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51–781 PDF 2009

S. Hrg. 111–154 

PANDEMIC FLU: CLOSING THE GAPS 

HEARING 

BEFORE THE

AD HOC SUBCOMMITTEE ON STATE, LOCAL, 

AND PRIVATE SECTOR PREPAREDNESS 

AND INTEGRATION 

OF THE

COMMITTEE ON 

HOMELAND SECURITY AND 

GOVERNMENTAL AFFAIRS 

UNITED STATES SENATE 

ONE HUNDRED ELEVENTH CONGRESS 

FIRST SESSION 

JUNE 3, 2009 

Available via http://www.gpoaccess.gov/congress/index.html 

Printed for the use of the Committee on Homeland Security 

and Governmental Affairs 

( 

(II) 

COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS 

JOSEPH I. LIEBERMAN, Connecticut, Chairman 

CARL LEVIN, Michigan 

DANIEL K. AKAKA, Hawaii 

THOMAS R. CARPER, Delaware 

MARK L. PRYOR, Arkansas 

MARY L. LANDRIEU, Louisiana 

CLAIRE MCCASKILL, Missouri 

JON TESTER, Montana 

ROLAND W. BURRIS, Illinois 

MICHAEL F. BENNET, Colorado 

SUSAN M. COLLINS, Maine 

TOM COBURN, Oklahoma 

JOHN MCCAIN, Arizona 

GEORGE V. VOINOVICH, Ohio 

JOHN ENSIGN, Nevada 

LINDSEY GRAHAM, South Carolina 

MICHAEL L. ALEXANDER, Staff Director 

BRANDON L. MILHORN, Minority Staff Director and Chief Counsel 

TRINA DRIESSNACK TYRER, Chief Clerk 

AD HOC SUBCOMMITTEE ON STATE, LOCAL, AND PRIVATE SECTOR 

PREPAREDNESS AND INTEGRATION 

MARK L. PRYOR, Arkansas, Chairman 

DANIEL K. AKAKA, Hawaii 

MARY L. LANDRIEU, Louisiana 

JON TESTER, Montana 

MICHAEL F. BENNET, Colorado 

JOHN ENSIGN, Nevada 

GEORGE V. VOINOVICH, Ohio 

LINDSEY GRAHAM, South Carolina 

KRISTEN SHARP, Staff Director 

MIKE MCBRIDE, Minority Staff Director 

KELSEY STROUD, Chief Clerk 

(III) 

C O N T E N T S 

Opening statement: Page 

Senator Pryor .................................................................................................... 1 

Prepared statement: 

Senator Ensign ................................................................................................. 23 

WITNESSES 

WEDNESDAY, JUNE 3, 2009 

Bernice Steinhardt, Director, Strategic Issues, U.S. Government Accountability Office ......................................................................................................... 2 

John Thomasian, Director, National Governors Association Center for Best 

Practices ................................................................................................................ 4 

Paul E. Jarris, M.D., MBA, Executive Director, Association of State and 

Territorial Health Officials .................................................................................. 6 

Stephen M. Ostroff, M.D., Director, Bureau of Epidemiology and Acting Physician General, Pennsylvania Department of Health .......................................... 8 

ALPHABETICAL LIST OF WITNESSES

Jarris, Paul E., M.D., MBA: 

Testimony .......................................................................................................... 6 

Prepared statement .......................................................................................... 62 

Ostroff, Stephen, M.D.: 

Testimony .......................................................................................................... 8 

Prepared statement .......................................................................................... 69 

Steinhardt, Bernice: 

Testimony .......................................................................................................... 2 

Prepared statement .......................................................................................... 24 

Thomasian, John: 

Testimony .......................................................................................................... 4 

Prepared statement .......................................................................................... 48 

APPENDIX 

Questions and responses submitted for the Record from: 

Mr. Thomasian .................................................................................................. 76 

Dr. Jarris ........................................................................................................... 83 

Dr. Ostroff ......................................................................................................... 86 

Map of ‘‘Confirmed Cases Of Swine Flu Across The Globe,’’ submitted by 

Senator Pryor ....................................................................................................... 93 

(1) 

PANDEMIC FLU: CLOSING THE GAPS 

WEDNESDAY, JUNE 3, 2009 

U.S. SENATE, AD HOC SUBCOMMITTEE ON STATE, LOCAL, AND

PRIVATE SECTOR PREPAREDNESS AND INTEGRATION, OF THE COMMITTEE ON HOMELAND SECURITY

AND GOVERNMENTAL AFFAIRS, Washington, DC. 

The Subcommittee met, pursuant to notice, at 2:05 p.m., in room 

SD–342, Dirksen Senate Office Building, Hon. Mark L. Pryor, 

Chairman of the Subcommittee, presiding. 

Present: Senator Pryor. 

OPENING STATEMENT OF SENATOR PRYOR 

Senator PRYOR. I will go ahead and call our meeting to order. I 

want to thank everyone for being here today. This is the Subcommittee on State, Local, and Private Sector Preparedness and 

Integration and it is time for us to update our efforts on pandemic 

influenza. 

The Centers for Disease Control (CDC) has described pandemic 

flu as both inevitable and as one of the biggest threats to public 

health in the Nation. In October 2007, I chaired a hearing entitled, 

‘‘Pandemic Influenza: State and Local Efforts to Prepare.’’ At that 

hearing, HHS, DHS, and State and local health officials testified. 

The witnesses cited efforts underway that included national strategies, plans, and exercises. Now less than 2 years later, we are faced 

with the reality of a pandemic threat. 

In late March and early April 2009, the first cases of a new flu 

virus, the H1N1, were reported in Southern California and San Antonio, Texas. So far, the CDC has confirmed 10,053 cases in 50 

States and in the District of Columbia. This includes seven cases 

in my home State of Arkansas according to the CDC. The CDC reports that most of the influenza viruses being detected now in the 

United States are of the strain. Further, CDC’s Dr. Anne Schuchat 

has said this will be a marathon and not a sprint, and even if this 

outbreak is a small one, we can anticipate that we may have a subsequent or follow-up outbreak several months later and we need to 

stay ready. 

One of the things we have talked about in this Subcommittee before is hurricane preparedness. Years ago, there was an exercise 

authorized and then for whatever reason, the money wasn’t available to conduct the Hurricane Pam exercise, which was almost 

identical to the scenario we saw when Hurricane Katrina struck. 

2 

1The prepared statement of Ms. Steinhardt appears in the Appendix on page 24. 

We find ourselves today in somewhat of a similar situation in 

that we have had this flu scare already this spring and now it 

looks like, if flu behaves like it normally does, we will have a few 

months where it won’t be that active, and then I hope I am wrong, 

but it looks like it may come back in the fall. We just need to make 

sure that we are ready, that we are doing everything that we can 

do, and that the State, local, and private sector are working together on this. 

So what I would like to do is introduce the panel and ask each 

of you to make a 5-minute statement. We may be joined by some 

other Senators. I know Senator Ensign has been trying to change 

his schedule to get here. We will keep the record open after the 

conclusion of the hearing for a couple of weeks and let Senators 

submit questions, and if there are follow-ups that we need to work 

with you on, we will do that. 

Let me introduce the panel. First, we have Bernice Steinhardt. 

She is Director of the Government Accountability Office’s Governmentwide Management Issues. She has led the preparation of 11 

GAO reports, the most recent, ‘‘Sustaining Focus on the Nation’s 

Planning and Preparedness Efforts.’’ It synthesizes 23 recommendations that we should be working on now. Ten of them 

have yet to be acted on. 

Our second panelist will be John Thomasian. He is the Director 

of the National Governors Association’s Center for Best Practices. 

Next, we will have Dr. Paul Jarris. Dr. Jarris is the Executive 

Director of the Association of State and Territorial Health Officials 

(ASTHO). 

Finally, we will have Dr. Ostroff. Dr. Ostroff is the Acting Physician General and Director of the Bureau of Epidemiology for the 

Pennsylvania Department of Health. 

What I would like to do is open it up, 5 minutes each, and then 

we will ask questions. Go ahead. 

TESTIMONY OF BERNICE STEINHARDT,1 DIRECTOR, STRATEGIC ISSUES, U.S. GOVERNMENT ACCOUNTABILITY OFFICE 

Ms. STEINHARDT. Thank you very much, Senator Pryor. I really 

appreciate the chance to be here today. I wanted to talk to you 

about the report that you mentioned a moment ago that we issued 

this past February which synthesized the results of close to a dozen 

reports that we have issued since 2006. In that February report, 

we pointed out that despite the economic crisis and other national 

priorities that had become top priorities for the country, a pandemic influenza is still a very real threat and requires continued 

leadership attention. When the H1N1 virus emerged 2 months 

later, that warning was dramatically underscored. 

Before I go into the findings of our reports, I want first just to 

acknowledge the important progress that we have made in the last 

few years. In addition to the National Pandemic Strategy and Implementation Plan that was developed by the Federal Government, 

all 50 States and the District of Columbia now have pandemic 

plans, as do many local governments and private companies, and 

we have clearly benefited from all of this planning. 

3 

But that said, there are still some significant gaps in our planning and preparedness. For one thing, the leadership roles in a 

pandemic, the ‘‘Who is in charge?’’ question, have not been clearly 

worked out and tested. Under the National Pandemic Plan, the 

Secretaries of Health and Human Services and the Secretary of 

Homeland Security are supposed to share leadership responsibilities along with a system of Federal Coordinating Officials and also 

Principal Federal Officials and the FEMA Administrator. And all 

of these positions may be vital in a pandemic, but how they will 

work together has not been tested yet. 

So in 2007, we recommended that HHS and DHS work together 

to develop and conduct national tests and exercises, and the Departments agreed with our recommendation, but since that time, 

there still has not been a national exercise for this purpose. Now 

that we have new people filling some of these leadership positions, 

the need to clarify these relationships in practice is only heightened. 

Beyond the lack of clarity on leadership roles, the National Strategy and Plan have a number of other missing pieces, and I will 

mention just a couple. First of all, key stakeholders, like State and 

local and tribal governments, were not directly involved in developing the plan, even though the plan relies on them in a number 

of instances to carry out some key elements of the plan. 

Second, there were no mechanisms described in the plan for updating the plan and reporting on its progress, and this issue of updating the plan is particularly timely since this is a 3-year plan 

and it was developed in May 2006. 

To fill these gaps, we recommended that the Homeland Security 

Council establish a process for updating the plan that would, first 

of all, involve key stakeholders and incorporate lessons learned 

from exercises and other sources. We made that recommendation 

in 2007, but the Homeland Security Council didn’t comment on it, 

nor did they indicate whether they would act on it. But I would say 

that it is especially pertinent today as we try to learn from the experiences of the H1N1 outbreak. 

As we go forward, it is also essential for the Federal Government 

to share its expertise and coordinate its decisions with other levels 

of government and the private sector. A number of mechanisms 

were developed for these purposes, but they could be used even 

more, and I will mention one example. 

In a 2008 report that we did on State and local pandemic planning, we pointed out that an HHS-led assessment of State plans 

found many major gaps in 16 of 22 priority areas that included 

policies related to school closures and community containment. At 

that same time, a number of the State and local officials that we 

were talking to told us that they would welcome additional guidance from the Federal Government in these same areas, and I 

know the National Governors Association found many of the same 

kinds of issues. 

DHS and HHS at that time had earlier convened a series of regional workshops with State officials to help them with their planning efforts and we thought that the two Departments could use 

additional workshops to help States address the gaps in their pandemic plans. The two Departments, HHS and DHS, agreed with 

4 

1The prepared statement of Mr. Thomasian appears in the Appendix on page 48. 

our recommendation, but they haven’t held any additional meetings since then. 

In closing, I just want to point out that it’s important to bear in 

mind that while the current H1N1 outbreaks seem to have been 

relatively mild, the virus could return, as you pointed out, Senator. 

It could return in a second wave this fall or winter in a more virulent form. So given this risk, the Administration and Federal agencies should be turning their attention to filling some of the gaps 

that our work has pointed out, while time is still on our side. 

Thanks very much. 

Senator PRYOR. Thank you. Mr. Thomasian. 

TESTIMONY OF JOHN THOMASIAN,1 DIRECTOR, NATIONAL 

GOVERNORS ASSOCIATION CENTER FOR BEST PRACTICES 

Mr. THOMASIAN. Thank you, Mr. Chairman. As you pointed out, 

my name is John Thomasian and I direct the National Governors 

Association Center for Best Practices and I appreciate the opportunity to testify before you today on pandemic influenza and how 

we can close potential gaps in our capacity to respond. My comments today are based on the work we have done over the past several years with the States on pandemic planning that began in 

2006 with a Governor’s Guide. It included training workshops, nine 

regional training workshops for all 50 States and four territories in 

2007 and 2008, and our work continues today as we assist the Governors’ Homeland Security Advisors in responding to the recent 

outbreak. 

I am going to focus on five key areas very quickly: Information 

sharing, interagency coordination, school closings, continuity of 

government and coordination with the private sector, and communication with the public. Each of these were identified as problems 

in our previous work and I will discuss how each of them were handled in the current outbreak. 

Information sharing—information sharing during the recent flu 

event demonstrated that systems worked much better than we anticipated. The flow of information between the Federal Government 

and the States was nearly constant during the initial weeks of the 

outbreak and case counts were updated daily. Morbidity and mortality figures were readily available. And the Federal Government 

did a good job pushing information down to State and local government. 

That being said, there is room for improvement. Both CDC and 

DHS began to hold independent daily briefings for State officials in 

the early weeks. These briefings often contained the same information and often contained the same Federal officials. But States 

were never sure if all the information was new, so they put time 

aside for all the briefings. As a result, State officials spent several 

hours each day monitoring conference calls instead of response activities. In the future, DHS and CDC should hold a single daily 

briefing with States on all essential information. 

Interagency coordination—when we held our workshops in 2007 

and 2008, many State teams were meeting for the first time. They 

were not clear on their own responsibilities, much less those of 

5 

their Federal counterparts. Three years later, with additional planning and exercises, the situation has improved. I think the Centers 

for Disease Control and Department of Homeland Security worked 

well together during the recent outbreak and provided a relatively 

seamless portal to Federal resources and technical assistance. At 

the State level, homeland security agencies began coordinating immediately with their health departments and many States enacted 

emergency declarations and other orders to begin mobilizing broader State resources, if needed. 

Looking ahead, we must recognize that good interagency coordination deteriorates without practice. To maintain performance, 

States must be given encouragement and resources to conduct preparedness exercises with multiple agencies and levels of government. This is a capacity that will go away over time. 

School closures—school closure policy was a topic of intense discussion at each of our national workshops with little consistency in 

approach. It was not a surprise, therefore, when the recent outbreak led to a patchwork of school closure decisions. One issue was 

that the Centers for Disease Control’s written guidance suggested 

that closures should be based on laboratory-confirmed cases, while 

public comments by some Federal officials suggested decisions 

should be based on suspected or probable cases or even when students had a family member with the disease. 

Also missing was advice to parents and students on actions to be 

taken outside of the classroom to limit the spread of the disease. 

In many cases, dismissed students simply recongregated at shopping malls or other venues to share potential infections. More precise advice will be needed from CDC in the future to help States 

and districts implement a more consistent approach to school closure. Guidance should also address prevention actions beyond 

school grounds. 

Continuity of government and coordination with the private sector on critical services—in our workshops, we asked States to envision a rate of absenteeism that could approach 40 percent. To cope 

with this possibility, States needed to develop detailed continuity 

of government plans and work with the private sector to ensure the 

availability of critical goods and services. This mild outbreak simply did not test these contingencies. They remain among the unknowns of our preparedness and should be revisited before we 

enter the next flu season. 

Finally, communication with the public. In the recent outbreak, 

government and the media did a good job informing the public on 

the spread of the disease and what individuals should do to avoid 

infection. However, the Federal Government did not adequately explain the type of response options they had at their disposal, what 

was being considered or rejected, and why. This led to a great deal 

of confusion in the early stages regarding what might happen next. 

To address this gap, the public must be given information on the 

appropriateness and implications of specific actions, such as quarantine, social distancing, travel bans, school closings, and the use 

of personal protective equipment. 

In conclusion, the spring outbreak has so far resulted in less 

than 9,000 confirmed cases nationwide. In contrast, we must remember that a severe pandemic would produce tens of millions of 

6 

1The prepared statement of Dr. Jarris appears in the Appendix on page 62. 

infections. Before the onset of the next influenza season, we should 

take the time to address the weaknesses this initial outbreak exposed. We should clarify the guidance on school closures to ensure 

consistency. Information exchange should be improved so that responders can allocate their time more efficiently. The public must 

be educated on the benefits and costs of mitigation strategies. And 

States should be encouraged and supported to conduct periodic 

pandemic exercises with Federal agencies, local governments, and 

the private sector. 

Thank you, Mr. Chairman. I am pleased to answer any questions 

later. 

Senator PRYOR. Thank you. Dr. Jarris. 

TESTIMONY OF PAUL E. JARRIS, M.D., MBA,1 EXECUTIVE DIRECTOR, ASSOCIATION OF STATE AND TERRITORIAL 

HEALTH OFFICIALS 

Dr. JARRIS. Mr. Chairman, thank you for the opportunity to 

speak. I would like to make a couple of points that have not been 

made before. 

One is that this is not over. We still have an outbreak and an 

epidemic going on in this country. Just over the last day, the cases 

have increased to 11,000, which is a tremendous undercount, and 

your State of Arkansas is now nine rather than seven. You have 

been relatively spared, but other States have been hit much harder, including New York and currently Massachusetts has a dramatic outbreak ongoing. So this has never gone away. It is really 

not a matter of if it comes back in the fall. It hasn’t left yet. The 

question will be, when it comes back in the fall, will it have evolved 

to a more severe pandemic or epidemic than the epidemic we are 

having right now? 

Furthermore, it is not just another seasonal flu, as we hear people saying. This is not the time of year you have a flu outbreak. 

That is one of the ways we search for new viruses and find them. 

Second, this is primarily young people being affected. The average age of individuals being affected is between 11 and 19 years 

old. The average age of someone in the intensive care unit is 23 

years old. And the average death rate is in the 40s. That is not seasonal influenza, which largely affects the elderly and otherwise 

people with immune compromise. So this is a novel virus, and what 

we have to understand is we do not know how this is going to behave. 

In 1918 at this time, it was behaving very similar to this. Now, 

whether or not it will come back as severe a category four or five 

in the fall, we simply don’t know. But the prudent thing is to plan 

for a range of an outbreak consistent with what we have now all 

the way to a severe pandemic worldwide. The World Health Organization is right now considering whether to raise it to a pandemic 

level six, but frankly, that is not that important to this country because we already have an epidemic ongoing. Pandemic just means 

the epidemic has spread around the world. We have it already. 

The response to date, I believe, has been a good response. The 

Federal Government, State government, and local governments 

7 

have acted in concert with each other and as a National Government response. Harvard did a study which showed 80 percent of 

Americans were satisfied with the response. Eighty-eight percent 

were satisfied with the information they were getting. That was 

the result not only of the Federal Government giving us guidance, 

but the State public health officials and homeland security officials 

going back to the Federal Government to say, here is what is happening on the ground and giving them situational awareness. 

We also have learned that there is much to be done with our 

planning. There were many assumptions made which proved not to 

be true. There were many planning plans that were made which 

were not nearly granular enough. So now that we are in a response, much more so than just a drill, we have learned about the 

shortcomings in our planning and what has to be happening. We 

have now a window of 12 to 16 weeks before this thing would escalate, as the 1918 virus did, before the return of the seasonal influenza, which will come on top of this current influenza outbreak. 

The reason I say it is not scalable, there has been about a 25 percent cut in State and local emergency preparedness funding over 

the last several years. We have had about a 20 to 25 percent cut 

in hospital preparedness funding. And the single appropriation of 

pandemic influenza funding in 2006 was completely spent by August 2008. There is no money from the Federal Government to 

state and local government, public health, to respond and plan for 

the fall and we simply have no alternative. So we must take advantage of this window of opportunity now to protect the American 

people. 

And let me give you the orders of magnitude here because frankly, I think we are all having a little bit of sticker shock when we 

think about what it will take to respond and protect the American 

people. For one, we are asking for $350 million, another bolus, if 

you will, of planning money to carry the State and local governments not only through the response right now, but to plan and 

work on transitioning from planning to implementation for the fall. 

But importantly, there has been much talked about vaccine, the 

single most effective thing we can do to protect our population. Our 

plans call for protecting the entire U.S. population. That is 300 million people. We do believe that it will be two doses per person. By 

the time we know different, it is too late to produce the extra doses. 

So if conservatively that is $5 per dose, we are talking about $6 

billion just to buy the vaccine. 

Now, vaccine isn’t a good luck charm. It has to be given to people. We can give you the numbers and the information, but conservatively, it is $15 a dose to provide vaccine under the government-run program. That is less than the private sector. But much 

of the workforce giving this will be private sector. So we are talking 

about $15 billion to give those 600 million doses. So just there 

alone, we are in the $14 to $15 billion range. So we really have to 

come to grips very rapidly with how serious are we as a Nation in 

protecting the people of the United States and will we make those 

resources available now or will we stare the American people in the 

eye come the fall and say, when we had an opportunity, we didn’t 

do it. Thank you, sir. 

Senator PRYOR. Thank you. Dr. Ostroff. 

8 

1The prepared statement of Dr. Ostroff appears in the Appendix on page 69. 

TESTIMONY OF STEPHEN OSTROFF, M.D.,1 DIRECTOR, BUREAU 

OF EPIDEMIOLOGY AND ACTING PHYSICIAN GENERAL, 

PENNSYLVANIA DEPARTMENT OF HEALTH 

Dr. OSTROFF. Thank you, Senator. Influenza is unquestionably 

one of the most unpredictable public health issues we face. Just 

when you think you understand what is going on, it always throws 

you a curve ball. 

For several years, we have been focused on the emerging threat 

of bird flu in Asia, and rightly so. It is highly lethal, it has continuously circulated for 6 years, and it has devastating consequences 

for agriculture. Most of our planning assumptions have been based 

on a scenario that a pandemic would start in Asia, that it would 

be noticed there, and that we could delay its introduction and 

spread. 

And then out of nowhere, a new virus lands right on our doorstep, isn’t noticed until it is already here, and renders many of our 

planning assumptions irrelevant. Fortunately, so far, its public 

health impact as measured by illness and death has been modest, 

but its overall impact has been anything but. It has caused tremendous disruption to individuals, families, schools, and communities, 

and we don’t know what the future holds for this virus. 

Like the other States, we in Pennsylvania immediately ramped 

up our disease monitoring and response as soon as we learned of 

this new flu strain. Over the last 2 months, despite the fact that 

we have not had that many cases in Pennsylvania, it has been 

enormously labor intensive and challenging to address the myriad 

of issues that it presents. 

We have established a State-wide task force that includes our 

public health and emergency response partners. We have partly activated our emergency operations center. And we set up an internal 

health department task force. We have reached out to the education and agriculture sectors, migrant centers, medical societies, 

the rich array of academic centers in our State, the pharmaceutical 

sector, and the State’s major vaccine manufacturer. And most importantly, we have closely integrated our work with that of our network of district and local health departments who form our frontline eyes and ears through daily group phone calls to discuss cases 

and disease clusters. 

We have greatly relied upon the excellent work done by the CDC, 

including their guidelines, lab support, the pharmaceutical stockpile, and their technical back-up. We in the States have had an ongoing dialogue with CDC about all aspects of this event, and sometimes we have disagreed, like in the school closure area. But CDC 

has been very willing to listen and change course when appropriate. 

Some aspects of our response have gone quite well. These include 

risk communications, disease monitoring and investigation, and applying control measures to limit disease spread. Other areas have 

been more challenging, especially lab support, where backlogs 

quickly developed when specimens had to go to CDC. 

We in Pennsylvania continue to individually count, investigate, 

and respond to each identified case of illness due to this new virus. 

9 

With less than 300 cases, even this has been very resource intensive and has strained our disease investigators and our laboratory. 

Like most States, we have been impacted by the economic situation. We have hiring freezes in place and our bench strength is not 

very deep at all. 

Because in general we don’t count individual cases of seasonal influenza, many of the most heavily impacted States are now no 

longer doing it for this new flu strain, either. Instead, they only 

count severe cases and those in special circumstances, like health 

care workers and pregnant women. This makes the national numbers that you are hearing now being reported very tough to interpret, since States are counting cases differently. 

In Pennsylvania, because many parts of the State have still been 

minimally affected by this virus, we think it is important to understand where the virus is, how it is spreading, and who it is affecting, so we will continue to count until it is no longer feasible for 

us to do so. 

So far, many aspects of our preparedness efforts have not been 

engaged. As examples, we have not dipped into our pharmaceutical 

stockpile. We have not mass distributed vaccines or antivirals. We 

have not handled large numbers of sick or dying people. And we 

have not implemented full community mitigation efforts, and hopefully we won’t have to do so. But it is important to be prepared in 

case we need to. 

So we in Pennsylvania have just initiated a process to review our 

efforts to date and see what has gone well and where we need to 

improve. We are also embarking on a planning effort to prepare for 

what the virus has in store for us in the coming months. This includes doing better monitoring, planning for distribution and administration of stockpile material and vaccines, and dealing with 

health care surge needs. 

The flu is just one of a long line of emerging infectious disease 

threats. Others include SARS, MRSA, West Nile, foodborne outbreaks, and vaccine-preventable diseases. All of these highlight the 

need for a robust and a well-trained public health workforce and 

for flexible resources that allow us to best apply the resources that 

we have where they are needed. 

At the State and local level, the same people address all these 

problems in the field and in the lab. While our preparedness resources have helped, they do not cover nearly all of our needs and 

our resources for emerging infections have dwindled in recent 

years. Despite these problems, all of us are firmly committed to 

continue to address this new flu virus while continuing to confront 

the other public health threats that we face. 

I will be happy to answer any questions. 

Senator PRYOR. Thank you. 

Let me start with you, Ms. Steinhardt. In your GAO report, you 

have several criticisms of the state of affairs right now. One of 

those is that the roles are not very clear between State, Federal, 

local, and who makes the decisions on certain things. What would 

you recommend that State and local officials do to clarify their 

roles? 

Ms. STEINHARDT. Well, the important thing, and this is the lesson that we learned, I think, most vividly from Hurricane Katrina, 

10 

the important thing is to test and exercise. It has often been said 

that you don’t make friends in the middle of a disaster. People 

need to know each other and figure out how they are going to work 

together in advance of a true emergency, and that is what needs 

to happen here, as well. 

Senator PRYOR. OK. I notice that the GAO, the NGA, and the 

ASTHO have reports that say that you need more guidance in 

school closures, you mentioned, and several other areas, like private sector workforce, situational awareness, etc. Do you think the 

Federal Government could distribute policies on these issues by 

this fall or is it too late for this year? 

Ms. STEINHARDT. I would hope that the Federal Government 

could do that. As my fellow panelists have said, there is a lot that 

we are still learning about this virus. But certainly there is more— 

some of those lessons learned can and should be shared with States 

and local governments, as well. 

Senator PRYOR. Mr. Thomasian, in your experience in terms of 

defining roles and some of the gaps that Ms. Steinhardt has identified, how has the Federal Government been to work with? 

Mr. THOMASIAN. In the past Administration, I would say the lead 

agency was clearly HHS. Secretary Leavitt took it on himself. 

Under his watch, he was going to try to avoid not having these 

roles defined. So I think we got one strong but one siloed lens looking at that. 

Senator PRYOR. He wanted to not define the roles? 

Mr. THOMASIAN. No, he did want to define the roles, but since 

he represented a single agency, he had certain boundaries. 

Senator PRYOR. I see. 

Mr. THOMASIAN. So I think we got halfway there. I think we still 

have a ways to go. I was pleased to see that the Department of 

Homeland Security worked well together with HHS during this initial crisis. Again, we have not been fully tested, so all the roles 

have not been fully defined or explored and the tensions have not 

been exposed to a large degree. But it was an initial good first step. 

So I do believe they have tried to do a good job and I will reiterate my panelist assertion that the best way to define a role is to 

initially put some aspects down on paper, but you have to exercise. 

You have to test it. Relationships need to be built. 

Senator PRYOR. OK. Let me follow up on that. When the National Response Framework and the National Pandemic Implementation Plan were being put together, there was a lot of criticism 

that the Federal Government did not work with and talk to the 

State and local governments effectively. Now they have been working on the First Responder Health Surge Capacity Action Directive. 

Have they been working with the States and with the local folks 

as they are putting that together? 

Mr. THOMASIAN. They are. We work very closely, I should say, 

with the Governors’ Homeland Security Advisors. In fact, we have 

formed an association within our association called the Governors’ 

Homeland Security Advisors Council, and it is our understanding 

they are working together with them. Again, though, it does take 

a while for all this to trickle down through the States. This has 

been a constant refrain from the Governors’ Homeland Security 

community, that the Federal Government needs to fully advise and 

11 

work through issues with the States. I believe we are on the right 

path. It is too early to tell that it is taking place in all cases, 

though. 

Senator PRYOR. Dr. Jarris, did you have any comments on that? 

Dr. JARRIS. Yes. I think it is worth questioning the model. The 

model that the Federal Government will sequester itself and develop guidance for the Nation is a model that doesn’t work well. 

There is a certain amount of expertise, whether it is scientific or 

law enforcement, in the Federal Government. But actually, the people who implement this guidance are at the State and local levels, 

and what we fail to appreciate is the expertise in implementation. 

So a model that will work much better is if Federal, State, and 

local all work jointly on guidance. Right now, what we do is we 

play ping-pong. The Federal Government comes out with something, lobs it over the table. We say it doesn’t work. We lob it back. 

We don’t have time for that in 14 to 16 weeks. 

What worked well in this response to date is that we really were 

working together, information flowing up and down, modifying 

what each other was doing. Now we seem once again to be flipping 

back into the old model of the Federal Government will come up 

with guidance for the fall. It simply won’t work. 

For example, school closure. That is primarily a public and political decision to close schools. It is not fundamentally a sciencebased decision. So what we need to do is to work with the mayors, 

the governors, and those who make the school closures, and the 

health officials who will make recommendations to them, to truly 

understand all the issues there so we can do, if you will, a costbenefit analysis. There is no way that the Federal Government 

guidance can come out without true involvement of the local and 

State officials making these decisions and have it work. 

Senator PRYOR. So are you recommending that we get some sort 

of summit together? 

Dr. JARRIS. Well, a summit would be helpful, but an ongoing 

working relationship would be far more helpful. 

Senator PRYOR. And does that not exist right now? 

Dr. JARRIS. The tendency is for Federal Government to develop 

guidance. There may be input sought, but then it goes back into 

a sequestered environment and the guidance comes out. And I 

think it is much more efficient, actually, if we could sit down as 

Federal, State, and local and jointly work on guidance. 

Senator PRYOR. OK. This is a little bit of a follow-up to something I think you said in your opening statement. There are a lot 

of assumptions about the flu and the H1N1 did not really follow 

those assumptions. 

Dr. JARRIS. Yes. 

Senator PRYOR. It didn’t start in Asia. It didn’t go from a bird 

population to human population. What do you recommend, or how 

do you recommend that we build in flexibility to all this planning 

so that if a different scenario presents itself, like H1N1 has so far, 

it doesn’t really follow the textbook example, how do you build in 

the flexibility? 

Dr. JARRIS. Yes. I think with a novel virus, it is a mistake to assume there is a textbook. They all operate differently. So really 

what we need is to have much more robust planning. It is not just 

12 

a matter of scientifically planning for it. We need to have modelers 

in there. We need to have systems engineers come in and figure out 

what is going to happen. So, for example, we should plan for a best 

case, a worst case, and a most likely case scenario and hope that 

covers the bases. Of course, something out of the blue will happen. 

But, for example, if we look at the vaccination campaign for the 

fall, we will have an initial bolus of vaccine coming out probably 

sometime around October, but we don’t know how fast it is going 

to grow. That vaccine will come out with an initial bolus. We don’t 

know how much that will be. It will then come out with weekly 

numbers, so a certain amount per week. We don’t know how much 

that will be. That will be distributed on a per capita basis to the 

country and we have to go down a priority list, which incidentally 

the priority list we have is for H5N1, not H1N1. 

So you see how many unknowns there are here. What will the 

adjutant do? We haven’t gone through the safety studies yet. We 

actually don’t know if it is one dose or two doses. So there are so 

many complexities here and we will not know ahead of time 

enough information to make the decisions. So at the outset, we 

have to come up with operational assumptions and plan around 

those assumptions with different scenarios. 

Senator PRYOR. And you had mentioned the costs of providing a 

vaccine to every American. What is your overall estimated cost on 

that? 

Dr. JARRIS. Well, we don’t quite know again, what the vaccine is 

going to cost. It hasn’t been developed yet. We don’t know the cost 

of the adjutants that may be in it. So probably between $5 and $10 

a dose, $10 is what it normally costs for regular seasonal flu. And 

we assume 600 million doses, so we are talking somewhere in the 

$6 billion range. It could be more, could be less. 

But then we actually have to give the vaccine, and we estimated 

this a number of ways. We had dozens of States and local health 

departments who did a cost basis for them to give a vaccine. Medicare pays $18 to $20. Medicare pays costs. We checked with Visiting Nurse Associations. We checked with private sector. So the 

ranges are anywhere from about $12 to $30. We picked $15, which 

we think is a reasonable dose. So $15 times 600 million, we are 

talking about another $9 billion. 

Senator PRYOR. And how does that square with your thoughts on 

planning, though, because at some point, you have got to pull the 

trigger on the vaccine, about whether you are going to go with this 

particular vaccine or not. And if the strain changes, like down in 

the Southern Hemisphere it could be a different strain this fall or 

whatever the case may be. So when is that point where you have 

to pull that trigger? 

Dr. JARRIS. There is seed stock developed now, it is my understanding—and I am not Dr. Fauci—that the variation has not been 

tremendous around the world yet. So we think we will have a vaccine that will probably cover all the options unless there is a major 

mutation. So that seed stock will then have to go into production. 

At the same time, we need 2 to 3 months to do the scientific testing 

for safety, for response, for dosage, and things like that. 

So we will have to make a decision soon to purchase—we have 

already put a purchase order in for this country—not only because 

13 

we need the lead time to develop the vaccine, but because other 

countries are already in line, Great Britain, France, things like 

that. So in order to put our place in line, we are going to have to 

make a purchase decision very soon. 

Now, it is one decision to purchase. That, we will have to do 

early. It is another decision to give it. We are going to have to look 

in the fall, based on the safety studies, to say, OK, given what we 

know, we have this vaccine. Should we actually give it to people? 

And I think we have to carefully consider that, because all vaccine 

has side effects and we will have to weigh the severity of the illness in the fall versus potential side effects of the vaccine. So that 

is a later decision, I would guess, that is going to be made probably 

in the August to September time frame. 

Senator PRYOR. Mr. Thomasian, let me ask you a follow-up to 

what Dr. Jarris was talking about. We have talked about a lot of 

different scenarios about administering a vaccine and how to distribute it around the country, around the various States. From 

your standpoint, how should that be done? Should you let the various States make that decision on how it is distributed, or should 

there be one national policy that the States just follow? 

Mr. THOMASIAN. Well, the way it is currently laid out is the 

States have prepared plans on how they would distribute vaccines 

and antivirals and they have priority lists that match up to a good 

extent to the Federal senses of priority. So I don’t think there is 

a huge variation out there. So I would say, let the States administer it with a joint discussion between the Federal Government 

and the States on the type of priorities. 

I am saying that because I am assuming, and I think it is safe 

to assume, that we would not have vaccines for everybody, so we 

would have to be focusing on the essential service individuals and 

the most vulnerable populations. Otherwise, I think we can probably go to the open market distribution of the vaccines. 

Senator PRYOR. Dr. Ostroff, do you have any thoughts on that? 

Dr. OSTROFF. Specifically about the vaccine? There is obviously 

a lot of unknowns, I think, as Dr. Jarris pointed out. 

Senator PRYOR. And let me just interrupt there. It seems to me 

that you can do a lot of planning and you can be prepared in some 

ways, but because the vaccine needs so much lead time, that is sort 

of a separate question that just makes it hard to figure out what 

the best way to go is, but go ahead. 

Dr. OSTROFF. Well, I think a couple of other points just to consider—one of them is, I think as Dr. Jarris rightly pointed out, we 

shouldn’t look at the current situation as being in the past tense. 

We in Pennsylvania, our numbers have gone up by a third just 

since I put my testimony together this weekend, so it is quite active right now in Pennsylvania. It shows no signs of abating. I 

think that we all anticipated that it would dampen down over the 

summer months. The virus may not have read the textbook and 

may decide not to do that. 

The other thing that we have to remember is that in 1918, which 

is the model that we have all been looking at, the virus came back 

very early. It came back in September and it came back with a 

vengeance in September. It didn’t wait until the usual winter influenza season. And so in terms of our thinking about what to do reVerDate Nov 24 2008 12:05 Nov 16, 2009 Jkt 051781 PO 00000 Frm 00017 Fmt 6633 Sfmt 6633 P:\DOCS\51781.TXT SAFFAIRS PsN: PAT
14 

lated to vaccine, I think that we have to really put our decision 

making on the fast track about what to do because by the time we 

make decisions over the next couple of months, the virus may have 

jumped out ahead of us and it could come back in a form that is 

more severe than it currently is. 

The other, I think, issue to also keep in mind is that we are relying quite heavily on antiviral drugs. The antiviral drug of choice, 

if you look at the seasonal strain that was just floating around the 

country, that was resistant to that particular drug. And so if this 

particular virus decides to get together with that one and transfers 

its resistance, then that is a program for our assumptions and 

planning. 

And so I think as far as the vaccine, I am not sure that we have 

a lot of time to be able to make these decisions. I think the virus 

is telling us, because right now, virtually all influenza in the 

United States—and again, it is a very unusual time to be seeing 

this disease—is this virus. And so it may not be an option, the regular one versus this one. I think that we have to look seriously at 

what the virus is telling us right now and make our decisions relatively quickly. 

Senator PRYOR. OK. Given all the circumstances that we are in 

right now and also given the fact that in the supplemental appropriation that is working its way through the Congress and hopefully will get to the President’s desk in the next couple of weeks, 

we put $1 billion in there for pandemic flu issues and preparedness. Do you have an idea on how that money should be prioritized, 

what the most critical needs are to get us ready for this? 

Dr. OSTROFF. Well, there are a lot of needs and I think many of 

them have been pointed out. Again, we have not been fully exercising the full gamut of things that we would need to do for a fullfledged pandemic. I think that we do need to very quickly come up 

with our plans as to how we would distribute the vaccine. I think 

when the vaccine becomes available, there is not going to be 

enough for everybody and we are going to have to make decisions 

about how to prioritize who gets it and who doesn’t, and we generally do that based on what we see about the patterns of disease. 

I think that we have to work out much better than we did how 

to distribute antiviral medications. In addition to that, I do think 

that we have to very quickly figure out what we are going to do 

about the medical surge issues, because again, most of us haven’t 

had to exercise that part of our pandemic plan. 

And the last thing that I will say is that for us, if there is a lot 

of disease, both being able to monitor what is going on as well as 

do the diagnostic work in our laboratory—I mean, Pennsylvania is 

a large State. We are the sixth largest State in terms of population. 

We only have 300 cases, and it has been all we could do to be able 

to count what we are seeing and to make the diagnoses in our laboratory. We are sort of relying on two people in our laboratory to 

do all this work, and if one of them gets the flu, then we are down 

by 50 percent. So we need to, I think, pretty quickly figure out how 

we deepen our bench strength between now and the fall because 

I think that these will all be serious gaps for us. 

The last thing that I will say is that in terms of the Federal guidance, one of the things I think that is important—and I have a fairVerDate Nov 24 2008 12:05 Nov 16, 2009 Jkt 051781 PO 00000 Frm 00018 Fmt 6633 Sfmt 6633 P:\DOCS\51781.TXT SAFFAIRS PsN: PAT
15 

ly unique perspective, because I worked at the CDC for 20-some 

years, so I was on the giving end rather than the receiving end for 

all that time period—is that we don’t like it to be so prescriptive 

that there is not a lot of wiggle room. We in Pennsylvania, as far 

as school closures, we set up our policy right from the very beginning. We have held to that policy all along. We didn’t think that 

the initial recommendations from the CDC were quite correct and 

we didn’t think the revised recommendations were quite correct, either. 

So we don’t want them to be so prescriptive that it looks like we 

are not following what other people are doing. Each State has to 

take that guidance and interpret it and translate it to their local 

circumstances. That is what is being done in Arkansas and that is 

what we are doing in Pennsylvania. 

Senator PRYOR. Let me ask about this medical surge question 

that you brought up. It is really just for the panel at large. Given 

the economic downturn and given that certain hospitals, first responders, you name it, there have been some layoffs and some cutbacks, a lot of cities and counties and States are having to do cutbacks and this can be very painful. But it seems to me this is the 

worst time that they could be cutting back on these type of healthrelated services, but the reality is what it is. So any advice for this 

fall? Dr. Jarris. 

Dr. JARRIS. Yes. It is an excellent question, Senator. We have 

looked at the State and local public health agencies, and due to the 

budget constraints in the States, we have lost over 11,000 positions 

in the last year and that pace is continuing. Given an outbreak, 

and we have already seen this in the last several weeks, we have 

taken a drastically diminished workforce and put them on two 

shifts from one shift. There is only so much people can do, and that 

really strained the system. On top of that, of course, we have had 

certain States who have actually run out of places to build the pandemic response so they are actually ramping down in the face of 

an escalating outbreak. So this is again the reason why we need 

some Federal assistance to mount the response and protect the 

American people. 

Senator PRYOR. Mr. Thomasian, do you have any thoughts on 

that? 

Mr. THOMASIAN. Well, it is an excellent point. I will say that in 

our work at NGA, we projected even after the recovery dollars are 

spent that States will be facing over the next 2 years somewhere 

between $170 and $230 billion in deficits across the States, so it 

is a tough time. It is very difficult to build a government around 

a peak event that may not occur. 

I do feel, though, that if further resources were available to 

States, there are some critical areas that would certainly help. It 

may not address all the surge capacity, but certainly one is laboratory capacity is sorely needed in the States. Also, assistance again 

on exercising. Clearly, States will need to build as much capacity 

as they can afford to do in these areas, but honestly, I think this 

is an area that we have not been tested in and we will probably 

find that we will be sorely behind if a large event does come. 

Senator PRYOR. Yes, Mr. Steinhardt. 

16 

Ms. STEINHARDT. Just to add to the comments that have already 

been made, looking at vaccine production, at best, at least from my 

understanding, if we begin today, we are looking at November for 

the initial production lines for this virus. So we still have this long 

period between now and then in which communities have to be able 

to respond to the continuing epidemic or a resurgence in a more 

virulent form. And so the kind of planning, the kinds of activities 

that have to take place before we even have a vaccine are really 

our first—need to be our first considerations here. What kinds of 

capacities do we need to build into communities? And I think as 

we look at priorities for funding and allocations of funding, we need 

to keep that very much in mind. 

Senator PRYOR. OK. As I understand it, the World Health Organization is deliberating whether to move this from a Phase Five to 

a Phase Six. First, I don’t understand the complete significance of 

that. And second, I guess, Dr. Ostroff, if they move from a Phase 

Five to a Phase Six, what does that mean for the United States? 

How does that change things here? 

Dr. OSTROFF. I think in practical terms, it really doesn’t change 

very much for us. Our planning, our thinking, our activities are all 

predicated on what we think the appropriate things to do in the 

United States are. I do think that part of the difficulty and why 

World Health Organization (WHO) has been having such struggles 

around this particular issue is that when you move to Phase Six, 

it sort of trips off a whole lot of activities in other parts of the 

world, some of them appropriate and some of them inappropriate 

based on their particular circumstances. And so I think it does 

make a difference. 

I think that we have seen many countries do things that, in 

terms of entry and exit screening, etc., that may not necessarily be 

the best application of resources and if this would give them further reason to do some of those things, then I think it would be 

somewhat problematic. But in terms of the way that we would approach what needs to be done here in the United States, I don’t 

really think it makes that much of a difference, which level they 

define it as. 

Senator PRYOR. Dr. Jarris. 

Dr. JARRIS. Yes. I would agree with my colleague that in terms 

of our response in the United States, within our borders, it probably doesn’t change what we do because we have the epidemic. But 

as a global leader, it may very well change what we do. 

One is as this continues to spread around the world, which it has 

been, and frankly, it is almost academic whether they declare it 

Phase Six or not because I think they met the criteria a month or 

more ago but there have been political discussions. But the issue 

is what role will the United States play in terms of a health diplomacy role worldwide if we have outbreaks hitting undeveloped 

countries or developing countries who do not have an infrastructure for public health and we see many more deaths because some 

of these countries have high rates of HIV, what will the United 

States do? Will we feel a responsibility to go and assist these nations? 

And what is our responsibility to the rest of the world with regard to things like vaccine and antivirals? If we were producing 

17 

1The map referred to by Senator Pryor appears in the Appendix on page 93. 

antivirals with our domestic capacity only for the United States, we 

might produce it one way without the vaccine sparing adjutants. 

However, the whole world needs the vaccine, and if we need to help 

other parts of the world, we probably do have to put adjutants to 

stretch the supply that we can produce even further. 

So I would suggest that our political leadership involved and scientific community involved with global health issues will have 

some significant questions to address in terms of the U.S. leadership. 

Senator PRYOR. That is fair enough. 

Let me ask about this map that we have here.1 You can see the 

confirmed cases around the world. When you see a map like this 

and when you look at the numbers, the quantity of this around the 

world and the fact that it is spread out geographically, from a scientific perspective, does that increase the chance of mutation or 

does that have any bearing on the chances of mutation? 

Dr. JARRIS. Every infection increases the chance. Viruses do mutate rapidly, and as they travel around the world and are exposed 

to different populations of humans, of animals, there is an increased chance of resortment. So yes, the more it spreads, the more 

the chance of resortment. 

Now, one thing to consider is since this is a novel virus, there 

isn’t a heavy evolutionary pressure on it to evolve. In and of itself, 

it is making people sick and surviving. So we can’t conclusively say 

whether it will resort or not. The great fear, of course, is that it 

does mix with someone with an H5N1 or mix with a seasonal influenza that is Tamiflu-resistant and then we are in trouble. But that 

really is another one of the unknowables. 

Senator PRYOR. Mr. Thomasian, let me ask you about the Medical Reserve Corps. Can the States activate that, and what is that 

process? 

Mr. THOMASIAN. I am not completely familiar with the activation 

process. I believe they can, but I would have to get back to you on 

that. 

Senator PRYOR. Dr. Jarris, did you—— 

Dr. JARRIS. Yes. There is a Medical Reserve Corps that has been 

very helpful in certain limited disasters around the country. What 

we have found in areas severely hit, in Texas and Louisiana during 

their hurricanes, though, is the Medical Reserve Corps are people 

who have other jobs, and so when you are mounting a sustained 

response, they can’t be counted on to be there day in and day out 

in shifts, so the doctors have to go back to their office to practice 

and nurses have to go back to the hospital or the health departments to their shift. 

So what Texas has found, in fact, is that although they welcome 

them and like to work with them, they have actually had to go out 

and contract for paid professionals to come in and work for them 

because then you have performance standards that you can maintain. That again will be important with the vaccinations in the fall 

as well as if we have to do mass dispensing of Tamiflu. We are 

going to have to hire in contract nurses or hospital nurses or VNA 

18 

nurses, which means with them having other jobs, time-and-a-half, 

weekend pay, and things like that. 

Senator PRYOR. OK. Let me ask this. I am getting down to the 

end of my questions, and like I said, we will keep the record open 

and some other Senators will probably have other questions. But 

given the last few months where the flu was first discovered in 

North America and it was almost wall-to-wall coverage there for 

several days on the cable news channels, etc., how did the media 

do and how did the public health officials and the elected officials 

do in getting the word out to the public and communicating the nature of this? Can you all grade that? Is that one of the lessons 

learned that we can improve? 

Mr. THOMASIAN. Well, in my comments, I addressed—I think I 

would give them high marks. I would give the Federal officials and 

the public officials at the State and local level high marks for communicating to the public and communicating to the media, and the 

media did a good job, I think, reporting on the nature of the disease and where it was. Again, I think where the breakdown began 

in some areas was, well, so what do we do? What is the appropriate 

government response? And I think there was some initial hesitancy 

at the opening to talk about issues like quarantine and why you 

should and why you shouldn’t use it and issues like travel bans so 

that we got into this situation for a while where there was a discussion of, should we block the borders in Mexico, and that percolated for a few days. But initially, I do think that the communication was very good and I think the public had a sense that this disease was existing out there, it wasn’t a disaster, and they were getting up-to-date information. 

Senator PRYOR. Does anybody else want to add to that? 

Dr. JARRIS. There was a study done by Harvard University, a 

sample of the American people, and as I mentioned briefly before, 

88 percent of Americans that were surveyed expressed satisfaction 

with the information they were getting. So I think we did a good 

job. I think it was clear, and Dr. Besser should be commended. He 

did a wonderful job, the Acting Director of the CDC. 

The one place I think we are falling down right now is we have 

shut it down. I mean, you can’t find anything in the media anymore. We should be using this time to let people know that now 

is the time to prepare. Now they should figure out in the fall if 

their kids’ school is canceled, how are they going to take care of the 

kids? How are they going to telecommute? What if their elderly 

parent gets sick? We are missing an opportunity now, ahead of 

time, to have people think about the fall. 

Ms. STEINHARDT. If I can add to that—— 

Senator PRYOR. Yes, go ahead. 

Ms. STEINHARDT [continuing]. I think I would agree that the response and the communications were first-rate. But I think from 

our experience, looking at what happened several years ago when 

we first began to see cases of bird flu and outbreaks of H5N1 virus 

in humans, there was an enormous amount of attention, and then 

it fell off, and for most of the public, it seemed as though this issue 

went away completely. Unfortunately, what the public loses interest in, government often loses interest in, as well. I think within 

the public health community, members of the public health commuVerDate Nov 24 2008 12:05 Nov 16, 2009 Jkt 051781 PO 00000 Frm 00022 Fmt 6633 Sfmt 6633 P:\DOCS\51781.TXT SAFFAIRS PsN: PAT
19 

nity never lost sight of this problem, but otherwise, we let other 

issues take priority, and we know this from conversations we had 

with people in the private sector. Other food safety issues, whatever the issue of the day was, that is what took attention. So we 

need to, I think, somehow keep sight within government of our priorities and what the real dangers to the public are, whether it is 

covered in the media or not. 

Senator PRYOR. Dr. Ostroff. 

Dr. OSTROFF. Yes. I will just add a couple of comments, because 

I agree with everything that was said. I think that over the last 

few years, it has been ingrained in the public’s mind that when 

something happens related to flu, it is going to be like the big bang. 

When that didn’t quite happen right at the very beginning, I think 

there was a tendency for everyone to shrug their shoulders, saying, 

what is the big deal here? 

What you heard was a lot of descriptions of this as being mild. 

Flu is never mild, and we tried very vigorously to say that this is 

not a mild disease now and it could be even more severe in the 

coming months. And so I do think that there is a segment of the 

population who feels that this was sort of like oversold to them 

when, in point of fact, I think that many of us are very concerned 

about what we are seeing right now and we are awfully concerned 

about what is going to happen in the fall. So I do think that I 

would echo the comment that we have to continue to reinforce the 

message that what you have seen so far might not necessarily be 

what you see later on. 

But having said that, I would fully concur. I think that the Federal officials, in particular, did a fantastic job conveying information to the public. It was a transitional group of people, and given 

the circumstances and the amount of attention that this initially 

got, I think they did a wonderful job. 

Senator PRYOR. Let me follow up on that. Ms. Steinhardt, you 

may be the best one to ask. There is sort of a lull period right now 

in terms of public awareness on this. If it comes back this fall, the 

lull will be over. A lot of people will be looking back and saying, 

why didn’t we do something different? What would you recommend 

right now to the private sector in terms of the things they can be 

doing? It sounds like the government is going to continue to plan 

and work and try to coordinate, and there is a lot of work that we 

have talked about that needs to be done, but we haven’t talked a 

lot about the private sector yet. Do you have any suggestions for 

the private sector? 

Ms. STEINHARDT. Well, I have suggestions for the government in 

working with the private sector. We have this system of coordinating councils for critical infrastructure sectors. In fact, in work 

that we did here, we found that they could be used much more 

than they currently are. There are a lot of questions that the private sector has within these critical sectors that they have about 

how government policies are going to work. How are States and the 

Federal Government going to handle State border closings? These 

are vital issues for commerce. And those discussions should be happening today between private sector and government. We are not 

in this alone and these are issues that have to be resolved in tanVerDate Nov 24 2008 12:05 Nov 16, 2009 Jkt 051781 PO 00000 Frm 00023 Fmt 6633 Sfmt 6633 P:\DOCS\51781.TXT SAFFAIRS PsN: PAT
20 

dem, and that is one area where we certainly would urge greater 

attention. 

Senator PRYOR. I have one last follow-up question. It is really a 

two-part question. I want to ask each of you this, and that is what 

is the single most important step that we can take to increase our 

preparedness in the next 3 months, from now until the fall? What 

is the single most important step we can take, and how do you suggest that we do it? Dr. Ostroff. 

Dr. OSTROFF. Well, I wish I could tell you that there was a single 

step, because there isn’t. There is a series of steps that I think we 

need to deal with. 

Senator PRYOR. Is there one thing, though, that—— 

Dr. OSTROFF. Well, I think that the two areas that I really think 

that we need to focus on is we need to get our house in order for 

issues related to vaccination because we know for influenza that is 

the single best preventive measure we have available. And I do 

have concerns that we will see more morbidity and certainly more 

mortality for this as we go along and I do think we have to think 

about how we deal with medical surge issues. 

Senator PRYOR. And so you are thinking vaccine, even though it 

could mutate, but you are saying, place your bet on what you 

know—— 

Dr. OSTROFF. I think not placing your bet on what we currently 

know would be a significant mistake. 

Senator PRYOR. OK. Mr. Jarris. 

Dr. JARRIS. Limited to one, it is a very difficult question because 

there is so much that has to be done. But I would think that if I 

was in the shoes of Congress and the Administration, the single 

most important thing to do is to appropriate sufficient resources in 

the next 2 weeks with this supplemental. There is so much that 

needs to be done. We don’t have time to catch up later. Earlier, you asked how to prioritize the $1 billion, and that is a very difficult question because just the vaccines are $15 billion. 

Senator PRYOR. That sounds like a lot of money, but it is not—— 

Dr. JARRIS. Yes, in the old days. But frankly, if we appropriate less than what is needed, for example, the $15 billion for vaccines, 

and we need more than that, then the question that makes sense 

would be, well, if we appropriate $1 billion, which one-fifteenth of 

the American public are we willing to vaccinate and which fourteen-fifteenths are we not willing to vaccinate? 

Senator PRYOR. Mr. Thomasian. 

Mr. THOMASIAN. Thank you. Well, this is an excellent question 

and I will take mine beyond the public health arena. The one thing 

that we need to keep in mind is that this was not really a test. 

This was not really even a pop quiz. When we did our workshops, 

we asked States to envision a scenario where 90 million people 

came down with the disease and we had 1.5 million people needing 

intensive hospital care and an estimated 1.9 million deaths. 

And I would have the States, if they received resources for exercises and further planning, to consider how they would maintain 

continuity of society under those situations. How would public safety react? How would we handle the high degree of absenteeism in 

both State government as well as our critical services, such as food 

services, electricity, etc. So I would use these intervening months 

21 

to examine what would happen if this became the true pandemic 

and the scenarios that we thought we would be looking at under 

the 1918 scenario and go beyond the public health aspects and look 

at the public safety, as well. 

Senator PRYOR. OK. Ms. Steinhardt. 

Ms. STEINHARDT. Well, I would certainly support that. I would 

say this is our time now to take a look at what our plans are, what 

our plans have been, what we have learned from what has happened over this last month. What assumptions do we need to revisit? This is our opportunity to learn from a real live test, and it 

is also our opportunity to actually pull in the results of a number 

of different tests that have happened over the last few years. I 

don’t think we have learned nearly as much or incorporated the 

lessons learned from the various tests and exercises that have been 

done around the country and incorporated that into our thinking, 

but now we have this opportunity to just take that pause and think 

about what we know and what we need to change in our plans 

going forward. 

Senator PRYOR. Good. I want to thank all four panelists. I hope 

I didn’t grill you too much. We are going to leave the record open, 

as I mentioned, and I know Senator Ensign and others will submit 

some questions for the record. We would appreciate you getting 

those back to us within 14 days. 

Thank you very much for your attention, and I appreciate all the 

work you have done in your various capacities. You are playing a 

very important role in saving American lives and we just appreciate everything you are doing. 

So with that, we are going to conclude the hearing and leave the 

record open for 14 days. Thank you. 

[Whereupon, at 3:14 p.m., the Subcommittee was adjourned.] 

(23) 

A P P E N D I X 

PREPARED STATEMENT OF SENATOR ENSIGN 

While the media attention for the H1N1 virus has subsided, this hearing is no 

less important. Health officials believe that this virus could come back stronger during flu season this fall, and we have to be prepared for that. Right now, Federal 

officials are beginning to track this virus as it heads to the southern hemisphere 

to gain a better understanding of what it does in populations that are just entering 

the winter flu season. I am hopeful that whatever characteristics are identified will 

help us in our preparedness efforts. 

While the number of confirmed cases of H1N1 in Nevada is on the low end at 

102, a combination of guidance from the Federal Government and decisions made 

at the local level helped mitigate the spread of the disease. Two weeks ago, in 

Washoe County, Nevada, surveillance procedures revealed an increased absenteeism 

rate at Mendive Middle School. Local health district officials awaited word from the 

State laboratory as to whether or not the children were sick with H1N1. Upon confirmation, the Joint Health and Education Authorities Influenza Oversight Committee met quickly and decided to close the school. The decision was made when 

only five tests had come back positive for H1N1; however eight additional cases 

from the school have since been confirmed. State officials have noted that the guidance on school closures has been successful and the closure of Mendive is an excellent example of how the policy worked. 

Today we will hear from a number of witnesses who will help us understand how 

States have responded to this virus over the last month. Their testimony will highlight successful responses and areas that need improvement. As with any emergency, lessons learned can be invaluable. Ideally, the discussion we have here today 

will provide information for States as they update their State preparedness plans 

to address the potential for a more potent strain of H1N1. 

Approximately 36,000 people die as a result of influenza each year. Should this 

virus re-emerge as a stronger strain than we are seeing today, citizens should continue to exercise precaution and personal responsibility. While we can’t predict the 

severity of a possible mutation, we can do our best to minimize its effects. 

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