids it may be two to 3 days and then 24 hours later 

they are ready to go. So it is hard to give you a date specific. I 

think it is a child-to-child situation. Some have more serious cases. 

Some have lesser cases. But 24 hours without any medication since 

the time you have had a fever they say is safe to go back. 

Ms. CASTOR. Even though they could still infect other kids a few 

days after that? 

Secretary SEBELIUS. The doctor is telling me what they are seeing is that the vast majority can’t infect at that point, and that is 

why they have arrived at this 24 hours after the fever. 

Ms. CASTOR. Terrific. Okay. Thank you very much. 

Ms. DEGETTE. The gentleman from Iowa, Mr. Braley. 

Mr. BRALEY. Thank you Madam Secretary for joining us. And I 

think everyone is concerned about the public health implications, 

but there are some unintended consequences of the public health 

campaign that I think we also need to be conscious of. And one of 

the concerns that I expressed at an earlier hearing when we had 

representatives of the CDC here, was the decision to refer to this 

virus generically as swine flu, despite its origins, and the enormous 

negative impact it has had on our pork industry because of a lot 

of myths and misconceptions. 

And yet I know that public health officials have determined that 

it is easier to get college students’ attention about the need for getting prepared and exercising precaution when you refer to it by the 

name swine flu, as opposed to H1N1. So we have got these conflicting things going on. And one of the things that I am very concerned about is how we balance those interests, given the enormous 

economic implications to states like mine, when people have half 

truths and misinformation and yet the reports that I have seen as 

recently as this weekend in The Washington Post, ‘‘Sebelius encouraging news regarding swine flu vaccine, their choice, not 

yours.’’ New York Times, ‘‘One vaccine shot seen as protective for 

swine flu.’’ So how can we address the enormous public health challenge that we are all legitimately concerned about, and still address this enormous negative economic impact that it has had on 

our pork industry. 

Secretary SEBELIUS. Congressman, that is a great question, and 

I can tell you it is one that we are wrestling with a lot. I hope 

never out of my mouth have you ever heard that other term, or out 

of CDC or NIH or the FDA. And I have taken it on as a bit of a 

personal mission when I am with media, reporters and being interviewed to correct them and ask that they please use the terminology that is accurate, because there is a lot of misinformation 

and we have, on several occasions, and I join with Secretary 

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ing at all in this flu is related to eating pork. You can’t get it from 

pork. There is no crossover. 

But you are absolutely right. I know there has been over a billion 

dollars, if I understand it, and that may be very underestimated 

at this point. And we would welcome any suggestions. I think it is 

easier to do so they do it. But I would agree it is a huge, and it 

has an enormous economic impact. I have even suggested, and 

maybe you want to conduct your own media campaign, that maybe 

we should challenge people to use the right terminology. You could 

send them a pork chop every time they use the right term, but take 

it away. 

Mr. BRALEY. Or they could come to the Congressional rack of 

pork reception tomorrow night in the Longworth. 

Ms. DEGETTE. The Chair now recognizes the gentlelady from 

California, Mrs. Capps. 

Mrs. CAPPS. Thank you, Madam Chairman. Secretary Sebelius, 

you have been very patient this afternoon and I hope that this 

won’t take the full 5 minutes. But I want to thank you and I want 

the record to note that you really did hit the ground running. After 

your confirmation you had a lot of issues on our plate. I have seen 

you everywhere on both health care reform in very positive ways 

and also on this topic. And I am referring to a bicameral briefing 

that you and several Secretaries presented to Members of Congress. It was midsummer, if I am not mistaken, in between, sort 

of like the spring outbreak. And my question then was to acknowledge the role that a school nurse played in the first case in the 

Bronx that resulted in massive school closures. And as a former 

school nurse, I sort of emphasized, I know why districts close their 

schools, but it is chaotic when it happens. Parents have to—parents 

don’t have back up plans a lot of times and they miss work and 

all the things that ensue and you find kids in the mall and all 

kinds of places when that happens. 

So now I am pleased to follow the chain of questions that have 

been asked. And I will, since this topic has come up, I am interested in the nuances now that have occurred watching the epidemic 

as it has proceeded, and now as this school season hit, and many 

of the campuses, a little older teenagers, young adults and that 

captive environment which can be dealt with somewhat differently 

because they are not so dependent on parents and jobs and things. 

But still, I would like to have you address just for a minute for 

the record, because the relationship between your department and 

CDC and the local communities is very specific and I think, unlike 

many other departments, with very direct communication, and outline for us a few of the ways that you have been working with local 

health departments as they then are partners with local school districts to formulate and get the right kind of advice tailored to different parts of the country, so that we behave in the proper way 

as this comes out, both in terms of immunizations, vaccination 

plan, and also what to do when, like my colleague, Kathy Castor’s 

own child’s daughter’s friend, you know, what, how do you respond? 

Secretary SEBELIUS. Well, I think that is a great question. Since 

the spring I would say the three cabinet secretaries who have been 

sort of at the forefront of this effort are Secretary Napolitano with 

the Homeland Security and government coordination work, but 


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Secretary Duncan from the Department of Education, because, 

given the age group of the target population, that has been a real 

effort. And he has regular calls, regular outreach with superintendents and principals and teachers all throughout. The CDC has specific guidance that is on the flu.gov Web site at which we have 

asked schools to download and take a look at. 

And what happened to really change the school advice, the guidance that was out, from leaning toward closing schools to leaning 

toward keeping them open, was first realizing that it would not 

present itself as a more lethal disease. Secondly, recognizing that 

there are a whole series of other health impacts for children who 

are sent home, missing often school breakfast and lunch which has 

a nutritional impact, being in an unsafe environment, which has a 

significant impact if there is nobody home to take care of them. 

And on balance, given the way the disease was presenting, it 

seemed wiser that the guidance be toward keeping schools open, 

but trying to isolate and send home sick children, urging parents 

to keep them home in the first place, but if they show up at school, 

send them back home, isolate them until you can find a parent. I 

think that this may change as we go along. 

And what we know is that what we saw this spring there are 

going to be some areas of the country, some cities that have lots 

of cases like New York did in the spring. There have going to be 

others relatively close by that may have very few cases, so it is impossible to have a national protocol, and school decisions will continue to be very local. But that outreach, we do an every 2-week 

call; we have had a big flu summit and asked governors to send 

in their education secretaries, their homeland security, their emergency planner, their health, so the school folks have been part of 

this conversation in a very robust way from day one. 

Mrs. CAPPS. Thank you very much. 

Ms. DEGETTE. The gentleman from Georgia, Mr. Barrow. 

Mr. BARROW. Madam Secretary, thank you for your service, and 

thank you for coming here today and sharing with us on this. My 

name is John Barrow. I represent Savannah, Georgia, Augusta, 

Georgia and all points in between. Our prior response to seasonal 

flu might not be the best guide for what we should do, but it is 

probably a pretty good guide as to what we will do unless we do 

something different. And I am given to understand that less than 

half the targeted populations we reach out to on a regular seasonal 

basis get the vaccine that is suited for that situation. And so we 

have got to anticipate, unless we do something different we are 

going to have a similar success rate in response to this new threat. 

I understand that one of the targeted populations we are trying to 

reach in response to the H1N1 is the population of children and 

young adults 6 months to 24 years of age. 

Kind of sets it apart a little bit perhaps from the seasonal flu. 

I am having a telephone conference call this afternoon with a pretty influential bunch of folks with respect to that targeted population. My public health expert, Ms. Betty Dixon, is with me today, 

and she is going to be participating in this conference. We are 

going to be talking with every superintendent, every assistant superintendent, the principals from every elementary, middle and 


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high school in the district, and the deans of students at many of 

the 18 institutions of higher learning that we have in my district. 

So my question to you is sort of a general one. What can we do, 

what can we say in the course of that conversation, for that captive 

and very influential audience to help them get a higher success 

rate in reaching the targeted population they have some influence 

over than we have been able to do so far with respect to seasonal 

flu? What can we tell them that we are not already telling them? 

Secretary SEBELIUS. Well, I think that you can tell them that we 

know that they have the target population, and that if it is nothing 

more than just lots of folks getting the flu, that has a huge disruptive factor, so having, minimizing the spread right now, and then 

vaccinating we know is the best defense against the flu spread. We 

do have some great information on the Web site. I would suggest 

that maybe if you put the widget on your Web site and urge them 

to come and download, you know, we have got parent tool kits and 

information for teachers. 

Mr. BARROW. This is how to. What can we tell them as to why 

to? What can we tell them to motivate them to make a greater effort than has been made in the past? 

Secretary SEBELIUS. Well, they can keep people from being hospitalized and dying. If 36,000 children in this country die from this 

flu, I would suggest it will have a huge impact on communities 

around the country. And that is the average death rate for seasonal 

flu. So even if it is just like regular flu, given the population that, 

basically, they are responsible for, that is what it looks like. And 

so I think you need to convince them even the regular flu is particularly, is different because it is kids and it is young adults. They 

have no immunity to this whatsoever. 

So anybody with underlying health conditions is really at far 

higher risk. And I think just getting their hands around 200,000 

hospitalizations year in, year out with seasonal flu, 36,000 deaths, 

that is what the profile looks like, but typically, because of the age 

of the population who is typically affected and because of their frail 

condition I am not sure it has the kind of societal impact, community impact. There is, Dr. Schuchat tells me, a new tool kit for 

school immunization that will be on-line, well, that went online on 

the 13th. 

Mr. BARROW. Available at? 

Secretary SEBELIUS. But I just think, you know, getting their attention about how even mild flu is very serious. People die, people 

get very sick. And anything we can do to prevent that, really, we 

need them to do. 

Mr. BARROW. Thank you. 

Ms. DEGETTE. Mr. Pitts is now recognized for 3 minutes. 

Mr. PITTS. Thank you, Madam Chairman. Madam Secretary, 

what geographic regions of the country does HHS expect to be hit 

the hardest by the H1N1 strain during the winter flu season? Is 

there any projections that your Department has made? It seems 

like the south has reported an increase in cases. That might be just 

because they start school earlier in the south. I don’t know. Do you 

have any ideas on that? 

Secretary SEBELIUS. We really, Congressman, saw very scattered 

cases throughout the country over the spring, during the outbreak. 


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There was no one region, one area isolated. We think that the rise 

in cases in the southeast, which showed up first, is because of the 

fact that they did start school earlier and kids came together earlier. We are starting to see cases though, spread, Oregon, Kansas, 

I mean so it is beginning to spread out as people come back to 

school, as colleges re-engage. So we don’t have any information that 

gives us kind of a regional or local look at what is likely to be more 

of an outbreak, which is why it is so important that we keep watching it very closely and monitoring what is happening on the local 

level. 

Mr. PITTS. Have all of the States implemented what you would 

consider adequate stay preparedness plans for this? 

Secretary SEBELIUS. Well, Congressman, all States were required 

in order to access the funding available to help them implement, 

they were all required to submit plans. I think that the assessment 

was that many States are ready in a very robust way. Others were 

in okay shape, and some really needed a lot of help. We have provided technical assistant, support, on the ground surveillance. We 

also had teams that did site visits to try and verify that what was 

coming in in the written plan was actually accurate in terms of 

what was available. So we are trying to provide resources, help, 

support, and get States ready to go, because a lot of this will have 

to be, the shots in the arm are really going to be a State and local 

effort. 

Mr. PITTS. Will there be enough vaccine for all of the States to 

have? 

Secretary SEBELIUS. Yes. 

Mr. PITTS. And are they adequately stockpiled now? 

Secretary SEBELIUS. Well, the vaccine isn’t stockpiled because it 

hasn’t been produced, so that the vaccine, we hope, will begin to 

be widely available on the 15th of October, which is the target 

date. We anticipate having some early supplies as early as 10 days 

before that and it will be distributed as soon as it comes off the 

production lines. 

Mr. PITTS. Okay. My time is up. Thank you. 

Ms. DEGETTE. The gentlelady from California, Ms. Eshoo. 

Ms. ESHOO. Thank you, Madam Secretary. It is wonderful to see 

you. And I want to salute you for your very steady, strong, sensible 

leadership. Whether you are testifying here or I see and hear you 

on whatever TV program, I think that you speak very clearly to the 

American people, and I think that we all appreciate that. There 

are, what, five companies that are making the—responsible for 

the—— 

Secretary SEBELIUS. Five manufacturers. 

Ms. ESHOO. Making the vaccine. One of them is MedImmune, 

and they are in my Congressional district. Theirs is a nasal spray, 

while the others are the traditional injections. What I would like 

to know is, is this something that would be better used for children? Are you going to make a choice relative to that? Does it really matter? Is it good for adults? Is it as good for children? And how 

do you think that it might affect the voluntary compliance rate for 

those opting to get the H1N1 vaccine? And what I am going to do, 

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ing questions relative to this whole thing. But I will just stick with 

that for now. 

Secretary SEBELIUS. What Dr. Schuchat tells me is that it isn’t, 

the nasal mist is not recommended for the youngest children. 

Ms. ESHOO. Oh, it is not? 

Secretary SEBELIUS. Two to 49 seems to be the target population, 

as long as they don’t have underlying health conditions. So, again, 

some of the highest risk children would not be recommended to get 

the nasal mist instead. But it certainly is a viable alternative for 

a lot of population. 

Ms. ESHOO. Good. Well, thank you again for what I think is really special and highly needed leadership. We are proud of you. 

Thank you. 

Ms. DEGETTE. The gentleman from—Mr. Shimkus for questions. 

Mr. SHIMKUS. Yes, I just want to—again, I was here for some of 

the opening statements. Welcome, Madam Secretary here. Education, education, education is the key, especially for a couple of 

things. Obviously, just you know, passing of the food and the germs 

and all this other stuff. But also, we already have a run on hospitals, emergency rooms with people who are, in essence, just having the everyday flu-like concerns. And I know that we have to do 

a good job calming the public so that they use the services when 

they are needed but don’t over-utilize them when they are not. And 

I don’t know how you—I am not a health practitioner so I don’t 

know how you gauge that, but I do think that education is the key. 

And I would agree with my friend, Anna Eshoo, the calming 

presence that your position is going to be required to hold especially as we come into this season of the year. I have three small— 

well, they are not small. I have a junior, a freshman and a fourth 

grader, so we are all concerned when they start closing down 

schools and maybe before they should and so I just want to encourage you. I don’t have any answers. I would like to yield the rest 

of my time to Dr. Burgess. 

Mr. BURGESS. Thank you, Mr. Shimkus. I just had a follow-up 

question that came up. One of the questions down here was on the 

funding issue. And there was a little over $7.5 billion for the H1N1 

flu in the stimulus bill; is that correct? 

Secretary SEBELIUS. That is correct. 

Mr. BURGESS. So have these funds been disbursed? Are they 

readily available to you? Are they still being held somewhere in the 

stimulus pot? Or do you have all of the money you need? Do you 

have the funding that you need at this point? 

Secretary SEBELIUS. At this point, Congressman, we do. We are 

drawing that money down. We have made a couple of draw downs 

to buy vaccine and get ready to distribute it. Now that we have a 

little more clinical data, we are likely to have a more accurate picture of how much vaccine we are going to need. We have used some 

of it to replenish the stock piles of anti virals that we sent to the 

States to help, as I say, about a billion four so far has gone out 

to States and hospitals for surge capacity. We are buying protective 

equipment. So we are trying to do a step at a time. And at this 

point, the funding provided is extraordinary helpful, and we—— 


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Mr. BURGESS. So at the present time you don’t anticipate having 

additional funding requirements that we will be asked to deal 

with? 

Secretary SEBELIUS. At this point I don’t have them. Again, we 

are watching this very closely. If this turns more lethal, if it begins 

to present itself in a different way, if, you know, things change and 

the surge capacity wrong, at this point I think we are on target, 

but it is a day-by-day operation. 

Mr. BURGESS. Let me just ask you one other follow up for Mr. 

Walden. He, of course, alluded to the fact that we have got, and 

this is off the subject of the avian flu, but it is so important because in 3 months’ time, cardiologists, oncologists and, indeed, all 

physicians who practice under the Medicare system are going to receive a 21 percent reduction if Congress doesn’t do something. Now, 

we still have a vacancy at the head of the Center for Medicaid and 

Medicare Services, is that not correct? 

Secretary SEBELIUS. That is correct currently. 

Mr. BURGESS. How close are we to filling that position? 

Secretary SEBELIUS. We hope very close. 

Mr. BURGESS. This is a critical issue, and I would encourage you 

to get that done. And again, Congress has an obligation to its provider community to step up and do the right thing as far as the 

sustainable growth rate formula, but it is very, very difficult to 

even get an answer out of the Center for Medicare and Medicaid 

Services right now without anyone at the helm. 

Secretary SEBELIUS. We do have, as you probably know, Congressman, a new leader for the Medicare and a new leader for Medicaid who are in place, John Blum and Cindy Mann, and they are 

doing a spectacular job. But I share your concern about the leadership, and we are very close. 

Ms. DEGETTE. Thank you. The Chair now recognizes Mr. Sarbanes from Maryland for 3 minutes. 

Mr. SARBANES. Thank you, Madam Chair. Thanks so much for 

spending all this time with us. You are close to the end here. I 

know we are all very grateful that you are in this position at this 

time because you have handled things so superbly, and I think 

with a sense of calm that is contagious in a good way. So just don’t 

get the flu. 

Secretary SEBELIUS. Well, maybe I can walk people through it a 

step at a time. 

Mr. SARBANES. Right, exactly. I think you answered the first 

question I was going to ask, which is the lethality, the judgment 

about how lethal this thing can be could change. I know that initially there was concern that it be more lethal than it has turned 

out to be but you just alluded to the fact that it could turn back 

in the other direction; is that right? 

Secretary SEBELIUS. That is correct. 

Mr. SARBANES. Okay. And I was just curious. I imagine you have 

ways of judging the success of our overall effort to contain this pandemic as we go forward, which would include clearly looking at the 

number of lives lost in the process. I would imagine how well we 

are doing addressing these high risk groups out of the gate, what 

is happening in particular communities in terms of the modeling 

that that suggests. I wonder if you could just point to any other 


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sort of prime indicators you are going to be looking at, and also 

comment on whether you anticipate that there will be kind of pivot 

points along the way, where we may need to regroup and move in 

a kind of different direction than we are anticipating right now. 

Secretary SEBELIUS. Great questions. I think that one of the lessons learned from the ’76 experts was that there do need to be 

points along the way that you make sure we are still on track because, as people keep telling me, the predictable fact about the flu 

is it is unpredictable. It could change. So monitoring very closely 

what we are seeing and part of the lethality is really watching 

what happens when H1N1 begins to mix with the seasonal flu viruses. What we saw in the southern hemisphere is still encouraging, that it did not mutate into a significantly more dangerous 

virus. That is good news. But can that happen next month, the following month? You bet. 

So there will be continued monitoring and testing, particularly 

the more serious cases when they come to the hospital, and making 

sure that we know we are on target. The vaccine seems to be exactly what it should be to target H1N1. The robust response is 

great. The limited time that it is taking is very good. And the fact 

that one dose seems to actually produce a good immunity response. 

All of that is very good news. But I think watching the outbreak, 

certainly monitoring very carefully hospital capacity, how to deal 

with the more seriously ill folks, we really worry about, right now, 

anti viral treatments. We are, unfortunately, seeing many providers give anti virals prophylactically, so suggesting that people 

would fill a prescription and take it to prevent the flu. 

What our scientists tell us is exactly that is the wrong direction 

because it actually lowers people’s immune response. It could make 

them far sicker in the long run, and it will draw down our anti 

viral stockpile. So that is a particular concern that we put out new 

anti viral guidance. We are doing some aggressive outreach to the 

provider communities trying to remind them that that really is a 

strategy which is very counter productive in the long run. So I 

don’t know what is the next challenge like that. But we will have 

them. 

Ms. DEGETTE. Thank you. The gentleman from Washington, Mr. 

Inslee. 

Mr. INSLEE. Thank you. Do you have any issues as far as 

prioritization, geographically or otherwise, when we have a vaccine 

become available? Could you identify those issues that the public 

may be interested in or we may be interested? 

Secretary SEBELIUS. Well, there is certainly no geographic priority. We have asked the States to present plans, which they have. 

And the community on immunizations, I mean, the Committee on 

Immunizations has developed a priority list based on the science, 

basically five categories of people who total about 160 million 

Americans, pregnant women, caregivers of infants under the age of 

6 months, children 6 months to 24, particularly those with underlying health conditions, adults 24 and up with underlying health 

conditions and health care workers. 

And that is about 160 million people. We said to States, figure 

out how to get those folks to the front of the line. What are the 

best outreach opportunities, and that is where the vaccine will 


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flow. There will be about 90,000 sites that will receive vaccine 

based on the State plans that we have. So we are not targeting 

folk. We are not making, we are just trying to use our bully pulpit 

in the communication to say to those target populations, you really 

need to think about this. And one of the challenges, as you all 

know, will be to get parents ready to sign consent forms for kids, 

so information is going home in schools to say to parents, this will 

be available we think by the middle of October. But here is what 

the concept form is going to look like. Think about it. Get ready to 

sign it. So if we have a vaccination effort at your school, your child 

actually can be vaccinated. 

Mr. INSLEE. I heard a, to me, sort of surprising comment by an 

ER room doc last week when I was home suggesting that one of 

the problems may be overutilization of our ER room services associated with this, that they are concerned about people coming in. 

Secretary SEBELIUS. The worried well. 

Mr. INSLEE. The worried well. And we understand worry and we 

would all like to be well. You know, just to the extent we disseminate information, what would you tell us all? And you may have 

already talked about this, but it bears repeating, I think, in that 

regard. When should people really feel compelled to go into the ER 

room as opposed to calling your physician first or nurse? 

Secretary SEBELIUS. Well, I would even back it up a step; that 

if someone comes down with the flu, either an adult or a child, and 

there are no serious consequences more than a fever and aches and 

pains, go to bed, chicken soup, stay away from other folks. I am 

not sure you need to take additional steps. Anyone with underlying 

health conditions, asthma, diabetes, neuromuscular disorders, 

should contact a physician on presentation of flu-like symptoms. 

That is the population for anti virals. That is who needs Tamiflu 

fairly quickly, or Relenza. And then certainly anybody who then is 

more seriously ill or a child who becomes lethargic or, you know, 

there are a series of again, tips on the Web site. You take the next 

step. But it is really a triage. People who just come down with the 

flu probably don’t need to call a doctor or have an anti viral or certainly not go to the hospital. 

Mr. INSLEE. Thank you. Thanks for your work. 

Ms. DEGETTE. Thank you very much. The Chair will now recognize herself for, I think, the last questioning. And I want to thank 

you Madam Secretary and also the CDC staff again, for the remarkable job all of you have done in getting the information out, 

in tamping down panic. I think that the public health effort is 

going really well here. Several times in your testimony, you referred to the concern that we have that this virus could mutate. We 

hope that it won’t. It didn’t in the southern hemisphere. But we 

have had a number of hearings in this committee over the years 

about various flu strains. And, of course, the avian flu has been a 

big concern in this committee over the years. I am wondering, first 

of all, how are we coming in developing a cell-based vaccine, rather 

than the traditional egg-based vaccine that we are still using for 

development of the H1N1 vaccine? 

Secretary SEBELIUS. My understanding, Congresswoman, is we 

are still a couple of years away from the different technology. Cellbased, I think, is the sort of high tech version. Actually tobacco 


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growing is also regarded by folks as sort of promising, but we are 

not close to, I mean the last time I talked to folks it is probably 

still a couple of years away. 

Ms. DEGETTE. But are we making a real effort towards these 

other vaccines? Because part of the problem we have, and part of 

our concern last spring with H1N1, was that we might not be able 

to identify the strain quickly enough to make a vaccination because 

we do have to produce the eggs. 

Secretary SEBELIUS. Well, that, investing in developing a faster 

newer technology is still very much underway. It is part of what 

we are doing on an ongoing basis. So we are trying to accelerate 

the work. But it is not imminent that we will have another methodology for developing a vaccine than the egg-based methodology. 

Ms. DEGETTE. I think you can expect more hearings on this 

topic, and we are going to also ask some of the experts for the NIH 

and CDC because what could happen is if we have an avian flu or 

some other kind of epidemic that is as fast moving as this H1N1 

then we would have really been in trouble. 

Secretary SEBELIUS. Well, I think you are absolutely right. And 

I think this is a, hopefully it won’t be more than this, but a sort 

of wake up call that up till now it has been hypothetical. It is now 

very real and we are watching a disease spread enormously quickly, not only in this country but it has now presented in about 120 

countries around the world. So we know this is real. 

Ms. DEGETTE. Right. And with great rapidity. What are we doing 

for people who are allergic to the egg-based vaccines with the 

H1N1 vaccine? Can they just not get it? 

Secretary SEBELIUS. I was just told that they can not get it. But 

vaccinating those around them is the best way to help to protect. 

Ms. DEGETTE. Now, what is it status right now of H1N1, the 

avian flu virus? Is it still lurking out there in parts of the world. 

Secretary SEBELIUS. It is still there. It is continuing to cause disease, but it isn’t being transmitted very easily. 

Ms. DEGETTE. I have a last question. Ms. Castor has the 9 and 

10-year-olds at home. I have the college student. And the college 

students now, this was like when our kids were little and we had 

the chicken pox parties, the college students are now having flu 

parties where they are trying to purposefully get—I don’t want to 

know exactly how they are trying to share the virus, but they are. 

Secretary SEBELIUS. Sneezing on each other. 

Ms. DEGETTE. And so she and her friends asked me to ask you, 

what is your advice about this practice of these flu parties? 

Secretary SEBELIUS. I would say it is a pretty bad idea. 

Ms. DEGETTE. That was my motherly advice, too. So I just want 

to know from the expert. 

Secretary SEBELIUS. And I am sure they won’t listen any more 

to me than to you. But, again, this is a serious disease. Most people, getting the flu is a problem. You miss work, you miss—but for 

a lot of people, this is deadly. And so doing anything to transmit 

the disease, and particularly I would say to our young and people 

who think they are invincible, a number of the younger folks may 

have health conditions that they are not even aware of and they 

really could be in serious trouble by voluntarily getting this flu. 


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Ms. DEGETTE. So, I mean, in all seriousness, the advice of the 

CDC and everybody else is that, for everyone, they should be taking hand-washing protocols, doing their best if they feel sick to isolate themselves to others and to keep this from spreading. 

Secretary SEBELIUS. Absolutely. And 6- to 24-year-olds, including 

the college age group, are in the first priority to get vaccinated. 

That is the best way on a college campus and a dorm to keep kids 

safe. We have done a lot of outreach to college presidents to say, 

find a dorm or find an isolation room. You can’t often send kids 

who are away from school home, but isolating them from one another. Don’t have them go to the school cafeteria to get meals. Figure out a way to get the meals. Keep them away from roommates. 

Because what we know is this spreads very, very rapidly. 

Ms. DEGETTE. And when the vaccine does come out, the college 

students should all go get vaccinated. 

Secretary SEBELIUS. Exactly. 

Ms. DEGETTE. Thank you so much. We have ended under time, 

and we are very appreciative of your testimony today. We look forward to seeing you again. 

Secretary SEBELIUS. Glad to be here. 

Ms. DEGETTE. Before I adjourn the hearing, let me say the 

record will stay open for 7 days for members to submit additional 

questions. 

[Whereupon, at 3:16 p.m., the committee was adjourned.] 

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smartinez on DSK6TPTVN1PROD with HEARINGInsert offset folio 89 here 74097A.047
86 


smartinez on DSK6TPTVN1PROD with HEARINGInsert offset folio 90 here 74097A.048
87 


smartinez on DSK6TPTVN1PROD with HEARINGInsert offset folio 91 here 74097A.049