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STATE AND LOCAL PANDEMIC PREPAREDNESS

HEARING

BEFORE THE

COMMITTEE ON OVERSIGHT

AND GOVERNMENT REFORM

HOUSE OF REPRESENTATIVES

ONE HUNDRED ELEVENTH CONGRESS

FIRST SESSION

MAY 20, 2009

Serial No. 111–33

Printed for the use of the Committee on Oversight and Government Reform

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Available via the World Wide Web: http://www.gpoaccess.gov/congress/index.html

http://www.house.gov/reform

(II)

COMMITTEE ON OVERSIGHT AND GOVERNMENT REFORM

EDOLPHUS TOWNS, New York, Chairman

PAUL E. KANJORSKI, Pennsylvania

CAROLYN B. MALONEY, New York

ELIJAH E. CUMMINGS, Maryland

DENNIS J. KUCINICH, Ohio

JOHN F. TIERNEY, Massachusetts

WM. LACY CLAY, Missouri

DIANE E. WATSON, California

STEPHEN F. LYNCH, Massachusetts

JIM COOPER, Tennessee

GERALD E. CONNOLLY, Virginia

MIKE QUIGLEY, Illinois

MARCY KAPTUR, Ohio

ELEANOR HOLMES NORTON, District of

Columbia

PATRICK J. KENNEDY, Rhode Island

DANNY K. DAVIS, Illinois

CHRIS VAN HOLLEN, Maryland

HENRY CUELLAR, Texas

PAUL W. HODES, New Hampshire

CHRISTOPHER S. MURPHY, Connecticut

PETER WELCH, Vermont

BILL FOSTER, Illinois

JACKIE SPEIER, California

STEVE DRIEHAUS, Ohio

——— ———

DARRELL E. ISSA, California

DAN BURTON, Indiana

JOHN M. MCHUGH, New York

JOHN L. MICA, Florida

MARK E. SOUDER, Indiana

TODD RUSSELL PLATTS, Pennsylvania

JOHN J. DUNCAN, JR., Tennessee

MICHAEL R. TURNER, Ohio

LYNN A. WESTMORELAND, Georgia

PATRICK T. MCHENRY, North Carolina

BRIAN P. BILBRAY, California

JIM JORDAN, Ohio

JEFF FLAKE, Arizona

JEFF FORTENBERRY, Nebraska

JASON CHAFFETZ, Utah

AARON SCHOCK, Illinois

RON STROMAN, Staff Director

MICHAEL MCCARTHY, Deputy Staff Director

CARLA HULTBERG, Chief Clerk

LARRY BRADY, Minority Staff Director

(III)

C O N T E N T S

Page

Hearing held on May 20, 2009 ............................................................................... 1

Statement of:

Sosin, Daniel M., Director, Coordinating Office for Terrorism Preparedness and Emergency Response, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services; Guthrie

Birkhead, deputy commissioner for public health, New YorK State Department of Health; Rex Archer, director of health, Kansas City Health

Department; Terry Allan, health commissioner, county of Cuyahoga,

OH; and Paul Jarris, executive director, Association of State and Territorial Health Officials ................................................................................... 12

Allan, Terry ................................................................................................ 52

Archer, Rex ................................................................................................ 36

Birkhead, Guthrie ..................................................................................... 25

Jarris, Paul ................................................................................................ 58

Sosin, Daniel M. ........................................................................................ 12

Letters, statements, etc., submitted for the record by:

Allan, Terry, health commissioner, county of Cuyahoga, OH, prepared

statement of ................................................................................................... 54

Archer, Rex, director of health, Kansas City Health Department, prepared statement of ........................................................................................ 38

Birkhead, Guthrie, deputy commissioner for public health, New YorK

State Department of Health, prepared statement of ................................. 27

Issa, Hon. Darrell E., a Representative in Congress from the State of

California, prepared statement of ................................................................ 9

Jarris, Paul, executive director, Association of State and Territorial

Health Officials, prepared statement of ...................................................... 60

Sosin, Daniel M., Director, Coordinating Office for Terrorism Preparedness and Emergency Response, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, prepared

statement of ................................................................................................... 14

Towns, Chairman Edolphus, a Representative in Congress from the State

of New York, prepared statement of ........................................................... 3

(1)

STATE AND LOCAL PANDEMIC

PREPAREDNESS

WEDNESDAY, MAY 20, 2009

HOUSE OF REPRESENTATIVES, COMMITTEE ON OVERSIGHT AND GOVERNMENT REFORM, Washington, DC.

The committee met, pursuant to notice, at 2:43 p.m., in room

2154, Rayburn House Office Building, Hon. Edolphus Towns (chairman of the committee) presiding.

Present: Representatives Towns, Cummings, Kucinich, Clay,

Lynch, Kennedy, Van Hollen, Cuellar, Foster, Issa, Platts, and

Bilbray.

Staff present: Jason Powell, counsel and special policy advisor;

Kwane Drabo and Katherine Graham, investigators; Peter Fise,

staff assistant; Linda Good, deputy chief clerk; Jean Gosa, clerk;

Adam Hodge, deputy press secretary; Carla Hultberg, chief clerk;

Marc Johnson and Ophelia Rivas, assistant clerks; Jesse McCollum, senior advisor; Jenny Rosenberg, director of communications;

Shrita Sterlin, deputy director of communications; Ron Stroman,

staff director; Lawrence Brady, minority staff director; Jennifer

Safavian, minority chief counsel for oversight and investigations;

Dan Blankenburg, minority director of outreach and senior advisor;

Adam Fromm, minority chief clerk and Member liaison; Kurt

Bardella, minority press secretary; and Ashley Callen, minority

counsel.

Chairman TOWNS. The meeting will come to order. Good afternoon and thank you for being here.

This hearing comes as a dozen schools in New York City are

closed due to the H1N1 influenza outbreaks. This hearing also

comes as New York City, my hometown, suffers the first H1N1 fatality. I would like to begin this hearing by offering my sincere condolences to the family of Assistant Principal Mitch Wiener and also

to the students, faculty, and staff of Intermediate School 238.

With adequate preparation, our Nation responds better to natural emergencies than any other country. However, the 9/11 terror

attack and Hurricane Katrina demonstrated the consequences of

inadequate planning and preparation. These events have also

taught us that while national planning is required, it is the State

and local public health departments, safety professionals, and first

responders who are the most critical to get help to those in immediate need.

Today’s hearing will look at the ability of States and local communities to maintain an appropriate level of readiness to respond

to a pandemic flu, and how Federal authorities can assist them in

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mounting a sustained and effective response to a pandemic striking

the United States.

Unlike a typical natural disaster such as a hurricane or a wildfire, outbreaks of pandemic flu affect all regions of the country virtually at the same time, making regional cooperation impossible.

Also with a pandemic, it is necessary for public health teams to

function 24/7 in a three shift pattern for a period of several

months. These public health workers must conduct surveillance,

lab tests, and treatments while coordinating school closings, surges

at hospitals, and the storage and distribution of treatments and

vaccines.

Shifting national priorities and the impact of the current economic downturn have led to budget cuts in health departments

across the country. According to the National Association of County

and City Health Officials, 53 percent of local health departments

in the State of New York lost staff in 2008 and 40 percent expect

to make more layoffs this year.

While dealing with budget and work force challenges, New York

has become a focal point of the current H1N1 outbreak. Nationally,

the public health work force has been recently reduced by over

7,000 workers with more reductions expected. Over 85 percent of

local health departments reduced their staff in 2008 and 46 percent

are expected to lay off more workers in 2009.

A recent and seemingly prophetic GAO report published on February 26, 2009 warns of the continued threat of a pandemic as our

national priorities move from pandemic preparedness to the economy and other issues. Current events remind us that pandemics

can strike at any time and with little warning. Our communities

need to stay ready to respond to such a threat.

I am hopeful that this hearing will shed light on exactly how prepared we are to respond to a pandemic at the State and local level.

I am also hopeful that our witnesses will help us discover what we

all can do, not just in the Federal Government, to make sure our

communities are ready to handle what Mother Nature dishes out.

I want to thank all of our witnesses for appearing here today. I

look forward to your testimony as well.

At this time, I would like to yield to the ranking member from

California, Congressman Issa.

[The prepared statement of Chairman Edolphus Towns follows:]

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Mr. ISSA. Thank you, Mr. Chairman. Thank you for holding this

important hearing on State and local pandemic preparedness. I

also want to thank our witnesses for taking time out of their busy

schedules to testify before the committee. We recognize that in

order to prepare for a hearing like this it isn’t just the work of

those who will prepare, but in fact is of some of the most important

people in our local and State response units.

In the event of an outbreak of pandemic flu, a coordinated response between the Federal, State, and local authorities from the

Departments of Homeland Security and Health and Human Services to public health departments, hospitals, and emergency response teams in the smallest of American towns will be key to ensuring the health and safety of all Americans.

The question of whether there will be an outbreak of pandemic

flu somewhere in the world of a proportion similar to that of the

early 1900’s is not an if but a when. To address threats from SARS

and avian influenza, the Bush administration created the National

Strategy for Pandemic Influenza in 2005, a comprehensive approach for preparing for, detecting, and responding to a potential

pandemic. The Strategy established guidance for Federal, State,

and local preparedness and response. Additionally, since 2002 over

$9 billion in grants have gone out to the States to strengthen hospital and public health preparedness. This coordinated response

strategy is in the midst of having its first test, the outbreak of the

H1N1 or swine flu.

As comprehensive as our plans at the Federal level might be, absent proper coordination with State and local governments, any

type of emergency response will be lacking. Less than 2 months before the H1N1 outbreak first appeared, GAO reported that more

could be done to facilitate coordination between Federal, State, and

local governments and the private sector to prepare for a pandemic.

Questions also remain about the adequacy of the strategic national

stockpile, and how assets such as antivirals and respirators in the

stockpile are distributed to the States during an emergency. Today

we have an opportunity to learn more about the gaps that may

exist and what we can do to address them should this epidemic

worsen or before any health emergency.

Additionally, it is clear that we now have a number of financial

problems at the Federal, State, and local level. It is inevitable that

without an immediate requirement for pandemic flu preparation,

States and localities would begin trying to divert funds to other

areas. This would be done at perhaps the worst possible time. Even

as we speak, the national stockpiles in some areas are being depleted simply because they have reached their expiration.

Only a week ago, I had individuals involved in our anthrax preparedness in my office showing me a table of the expiration of anthrax. In fact, this material is being destroyed. A small amount of

it is going to our troops in Iraq and we are thankful for that. But

the majority of it in all likelihood will not be used unless health

officials begin to find either ways to certify a longer time before expiration or to disburse it to first responders who could, in fact, take

advantage today of preparation for a possible anthrax outbreak.

This and many other areas are of importance to this committee.

Although there has been good work done since 9/11 to help AmerVerDate 11-MAY-2000 10:40 Feb 18, 2010 Jkt 000000 PO 00000 Frm 00011 Fmt 6633 Sfmt 6633 U:\DOCS\54388.TXT KATIE PsN: KATIE
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ica be the best it can be in the case of any kind of an emergency—

including a man-made one—budget cuts at the Federal, State, and

local level are in fact of great concern to us. We have to know if

we will maintain our preparedness and even improve it, particularly with regard to our coordination. Or are we saving pennies

now to not be able to save lives later?

Thank you, Mr. Chairman, for holding this hearing. I yield back.

[The prepared statement of Hon. Darrell E. Issa follows:]

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Chairman TOWNS. Thank you very much for your statement. I

yield 5 minutes to the gentleman from Rhode Island, Patrick Kennedy.

Mr. KENNEDY. Thank you, Mr. Chairman. Welcome all of you.

I would like to get into the response to potential pandemic and

the necessity to address the psychological response. Obviously,

back in the 1940’s, 1950’s, 1960’s there was that civil preparedness.

Everybody got under their desks; everyone had a bomb shelter.

There was a sense that we needed to get people prepared in the

event of war, of World War III. One thing that it did for people is

it gave them a sense that they had some control over their situation. In light of these announcements from the 24 hour barrage of

the media, a lot of people get anxious and nervous because they

don’t know what they are supposed to do.

Do you not think that it is necessary for us to—even in light of

the fact that now we have terrorism—to have people prepared in

this country and to have a plan of action in advance at their workplaces, at their schools, when they are traveling to work, when they

are at home, or whatever the situation may be as to how to do,

what to do, and things they need to follow in order to respond to

a given scenario? Isn’t it important that they practice that scenario? Shouldn’t we, as a society, encourage that kind of civil preparedness so that there isn’t a mass deluge of people to the emergency rooms in this country, which is exactly the opposite of what

you want in a kind of situation like this? Would you all comment

on that?

Chairman TOWNS. Would the gentleman yield? We have not

sworn them in yet, so hold the question. You have made a note.

Then after I swear them in, they will give you an answer. All

right?

The gentleman from Texas, Mr. Cuellar.

Mr. CUELLAR. Mr. Chairman, I have some questions but I will reserve them so we can get started with the testimony. Thank you.

Chairman TOWNS. The gentleman from Illinois, Mr. Foster.

Mr. FOSTER. I thank the chairman for having this. I yield back.

Chairman TOWNS. Thank you very much.

Now will you please stand. I will swear you in so you can get to

Patrick’s question.

[Witnesses sworn.]

Chairman TOWNS. Let the record reflect that all of the witnesses

answered in the affirmative. You may be seated.

Why don’t we just go right down the line starting with you, Dr.

Sosin? We will just come right down the line.

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STATEMENTS OF DANIEL M. SOSIN, DIRECTOR, COORDINATING OFFICE FOR TERRORISM PREPAREDNESS AND EMERGENCY RESPONSE, CENTERS FOR DISEASE CONTROL AND

PREVENTION, U.S. DEPARTMENT OF HEALTH AND HUMAN

SERVICES; GUTHRIE BIRKHEAD, DEPUTY COMMISSIONER

FOR PUBLIC HEALTH, NEW YORK STATE DEPARTMENT OF

HEALTH; REX ARCHER, DIRECTOR OF HEALTH, KANSAS

CITY HEALTH DEPARTMENT; TERRY ALLAN, HEALTH COMMISSIONER, COUNTY OF CUYAHOGA, OH; AND PAUL JARRIS,

EXECUTIVE DIRECTOR, ASSOCIATION OF STATE AND TERRITORIAL HEALTH OFFICIALS

STATEMENT OF DANIEL M. SOSIN

Dr. SOSIN. Good afternoon, Chairman Towns, Ranking Member

Issa, and distinguished members of the committee. I am Dan Sosin,

Acting Director of the Coordinating Office for Terrorism Preparedness and Emergency Response from the Centers for Disease Control and Prevention. Thank you for the opportunity to discuss the

importance of State and local public health preparedness and response efforts and how we can further our response to public

health emergencies in the United States.

Our Nation’s current response to the 2009 novel H1N1 influenza

is a direct result of the investments and support from the Congress

for State and local public health preparedness and the hard work

of Federal, State, and local public health officials across the country. This outbreak has placed huge demands on State and local

public health departments to rapidly expand on the ground investigations and response activities, and has highlighted how necessary it is to have a trained work force at the ready.

State and local public health departments are first responders to

a wide variety of health threats, many of which never make the

evening news. The many duties of public health departments include tracking the source, spread, and severity of health threats;

educating the public on how to safeguard their health; and delivering medicines, guidance, and community interventions to lessen

disease. Public health departments must have flexible and scalable

capacity to respond to all hazards, both to major events such as influenza pandemics and terrorist attacks, and also to more routine

events including community outbreaks of infectious diseases, chemical spills, and natural disasters.

The primary Federal support for emergency preparedness and response at the State and local public health department level is

CDC’s Public Health Emergency Preparedness Cooperative Agreement. This Cooperative Agreement provides funding and scientific

expertise in areas such as surveillance and health monitoring, epidemiology, laboratory testing, countermeasure delivery, incident

management, and emergency communications.

In addition, public health departments received supplemental

funding for pandemic influenza preparedness from 2006 to 2008 to

support practical, community-based approaches to prevent or delay

the spread of an influenza pandemic. Activities related to this supplemental funding include planning; community summits to facilitate engagement across Government agencies, business, and nonprofit organizations; and exercises to test response capabilities such

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as providing antiviral drugs and vaccinating broad segments of the

community.

These efforts paid off. During the response to 2009 H1N1 influenza, public health departments at the State and local levels have

been working around the clock. Emergency operation centers have

been activated and emergency plans put into place across the country. Public health officials started tracking possible cases of H1N1

influenza, tested a large number of samples for the presence of the

virus, provided information to communities about how to slow the

spread of the virus, and educated the public about precautionary

measures they could take.

This education worked. A national survey conducted by the Harvard School of Public Health earlier this month found that two

thirds of respondents report that they or someone in their household washed their hands or used hand sanitizer more frequently in

response to reports about H1N1 flu. Over half say that they made

preparations to stay at home if they or a family member became

sick.

Despite the great strides in preparedness and response for pandemic influenza, work remains to be done. More can be done to bolster the public health work force, which is the foundation of effective preparedness and response. Ongoing shortages exist in key occupations such as epidemiology, laboratory science, and public

health nursing. It is also a challenge to have enough public health

workers at the ready to deliver medicines and medical supplies

during an emergency. The Nation’s systems for tracking disease

can also be improved. For example, we do not have nationwide electronic systems to automatically manage and share data such as

laboratory results that are vital for response efforts.

The path of the 2009 H1N1 outbreak may change. We need to

be prepared for possible resurgence of this virus in the fall, potentially in a more virulent form. Complicating matters, other public

health incidents that need our attention continue to arise such as

food-borne disease outbreaks, floods, wildfires, and soon the hurricane season will be here. We must remain vigilant throughout this

and subsequent outbreaks.

At no time in our Nation’s history have we been more prepared

to face this kind of challenge. Nevertheless, more work remains to

be done. We look forward to working closely with you to continue

to prepare the Nation for evolving health threats.

Thank you for the honor to speak before you today. I am happy

to answer questions.

[The prepared statement of Dr. Sosin follows:]

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Chairman TOWNS. Thank you very much, Dr. Sosin.

Dr. Birkhead, let me just say a few words about you. He is the

deputy commissioner for public health for the State of New York,

and is an associate professor of epidemiology at the University of

Albany School of Public Health. Dr. Birkhead.

STATEMENT OF GUTHRIE BIRKHEAD

Dr. BIRKHEAD. Thank you very much, Chairman Towns, Congressman Issa, and distinguished committee members. Thank you

for the opportunity to testify today.

The events of the last month with the dramatic emergence of the

H1N1 swine influenza and the equally rapid public health response

have proven the value of the investment we have made as a Nation

in health emergency preparedness planning in recent years. In a

short time we have learned a lot about H1N1, but we still have a

lot to learn. Last week it appeared that things were getting back

to normal, but the virus has continued to circulate in many communities. A number of schools, as the chairman noted, have been

closed in New York City this week due to high rates of absenteeism

from H1N1. In my testimony today I will provide a little background about New York’s response and address the committee’s

questions.

On April 25th, the New York Governor David Patterson directed

the State Health Department to activate its emergency preparedness plan in response to the H1N1 cases in New York State. This

plan was developed over a number of years of pandemic planning

and involves the collaboration of programs across the Health Department, other State governmental agencies, and local public

health departments including the New York City Department of

Health.

In terms of the committee’s question on the need for resources

and the impact of the economic downturn, two Federal funds

sources have played a critical role to the State in developing its

current preparedness: the CDC Public Health Preparedness Cooperative Agreement, which Dr. Sosin mentioned, and the DHHS

Hospital Preparedness Cooperative Agreement. These funds, I

would point out, have been reduced by 40 percent and 24 percent

respectively in the last 5 years. In addition, the State did receive

pandemic influenza supplemental funds, as Dr. Sosin noted, from

2005 to 2008, but those funds have now also ceased. New York City

also receives this same direct funding.

New York State has provided $60 million in the State budget to

support State preparedness programming. These funds have been

used to purchase supplies and medications for the State’s emergency stockpile, including the supply for New York City. We have

purchased the maximum number of antiviral treatment courses allowed under the Federal program and now have 3.1 million treatment courses of antivirals on hand. We also purchased other supplies such as 17,000 ventilators for patients with respiratory failure

during a pandemic.

New York has made it a priority to fund local health departments which are key to the local response, the boots on the ground

if you will, for local response. We have provided $96 million in

State and Federal funds over the last 7 years to our local health

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departments. Funding to locals was viewed as so important that

the State Health Department absorbed the entire cut in the CDC

preparedness grant in recent years in order to keep the county

funding whole. However, due to the current fiscal crisis, county

funding finally was reduced by almost 40 percent for the remainder

of the current contract cycle. Ironically, this occurred on April 1st,

just before the H1N1 hit. Many local health departments had to lay

off preparedness staff at that point. In this context, the current discussion of the additional $350 million in one-time Federal funding to State health departments and

locals to deal with H1N1 is welcome news, although the exact number should be examined to be sure it is enough when we are clear

on what we are being asked to do with it. Such funding will be critical for States to maintain and strengthen their public health response capabilities in the face of what will likely be an ongoing

threat. In particular, State and local health departments are likely

to play a key role in any mass vaccination efforts should an H1N1

influenza vaccine be made. Such a vaccination program would be

unprecedented in scope given the size of the population to be vaccinated. Federal funds will be critical to these efforts, but it is also

critical for Congress to look to restoration of the cuts I mentioned

in the base public health and hospital preparedness programs, respectively, that States have sustained over the last 5 years. Onetime funding cannot provide for ongoing infrastructure needed to

address H1N1 and future public health emergencies.

In conclusion, some have suggested that public health may have

overreacted to these events because a severe pandemic has not yet

materialized. I want to assure you that at each step of the way,

prudent steps were taken to prepare and protect the population in

the face of uncertainty about the virus. State Health Department

scientists who have spent their careers working on influenza have

commented to me that this H1N1 virus represents the biggest shift

in influenza viruses in their professional lifetimes.

While initial guidance, for example, to close schools following a

single case may seem in retrospect to have been overkill, I would

make the analogy to hurricane preparedness. When a hurricane is

bearing down on you, you don’t take the view that we can relax because it might veer off. You have to assume the worst and prepare

for it. That is what the public health community has done in the

past month with H1N1 influenza.

We are much better prepared than we were even a few years ago.

However, there are gaps in health preparedness infrastructure that

can only be addressed by stable base funding to maintain that infrastructure. I urge Congress to consider restoring those funds.

Thank you, Mr. Chairman. I look forward to answering your

questions.

[The prepared statement of Dr. Birkhead follows:]

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Chairman TOWNS. Thank you very much, Dr. Birkhead.

Dr. Rex Archer is the director of health for Kansas City, MO and

is a past president of the National Association of County and City

Health Officials. Welcome, Dr. Archer.

STATEMENT OF REX ARCHER

Dr. ARCHER. Good afternoon. Protecting and serving a population

of 475,000 in Kansas City, MO is a challenge. We have a 143-year

history and tradition of protecting against contagious and communicable diseases.

Approximately 10 years ago in the spring of 1999, I started asking where we were as a Nation at the local public health department level in preparing for bioterrorism or various emerging infectious disease threats. As often happens when you ask those questions, they put you as Chair of a committee. So we have had a committee in NACCHO for 10 years that has been working on these

issues. We have made a lot of progress but there is the old saying,

the only thing harder than preparing for a disaster is answering

the question of why you didn’t. So with that, I believe that our

charge is in looking at how we may need to reform some aspects

of public health.

Actually, we can borrow a model from fire departments. If you

think about a fire and influenza, a fire burns through buildings

and influenza burns through people. Fire departments don’t respond with the minimum they need to put out a fire. They come

in with extra trucks in our urban areas to put out that fire because

you don’t want to chase a fire. They have surge capacity to respond

to those types of events.

Ninety-nine percent of the time there aren’t fires going on in our

urban fire departments, but 99 percent of the time our local health

departments are being challenged with covering all their mandates

right now. So we don’t have that surge capacity that we need to

be able to respond. As an example, I really believe that if I think

about our health department and where we were back in 1999, we

were less than 5 percent prepared to manage a Category III pandemic from influenza. We have made tremendous progress, but I

think we peaked back in about 2006.

In a sense, we have a perfect storm going on with Federal, State,

and local funds being cut. We don’t have the people there to maintain our plans that were developed. The pandemic flu funding was

critical for us to develop relationships with our churches and our

faith community in general, with our schools, and with our business community. But this exercise that we have been going through

recently with this H1N1 has really pointed out that the things that

we put in place a few years ago, those communities are now asking

us to respond, but the people aren’t there anymore because the

funding went away.

As an example, I have 186 staff for serving that almost half a

million people, but only 20 of them are really available for this

kind of event. They are often funded out of grants, and that is an

issue I think we need to look at. We could change the Federal guidance so that people under grants are expected to be cross-trained

and prepared for these kinds of issues, whatever the funding source

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coming down, so that we would have them and be able to deploy

them in these kinds of incidents.

Basically, if we had had to go any longer with this event, we

were at the point where we had prepared to stop and reduce our

number of restaurant inspections, and to stop some of our contact

tracing for sexually transmitted diseases. We were running our

staff at 12 to 14 hours a day with half that time even over the

weekend. And that was all really voluntary because we don’t pay

them overtime. So it really makes it very difficult to manage.

Our response, though, was extremely effective. We activated and

CDC was very helpful in communicating with us; the National Public Health Information Coalition was useful. The things that we

had were in place. My fear is, though, that we are losing ground.

If I had to really sum up, I want to thank the other local health

departments, the State Health Department, and CDC for all of

their work. But we really need the staff to keep the relationships.

When you develop relationships with school systems, with faith

communities, and with businesses but then those people go away,

the plan can be there on the shelf but you can’t exercise the plan

in an emergency.

Thank you.

[The prepared statement of Dr. Archer follows:]

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Chairman TOWNS. Thank you very much.

I would like to yield to the gentleman from Ohio, Mr. Kucinich,

to introduce the next witness.

Mr. KUCINICH. Thank you very much, Mr. Chairman. It is my

pleasure to introduce Mr. Terry Allan. Mr. Allan is the health commissioner for Cuyahoga County, in which my constituency of the

10th district is included. He is the commissioner for the Cuyahoga

County Board of Health. The Cuyahoga County Board of Health is

the local public health authority for over 886,000 citizens and 57

greater Cleveland communities. So he has a lot of responsibilities.

Mr. Allan is also president-elect of the Association of Ohio Health

Commissioners and the former regional coordinator for Public

Health Preparedness in the northeast region of Ohio.

Thank you very much, Mr. Chairman. It is a pleasure to have

you here, Mr. Allan, for your testimony to our committee.

Chairman TOWNS. Thank you very much. We yield him 5 minutes.

STATEMENT OF TERRY ALLAN

Mr. ALLAN. Mr. Chairman, Ranking Member Issa, and Congressman Kucinich, thank you for the introduction, and members of the

committee, we appreciate the time to talk to you today.

I want to give you my perspective from greater Cleveland on

what we know and what we still need to do from our experience

over the last several weeks. The H1N1 response really has been a

live exercise testing our capabilities and illuminating our gaps and

challenges that we still have ahead of us as we really prepare for

what is to come, the unknowns for the coming flu season this fall.

Funding cuts have been mentioned. Close to 40 percent have effected Ohio as well as local health departments. Certainly, as we

look at the State and local funding challenges that everyone is facing, we expect those further cuts to be on the horizon. That is very

concerning to us just as we acknowledge our capabilities, which I

will talk a little bit about, but also illuminate our challenges.

In greater Cleveland, we have been working hard for many

years, working with our partners throughout the region on our 24/

7 response capability and our comprehensive planning; establishing

strong relationships with the first responder community, a regional

cooperation with mutual aid to assist across that five county region

that Congressman Kucinich mentioned; improving our ability to determine the distribution and determinants of disease, our epidemiology capacity; improving the ability to communicate with the public, which was very critical so that they had a trusted communication point during this event; and developing a working knowledge

of incident command structure that police and fire have been working with for many years.

In terms of our gaps, we still have a lot of work to do around

volunteer recruitment, training, and retention. Right now in the

greater Cleveland area, we have about 5,000 volunteers. We need

closer to 8,500. In our five county region, we need about 15,000 volunteers. They need to be trained; they need to be oriented; and

they need to be made available very quickly to assist us if we need

to ramp up.

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Our regional distributions of antivirals—which very much came

to point here in recent weeks to distribute those to our community

partners, to hospitals, and to perhaps the indigent folks who have

nowhere else to receive these services—are critical. So are alternate care site planning when hospitals are full, surge capacity in

terms of staffing that Dr. Archer mentioned, and social distancing

plans.

We may need to be telling folks if things were to get very severe,

in the worst of circumstances, to stay home from school, to stay

home from work, to telecommute. The kids would then need to stay

away from the mall so we are not in a position of passing the virus

around. Vulnerable populations, the poor and disabled, are particularly at risk. We need local surveillance capacity to be able to identify early on when an outbreak may hit your community.

In my view, public health is an essential partner and must be

viewed as part of the national defense system. Acquiring stable and

adequate funding for public health is absolutely critical if we are

going to be available and reliable for the public in a way that they

have a right to expect. Because of the budget cuts, we are particularly concerned and hopeful at the same time about the $350 million that was talked about in supplemental money that the House

was gracious enough to put into the budget. We are hopeful that

it will be part of a conference discussion.

In terms of personal preparedness that Congressman Kennedy

spoke of, we have suffered nationally, we believe, from pan-flu paralysis with the general public becoming fatigued from our calls.

They have an emergency plan for your community. Our H1N1 response is an opportunity to develop a culture of preparedness.

Folks are paying attention right now, so every family knows what

to do.

We need resources now, because as of August 2009, our pandemic flu funding will be zeroed out. So, it is our hope that we will

have the opportunity to continue these efforts. It really is about

people. It is people on the ground that are there to respond day in

and day out to assure the public and to limit the scope and magnitude of an outbreak.

Thank you, Mr. Chairman.

[The prepared statement of Mr. Allan follows:]

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Chairman TOWNS. Thank you very much.

Dr. Paul Jarris is a family physician currently serving as the executive director of the Association of State and Territorial Health

Officials. He is also the former commissioner of health for the State

of Vermont. Doctor, you have 5 minutes.

STATEMENT OF PAUL JARRIS

Dr. JARRIS. Thank you, Mr. Chairman, Ranking Member Issa,

and other Congressmen for this opportunity to speak before you. I

have submitted written testimony to you, but rather than repeating

some of what has been said before, I think I will try to emphasize

some points.

Chairman TOWNS. Your entire statement will be included in the

record.

Dr. JARRIS. Thank you. There are a couple of points that I think

are worth stressing. As much as we would like to believe that this

episode is over, this episode is not over in the United States. We

still face a novel influenza that is spreading rapidly in this country.

It is in 48 States as well as the District of Columbia. We have confirmed in the laboratory 5,700 ill individuals but there are probably

more along the order of 100,000 Americans who have been made

ill so far.

We frequently hear the comment that this is just like another

seasonal influenza. It simply is not. The average age of the ill individual with this outbreak right now is 19. The average age of an

individual in the intensive care unit with this illness is 23. That

is not a seasonal influenza. Seasonal influenzas also do not occur

this time of year. So this is a novel and new virus. We simply do

not understand it yet.

We do not know what is going to happen in the fall. I would

argue that if we are lucky, this will come back in the fall, if it goes

away in the summer, at the same level of virulence. But it would

not be responsible for us to not keep history in mind and recognize

that in 1918 that second wave was far more severe. In 1957 in

Japan, that influenza came back with a second wave that was

much more severe. So history would mandate that we are prepared

in the fall for what comes at us.

I do believe that we can be very proud and your committee can

be very proud of the performance of the Government. Dr. Sosin, Dr.

Besser, and all of Health and Human Services in the Federal Government should be commended on the way this was organized so

that the Federal Government, State governments, and local governments came together as a single public health entity to respond to

the American people. The Harvard survey is testament to that

when 80 percent of the public reports that they are satisfied with

the governmental response and 88 percent say that they are satisfied with the information they have gotten.

I think we all wish we could go home. It is not going to get any

better than that. But we still have many challenges yet to face.

Now we did, based on the investments Congress made, plan and

exercise these plans over the past number of years. Our response

to date has been quite good.

But as we all know, plans do not survive the first contact. Many

assumptions in our plans were incorrect. We assumed that this

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virus would start overseas, that we would have a month to 2

months to figure out how transmissible this virus was and how severe it was. Well, it didn’t. It began in North America so we had

to activate plans without really understanding the virus and how

transmissible and how severe it was. We don’t fully understand

that right now. But we were able to adopt and modify what we

were doing and I think provide a very good response.

As you have heard the other witnesses testify, there is a big difference between a 3-week response, which we have just gone

through, and a full epidemic or pandemic response which may be

6 months or more. We simply cannot sustain the level of response

we have had in this Nation to date. As was mentioned, we do not

have the work force. We don’t have the depth on the bench. It is

only humanly possible to work two to three shifts for so long with

a work force that has been cut by 11,000 in the past year and likely will be cut by 11,000 more at the local and State level. It is not

humanly possible to maintain this response. That is why we need

your help.

As was mentioned before, we have seen significant cuts in State

and local preparedness funding that comes through the CDC. We

have seen significant cuts in the hospital preparedness money

which comes out of ASPER in HHS. In addition, we have had no

pandemic planning funding at the State and local levels since August 2008. So what you are seeing is a response but there is no fuel

in the tank. We are asking you please to assist the States and the

locals to mount a response for what may come at us in the fall.

Very quickly, I will give you one example of what we have to prepare for. We are likely to develop a pandemic influenza vaccine.

This novel H1N1 vaccine for the fall, it likely will require two

doses. That is 600 million vaccinations we may have to give in the

fall on top of the usual 80 to 100 million doses we give for seasonal

influenza. So we are talking about potentially 700 million vaccinations to give in the fall with a work force that is diminished. The

complexity of that, not only the cost of it but the complexity of administering that to Americans in a timely fashion, is tremendous.

The vaccine will roll off the production line at 15,000 to 20,000

doses a week. It will be distributed by the Federal Government to

the States on a per capita basis. So it will be dribbling in over a

number of months and we have to go down a priority list to protect

the first responders, the health care providers, and others. So as

one example, that is the level of complexity we face and that is the

need. We need resources for the fall.

I would be happy to answer questions. I apologize for going over

time.

[The prepared statement of Dr. Jarris follows:]

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Chairman TOWNS. Thank you. Let me thank all of you for your

testimony.

Let me say that is sort of frightening when you think about it

in those terms and then with you saying that you are losing staff.

It seems to me that you should be adding staff at this time.

Dr. Birkhead, Dr. Archer, Mr. Allan, your States have created a

preparedness plan and you submitted it to CDC. Are your States

currently able to carry out those plans as submitted? Dr. Birkhead.

Dr. BIRKHEAD. Yes. I think, as Dr. Jarris said, we have been carrying them out for the last 3 weeks. It is fortunate that we had

gone through that planning process. We have actually implemented

the plans that we developed. But I think the point is how long it

is sustainable.

We at the State level have had to pull staff from many different

areas of the Health Department off of their regular duties. For a

couple weeks there we were working 7 days a week in 18 hour

shifts. The sustainability of that is hard to imagine for much

longer. Then, adding on to that the vaccination program which may

come about this fall, I think there is a huge need. So we are able

to maintain what has happened so far but I think, as Dr. Jarris

aptly said, the tank is empty at this point. We need to refuel.

Chairman TOWNS. Thank you, Dr. Birkhead. Dr. Archer.

Dr. ARCHER. In 2006 we were better able to. We had more staffing and had funding for some of the relationships on the plan. It

is one thing to say you are going to interact with your business

community because of these social distancing and other issues—

and we had done training—but it is another thing then to support

that if you don’t have the people there anymore.

So I would say that I am afraid that many local health departments across the country have lost ground in the last few years.

Yes, we can do almost anything for 2 or 3 weeks but we got to the

point of exhaustion just during this incident.

Chairman TOWNS. Yes, OK. Mr. Allan.

Mr. ALLAN. Mr. Chairman, I think that we know what to do. To

reiterate what has just been said, we just don’t have the horses to

do it over an extended period of time. If we had a higher severity

situation where we had a lot more cases, a more severe disease,

more contact tracing, and were dealing with a lot more fear—which

was already substantial even in this circumstance—compounded by

the confluence of things that Dr. Birkhead mentioned around a fall

vaccination campaign, we are going to be severely strapped. We

won’t be able to do it.

Chairman TOWNS. Right. You know, it is not really making a lot

of sense to have a plan if you can’t implement it, is it?

Dr. ARCHER. Well, just think about regular seasonal influenza.

We can’t vaccinate one third of our population in a regular year

when we have a year to prepare and plan for it.

Chairman TOWNS. Let me ask you this: Are you asking for

money? Quite often people will need it but they won’t ask for it.

Are you asking for additional money?

Dr. BIRKHEAD. Well, in my testimony I asked for two things. I

supported the idea of the one-time $350 million. That is going to

be desperately needed if we are going to vaccinate this fall. But I

also asked for restoration of the cuts that have occurred in the

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CDC and HHS hospital funding programs over the last 5 years.

That is partly why we are at reduced levels at this point.

Chairman TOWNS. Dr. Archer.

Dr. ARCHER. Sometimes public health is not very good at asking

for funds. We try to do what we can, and you are correct. We made

a mistake, I believe, when we asked originally after 9/11 in the anthrax attacks for just under $1 billion. The country deserves a level

of protection much more than that to truly have the infrastructure

to not only protect against these things but also when our health

care costs are going out of sight.

Our population in this country is down; 30 or 40 nations are

above us in regard to life expectancy because we are not investing

in prevention. So if we put the systems in place to truly work with

our communities to prevent illness on a day-to-day basis, that we

should be investing in. We could also turn that structure in these

kinds of emergencies and we would have those relationships. So I

actually would go out on a limb and say we need 5 to 10 times

what we are currently getting to really make a big difference in the

population’s health.

Chairman TOWNS. Thank you. Mr. Allan.

Mr. ALLAN. Thank you, Mr. Chairman. I think that as Dr. Archer

said, public health isn’t very good at asking. Often we just we are

out there trying to help the least among us. Certainly I am concerned about these vulnerable populations, the disabled and the

poor, that are most susceptible often to disease.

I think that the stability of funding is important. We see sort of

a seesaw effect and it is difficult to maintain staff to do whatever

it is that needs to be done. It is not really about building widgets

or counting widgets, as has been said. It is about having staff in

place to surge, to respond during these events. There is lots of work

in public health to do but to be able to put all hands on deck for

this response is critical. Right now, the resources aren’t there, particularly for the folks least able to fight off disease.

Chairman TOWNS. Thank you very much. I yield to the ranking

member, Congressman Issa from California.

Mr. ISSA. Thank you very much, Chairman. Dr. Jarris, I didn’t

intend to ask this question but I just want to followup on something you said in your opening statement. You said 150,000 units

a week. I am just trying to do the math. That doesn’t get you to

300 million in a year. I am assuming that whatever you can’t make

in the 1-year, you are not going to make the others. So there is no

plan based on that volume to achieve 600 million doses, right?

Dr. JARRIS. If I mis-spoke, I apologize. Initially, there will likely

be volume that comes off of the vaccine that is being produced. We

are not quite sure how large that will be. After that, 15 to 20 million doses a week should be coming out and being distributed. So

if we take the 600 million——

Mr. ISSA. 15 million?

Dr. JARRIS. Yes. I apologize if I mis-spoke.

Mr. ISSA. OK, that is a different number. The record may be

more accurate than my hearing. I just wanted to followup on that.

Dr. Sosin, pronounce it for me so I get it right.

Dr. SOSIN. It is Sosin, sir.

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Mr. ISSA. Sosin. Thank you. I apologize. With my name I should

be more sensitive to everyone’s name. Doctor, realistically, historically, in an outbreak, once we get past the first responders, don’t

we always allocate our resources to less than the entire population,

including the plan you have for smallpox? And I guess I am leading

up to the point that we do not have enough smallpox vaccine to

begin to do the entire population. That is not even in the plan, is

it?

Dr. SOSIN. Actually stockpiled, we do have sufficient smallpox

vaccine for the entire population. The challenges of administering

that vaccine are really where the bottleneck and the most difficult

challenges will lie. But your broader point, which is planning for

catastrophic events——

Mr. ISSA. OK. Let us take anthrax, for example. How many doses

do you have today in a stockpile? And more importantly, how many

will you have 5 years from now with the current no orders?

Dr. SOSIN. I will have to get back to you on the specific numbers.

We have both antibiotic treatments for anthrax as well as vaccine

for anthrax and a strategy for increasing vaccine as well as development of a new generation vaccine for anthrax. So there is a lot

of work in progress. And I will get you the specific numbers. The

broader question you raise of planning for catastrophic events,

which means the system fails inevitably runs into limitations of resources, and therefore prioritization and strategy to do the best we

can and address the best we can within the limitations of resources.

Mr. ISSA. And back to the resources for just a second, Dr. Sosin.

Since we spend about twice as much as the Europeans do on health

care, I am going to assume that money alone does not fix the problem based on how we spend money on health care in America, just

the fact that we already spend more than the nations we are being

compared to. Is not the most important thing for us to have is a

plan to ensure that our first responders, including all the health

care professionals that will receive people, are able to be continuously inoculated, prepared, or, if we do not have something, the

first to receive? Is that not sort of the crux, the most important

crux of the plan is that we not lose those people which Dr. Jarris

and others have said are already in short supply.

Dr. SOSIN. Clearly, there are a number of priorities for how we

respond most effectively. First line responders are one of those priority groups, whether that is in the health care system, whether

that is in emergency response and emergency management system.

I think the comments made earlier about vulnerable populations,

however, reflect also Government responsibility to assure that

there is a safety net for those with the least access and the greatest

need. So planning really has to be in the broadest sense. But there

are strategic priorities set for early stages versus later stages of response.

Mr. ISSA. OK. And one followup to something I said in my opening comment. Since the anthrax stockpile is expiring and it has

never been offered broadly to first responders, do you have a plan

to deal with making that available to first responders around the

country, including our health professionals, rather than destroy the

stockpile which is currently in the plan?

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Dr. SOSIN. There is ongoing discussions amongst the emergency

responder community with the Department of Homeland Security,

Department of Health and Human Services about the appropriateness, suitability of this vaccine in that setting. There have been advisory committees for immunization practices looking at and providing permissive guidance that without sufficient understanding

of risk there may be a point in time where risk is sufficient to warrant pre-vaccination of those populations. So there is discussion

about that. There is the ability to make that vaccine available before it expires. But that is active discussions going on right now.

Mr. ISSA. Let me just ask one final followup question, Mr. Chairman, if I may.

Chairman TOWNS. You may.

Mr. ISSA. Are our health care professionals, specifically doctors

and nurses at our community centers around the country, are they

not the most informed consent individuals? And if you have a distribution request and it is a voluntary taking by those individuals—remembering that our military is not voluntary, they get the

shots whether they like it or not; they go to combat, they are going

to have it—would that not be a group that by definition, the safeguards you are talking about protecting them from not having

enough informed consent, is this not a group of people that we normally rely on to advise people and, therefore, if a doctor at the

Cleveland Clinic or Cuyahoga Community Hospital wants that

medicine and has the normal informed consent, are they not by definition the people who should be allowed to make that decision, not

have it micromanaged in Washington?

Dr. SOSIN. Thank you, sir.

Mr. ISSA. You are most welcome.

Dr. SOSIN. My understanding is that the licensed vaccine is actually potentially commercially available. The company has indicated

that they have capacity to produce and sell the vaccine additionally. These questions are really about the purchases that the Federal Government has made and is there a strategy for making that

available to populations in need. I am not aware that the health

care community, in the similar way as they were not terribly interested in smallpox vaccine, has indicated an interest in anthrax vaccine at the same time.

The emergency responder community, we hear, is mixed in terms

of their perspective on whether that should be required or made

available to them. And the Department of Homeland Security is establishing whether this is appropriate for their approved equipment list and therefore the funds can be used from Homeland Security to do it. So there is complexity there. But your broader question of whether the medical community should be in a position to

utilize a licensed product, absolutely. That is the way our health

system works.

Mr. ISSA. Mr. Chairman, that was not my question. The question

is, before we throw this material away or actually spend money destroying it, will we make it available with ordinary, if you will, informed consent so that it not be literally thrown away while the

alternative to go buy, is what the hospitals, including the first responders in Cleveland, who asked me about this when I was there.

Chairman TOWNS. Right. And that is an excellent question.

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Let me just say before I yield to the gentleman from Rhode Island, you have a plan, but without the resources you do not have

a plan. You cannot carry it out. And I think that you need to be

honest about it and just sort of point it out and let us see if we

can get some help for you. It does not make you a bad commissioner, a bad administrator because you do not have the resources.

I think you have to fight to get the resources because this is serious. If you have a plan and you cannot implement it, it is no plan.

Dr. ARCHER. And one of those resources is the challenge, and the

failed challenge I think, in this country in regards to vaccine production. We have problems with standard vaccines not always

being there when we need them. We have to change our message

to the public. There are ways to fix it if we actually sat down and

talked about it. Having worked in Ford Motor Co., I could use the

analogy that if we had to make cars, decide how many were made

today 9 months ago, if you had to change the model every year, if

you had to throw every car away that was not sold within 3

months, and if you had to share the keys with others. Because half

the benefit of vaccines is not the individual but the herd immunity

effect, if you looked at all those dynamics, no wonder we are having

trouble producing vaccine at the level that we should be in this

country. We need to address that and fix that.

Talking about who is going to be a priority whether it is first responders or whatever, the real problem is we have not fixed a production issue of vaccines in this country so that we can get them

to everybody. Yes, there are challenges with smallpox, there are

challenges with anthrax, but that does not spread like wildfire or

like influenza. So it is a little different animal. We really do need

to be able to vaccinate every American for normal seasonal influenza.

Chairman TOWNS. I agree. I agree with you.

Dr. JARRIS. Mr. Chairman, may I comment?

Chairman TOWNS. Yes.

Dr. JARRIS. I think you are right and the comments have been

made appropriately that where we can mount a response, we cannot maintain it. So our plan is not adequate because the resources

are not there.

At the time we testified before the committees a couple of weeks

ago and we said we were requesting $350 million for State and

local preparedness, that was a figure that is a very low figure. That

figure would be equivalent to what we have gotten. We have had

a single $600 million appropriation in the past. We got $250 million and $350 million to support State and local preparedness. So

all we asked for was basically another sum of money to continue

the level of planning and preparedness we did.

Frankly, we made a mistake because that was before we knew

how serious this was and how serious the fall may be. So the $350

million in the House right now is probably not nearly enough and

it is a start to get us to revise our plans.

We also asked for some money to purchase antivirals, to get to

Mr. Issa’s point, for healthcare workers and critical responders.

Our strategic national stockpile right now only has countermeasures, masks and antivirals, for treatment, it does not have

masks and antivirals for prophylaxis for healthcare workers, public

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health workers, and ambulance. So we asked for money for that

also.

So, clearly, we need more money. As you say, it is not appropriate to put first responders, whether it be public health, fire, ambulance squads, in harm’s way without protecting them. And yet

our current strategic national stockpile does not have antivirals for

that prophylaxis. So we really do need more money and I am sorry

we under-asked.

Chairman TOWNS. Right. Thank you very much.

I yield to the gentleman from Rhode Island who had asked this

question. He might want to rephrase it now.

Mr. KENNEDY. No. I would really like, just as the chairman

asked, to get some real numbers in terms of what would be ideal

budgets. I serve on the Appropriations Health and Human Services

Committee for HHS. We are going to be going into markup in the

next couple of weeks. This is frightening.

All I know is that I would be derelict in my job as a Member of

Congress, as a member of that committee if next fall I am sitting

here in Congress and we have this flu, and by all accounts this flu

is coming back, and this scenario that you are painting for us is

happening, and I am sitting there after having sat in this hearing

and someone said weren’t you in that hearing, didn’t you hear what

they told you, and I did nothing about it.

For one thing, we have been told there are not going to be any

more supplementals. So this has to be part of this year’s budget.

It has to be part of this year’s appropriations. So we had better get

to it. And knowing the glazed-over look in appropriators’ eyes when

you talk about more money for this and that, if something is not

burning up, things are not going to get funded. We have to really,

as you all have said, seize the opportunity that we have right now

in terms of the public’s attention on this and really make the most

of it because we are not going to have this opportunity until next

fall and that may be too late.

So we had better move now. And I just want to underscore your

urgency about this and say, do not hold back. OK? You are not

stepping on anybody’s toes. OK? You are going to be derelict in

your own responsibilities to the administration which you work for

and to your own obligation to public health if you do not make

some really aggressive and ambitious budgets and put them forward in spite of whatever your higher-ups say. Frankly, I am going

to demand it, I am going to push for it, as I know the chairman

will, to get these answers.

The fact that you cannot even vaccinate one-third of your current

population when you had a year to prepare for it terrifies me. We

have just a few months to prepare for the H1N1 this fall and we

cannot even prepare to get a third of the yearly, which is only a

million and change, and we are talking about 600 million doses.

The scale of this thing is enormous and I do not think we have

even wrapped our heads around how big a challenge this is. So we

need to know the ratio of public health personnel to the population

that is needed. We need to know the ratio of volunteers that we

need, backup personnel that we need versus population. That is

going to be needed. We need to have the numbers of prophylactic

equipment and the like. All of those things need to be sized up.

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And again I would ask you, what do we have in terms of plans

for the faith community, for the private sector, for the public sector

and the like that they can exercise? Are we using technology for

the cell phones, for twitter, for email? What are we doing to be able

to message people when it comes to this modern society, to be able

to communicate with them so they are not just getting messages

from these 24-hour news that often are inflammatory and full of

misrepresentations in terms of news? How do we get facts out

there and real information in terms of what to do and where to go

so people feel empowered and not fearful? That is the key. That is

what I want to ask you guys. How do we make people feel empowered here?

Dr. SOSIN. Thank you, sir. Getting to your first points about having confidence in your Government, having confidence that you

know what to do and therefore responding more effectively, that is

absolutely critical. The numbers that Dr. Jarris shared about this

event where we approached it very aggressively, we did use twitter

and widgets and other kinds of tools to reach the broadest population we could, distributed from the Federal level, State and local

levels through practitioners as well as directly to the public, communications just in time about what you can do and what you can

expect, and what we know and what we do not know has been one

of the successes of our response so far. Maintaining the pace, addressing the complexity, those will be challenges in a larger scale

event for sure.

So, yes, we are responding to some of those communication challenges that empower the public, empower business, etc. We have

definitely come a long way with respect to engaging business, engaging the faith community, engaging the public and we have a lot

more work to do. I will point out that those plans discussed here

have been evaluated in quite a lot of detail. Twelve departments

and two offices of the White House participated in a joint review

of the pandemic influenza plans and there is a volume of information on the pandemicflu.gov Web site on those evaluations.

Importantly, the kinds of activities that we have been talking

about here that lie in the lane of public health were the strongest

parts of those plans. The weakest parts of those plans were the

broader interagency, intergovernmental coordination, interdisciplinary coordination with the emergency response community atlarge, with the service sectors, etc.

So even the plans that we have reflect gaps and needs for more

effort, not just sustainment of where we were 6 years ago.

Dr. BIRKHEAD. I would just like to add that I agree completely.

Public communication is critical. We cannot respond to a pandemic

in this country without people understanding what their role is,

what they need to do. We have invested a lot of effort in New York

and I know in the other States in trying to do that. We have also

worked with our business and faith communities. We have worked

with businesses to develop continuity of operations plans so they

can continue to operate in a pandemic, particularly if people can

work from home, that kind of thing.

That does not always work but to try and think through. In a

normal flu season we only vaccinate 100 million people because

there is not a demand out there for it. I think we have gotten their

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attention, as others have said, with this H1N1 and the challenge

will be how to meet the demand that I suspect we will see if we

did really roll out a vaccine and try to offer it to everybody. That

will be the real challenge.

And you are right, we need to have the detailed plan of how

many people we need to do that. We partly need to see when it is

going to happen, how quickly it will roll out, will we really see 15

million doses a week coming out. There is a lot of detail there to

give you a precise answer. But we need a lot more than we have

right now.

Mr. ALLAN. Congressman Kennedy, I think the whole issue of

this culture of preparedness, getting folks to think about this, Red

Cross has worked on this for some time. There is fatigue when people have a sense that nothing happens. They think that public

health is Chicken Little, you know. And I think from our end this

is a wake up call and we are hoping to now capitalize. CDC has

some great educational information that talks about, you know,

clean hands save lives. Just a basic message is critical.

But there is lots of fear and there is a tremendous amount of rumors that occur in the middle of this that everyone here has dealt

with that need to be dispelled as quickly as possible. And that individual preparedness and planning for families and understanding

messaging are, I think, essential. It is nice that there is attention

now being paid to public health and an understanding of the critical nature of what we do. So I am glad that this discussion is being

held.

Dr. JARRIS. Congressman Kennedy, you are bringing up a very

important point about communication and maintaining the credibility of Government. And what we saw in 1918, because of a lack of

transparency, is people did lose faith in the Government. We saw

some of the social fabric in this country, neighbor caring for neighbor, breaking down. So that is something that we very deliberately

have to pursue.

One thing I would ask you all to keep in mind is that we do not

have a separate work force in public health that we pull out of the

closet for a pandemic or a hurricane. These are our every day work

force and that is why we need to have that bench strength and

those professionals, those nurses, laboratory staff, and epidemiologists on board every day so we can surge with them. Part of that

system of public health that we so clearly need are experts in communication.

You mentioned that you are on the HHS Subcommittee. Very importantly, the communication was done so well because we had experts working on how to communicate with the public, who were

monitoring the twitters, the blogs, the Webs, the newspaper articles, the television media to see where the direction was, what are

people thinking, what are they reporting, so we could on a daily

basis adjust our messaging, and on a daily basis the CDC’s Director’s talking points were sent to the State health officials, were

sent to the local health officials who were on message.

One of the reasons I bring that up is that messaging is coordinated within the CDC and the National Center for Health Marketing, a terrible name and a very unfortunate name. But they are undergoing significant cuts in the budget. I believe it is $9 million in

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the fiscal year 2009 budget and $3 million in the 2010 budget. It

has a terrible name, marketing. We say what is that doing in public health. But what they are doing is understanding how to communicate expertly with the public. And much of our success was

due to that Center’s work. So I would ask you to take a hard look

at that. And maybe they can change their name. Thank you.

Dr. ARCHER. We will get back to you with the challenge you put

out to us on the ratios in regards to public health folks and volunteers, etc. And I think that is critical. To give you an example, we

have a full-time public information officer that is paid out of the

CDC funds for preparedness. That person does not just serve our

Kansas City but serves the whole region in regards to preparedness. Now they carry a 24/7 media pager. They will respond 90 percent of the time within 5 minutes.

If we do not get a call from the media in 2 days, we check the

battery or try to figure out what is going on because they are constantly having interaction with the media. That allows us to

change that message. When the message is wrong at the 6 o’clock

news, we can usually get it changed by the 10 o’clock news because

we have the interactions with the media. That is not present in all

of our communities and we need that support. But that person

burned out in this event and we had to send them home just to get

some rest.

Mr. KENNEDY. Well, I hate to bring up burned out, but National

Guard is already burned out. But I imagine you mentioned national security when you mention this. I imagine national security

would be invoked in favor of bringing in National Guard to help

you in some way. Maybe you could give us a response at some later

date about what you think of deploying National Guard, proper

training included.

Dr. ARCHER. We have the Medical Reserve Corps but that is done

on a shoe string. We really need some of those protections the National Guard have in regards to actually paying people for training

and those things. We could create a model that would really work

and we would love to work with you on that.

Chairman TOWNS. Right. The gentleman’s time has expired. Let

me recognize the Women’s Caucus and we have a lot of health care

people involved. We just want to thank you very much for your attendance. Thank you very much Women’s Caucus.

At this time I yield to Congressman Bilbray.

Mr. BILBRAY. Thank you very much, Mr. Chairman. Coming from

southern California, burned out takes on a different concept, especially after the couple of years that we have had.

What is the population of Vermont?

Dr. JARRIS. It is about 620,000 people, not including the cows.

Mr. BILBRAY. Wow. OK. I supervise the disaster preparedness

system and the health care system for the county of San Diego,

which is 3 million. I assume your disaster preparedness structure

is probably State-wide and not regional.

Dr. JARRIS. Well, I am no longer with the State of Vermont. But

yes, Vermont had a single structure for the whole State.

Mr. BILBRAY. Single structure. I figured so for that size. And Mr.

Archer, you pointed out on this, and this is where how this all

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works in, the network of how well integrated, you are all integrated

into the disaster preparedness structure, right?

Dr. ARCHER. Yes.

Mr. BILBRAY. Doctor, if you were going to be somebody who

wanted to plant a virus in 500 people that would have the most

impact on this country, if you were going to figure out a profession,

500 people, maybe two or three professions, have you guys looked

at exactly what group of people have the potential to spread the

problem fastest and easiest?

Dr. SOSIN. Sir, with respect to terrorism and biological terrorism,

there is a governmental process of establishing risk and conducting

a risk assessment that includes understanding of impact, of capabilities, of those who might attempt to do such things. That is not

what I am here prepared to speak about today. But I will acknowledge that nature as a terrorist here with influenza, it is about the

best reassorting virus to be able to pick up antiviral resistance and

modify during the course of a season that you could ever devise in

a laboratory. So we are up against something that is really quite

daunting.

Mr. BILBRAY. I am just thinking about what we can do as an

oversight committee rather than just complain about what the executive branch is not doing enough of, what we can do to be

proactive on this. And last October it became obvious to me as

somebody who had worked with public health that if there was

ever 500 people who could come in close proximity to a lot of people

all over this country, that all meet at one location and go out into

the country, it would be the Members of Congress. I mean you talk

about the vectors, paid for with taxpayer’s money, get out there

and kiss as many babies as you can, shake as many hands as you

can.

And frankly, Mr. Chairman, this is one of the concerns that I

have. There was a lot of discussion about the Members of Congress

getting inoculation. Frankly, I think it should be a requirement

that the Senators and House Members are required to be inoculated. Unless there is a medical reason for them not to be, with

how much exposure we constitute to the general public, that is one

of those things.

The other group that is probably the only group that is more

than your duly elected Representatives of the House and Senate

would be flight attendants and pilots. I do not know, there may be

other professions. But boy, I think history has proven the flight attendant potential for spreading disease. But I think we need to talk

about this in frank and open ways, back and forth, of what are we

not doing, are we requiring those involved with commercial aviation to be inoculated, and are we talking about ourselves, making

sure that we are not part of the problem.

But I want you to know that I listened to the Vice President. I

did not fly last week. I was very concerned about that and made

sure I stayed put.

Let us go on. Notifying the public. Mr. Kennedy raised this issue.

What is the potential in your city, in St. Louis? Do you have reverse 911 now?

Dr. ARCHER. I am in Kansas City, MO.

Mr. BILBRAY. Kansas City. I am sorry.

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Dr. ARCHER. We do not have reverse 911. We do have tremendous cooperation with all of our TV stations. So as long as they

have power and can broadcast, we have that mechanism to get information out.

Mr. BILBRAY. When you were in Vermont did they have reverse

911?

Dr. JARRIS. No.

Mr. BILBRAY. Anybody?

Mr. ALLAN. The city of Cleveland has a warning system within

the city boundaries and some select, more financially well off suburbs have some capacity. But it is not uniform outside of the city.

Mr. BILBRAY. But the city has the ability to call people’s homes

with a message telling them, being able to call into them?

Mr. ALLAN. Yes. With a message, it is a one-way type, right.

Mr. BILBRAY. OK. Just explaining it, because we developed that

because of our fires. We can actually tell street by street, neighborhood by neighborhood what the conditions were, be informed. I am

sorry that Mr. Kennedy is not here because there is a place of

being able to empower and the locals being able to be that bridge.

There is a very real possibility with this new strain that we will

not see the drop off during the summer. Has anybody even discussed that, that we may have this right through the summer?

Dr. SOSIN. There is a lot of attention to the virus domestically

as well as abroad, and in particular in the Southern Hemisphere

which is entering its typical seasonal influenza season. So we are

not standing down and I do not believe any of the folks at this

table are really returning to business as usual. We do not typically

see much virus activity. But as Dr. Jarris pointed out, this has not

been a typical virus. So we are watching very carefully. This is still

very early on in this outbreak and anything is possible with this

virus.

Mr. BILBRAY. Mr. Chairman, one last question. We are talking

about what we can do. If you had FDA approve a post-exposure

treatment that was genetically engineered to address 11 out of 16

different strains, if you had the ability to have an effective postexposure treatment or had a vaccine that was multi-strain, if you

had that lined up and ready in time for the next cycle, would that

not be a major plus for you to be able to start tooling up? And this

gets down to your issue of us changing our operations and getting

the stuff available. Just comment on that.

Dr. BIRKHEAD. Well I think we are not talking about post-exposure, but the vaccine we are talking about would be exactly what

you are saying. And yes, that is what we need.

Mr. BILBRAY. OK. I just want you guys to keep raising the issue

that we have to also put pressure on FDA. When we talk about crisis alarm, they need to change their procedures and we need to

change our procedures to make sure that we don’t, like the British

when they are fighting the Zulus, have everybody lined up in

straight little rows while they are being wiped out because the regulations say that is what you have to do to get ammo. We need to

change our procedures to make sure you have the assets that could

be available to you, not just because of monetary but because of

regulatory obstructions. Doctor, do you want to comment on that?

77

Dr. JARRIS. Yes. I think there is a very good example of where

we could use assistance in this regard. There is a shelf life extension program currently that the Department of Defense, VA, the

SNS—I think those are the organizations—use. In that program,

the Tamiflu has been extended now for up to 10 years, the shelf

life. The Tamiflu in the State stockpiles is not under a shelf life

extension program. We worked very hard with the FDA and the

manufacturers so that it went from 5 years to 7 years. That saved

us $200 million in the States.

If we could develop a shelf life extension program so that we

aren’t discarding hundreds of millions of dollars worth of antivirals,

that would be extremely valuable. It would be minimal cost for

huge savings. That is clearly an intergovernmental affair.

Chairman TOWNS. The gentleman’s time has expired. I will allow

you to answer. Go ahead.

Dr. SOSIN. I just want to correct one issue. The issue with

Tamiflu is the manufacturer went to FDA and said, look, our product actually can last 7 years, not 5 years, allowing for a process of

relabeling and extending the expiration date. So that process actually is available to States who have received Tamiflu from the Federal supply. There is a process that has to be gone through. But

the shelf life extension program is a broader issue about all expiring products.

Mr. BILBRAY. Thank you, Mr. Chairman. I just think that we

need to be more proactive in looking at this and have as much passion about changing our regulations to make the resources as we

are about spending money and throwing money at the problem.

Here is one of those items that Mr. Issa was pointing out. Thank

you.

Chairman TOWNS. Thank you very much. The gentleman’s time

is expired. The Congressman from Texas, Congressman Cuellar?

Mr. CUELLAR. Mr. Chairman, thank you very much for having

this meeting. I want to thank the witnesses for being here. I chair

the Subcommittee on Response and Preparedness of the Homeland

Security Committee so I value what you all have been saying. I appreciate it. I will start off with my first question to Dr. Sosin.

Again, thank you for the work that you do there at CDC. My

question refers to the time that you were dealing with bio-surveillance. I am from Laredo, TX, right at the U.S.-Mexico border. As

you know, we have been hit pretty hard by the H1N1 cases that

we have had. I know that the surveillance information is critical

for those in leadership positions to make the best decisions regarding resource allocation, school closures, those types of decisions.

Can you tell me how the information being put out by CDC by

its various biosurveillance efforts is helping the States, territories,

tribes, and localities to make those decisions? Then what sorts of

lessons have we learned so far from the H1N1 situation? How do

you see those being incorporated into the current system so that we

are better prepared as a Nation if the disease gets worse, particularly this coming winter?

Dr. SOSIN. Thank you, sir. One thing I would like to start off by

acknowledging is that surveillance and biosurveillance begins at

the local and State level. What we are able to provide back to State

and locals to help inform them is a broader, bigger national picture

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that crosses jurisdictional boundaries. So it is a partnership from

the ground up.

Biosurveillance, some of the efforts to get earlier cues of events

that might be happening, to detect them and respond to them more

quickly, that narrower piece really had a relatively smaller role to

play in the early development of this outbreak. It was laboratorydetected very early on and a major focus at the public health level

was to go out and investigate laboratory confirmed cases to better

understand this outbreak. As the outbreak spread, our ability to

understand what is going on broadly in communities where the laboratory was only one small piece of the broader outbreak, that information is becoming more valuable.

Certainly, probably the most useful piece of focus that we have

made in biosurveillance in the past few years is how we integrate

information from multiple different types of information streams

and then present that to decisionmakers on a daily basis in briefings, in slide sets, and whatever else that we share broadly. We

have had some success there as well.

So I think that the feedback on biosurveillance efforts is too early

in this outbreak to tell you entirely. I think the focus on biosurveillance as syndromic influenza-like illness is too narrow. The focus

on health information technology and electronic laboratory information, death certificate information and hospital or medical information, is a place where at the State, local, and Federal levels we

need to continue to advance those developments.

Mr. CUELLAR. How are we doing on the transition, doctor, from

developing vaccines in eggs—as you know, they are developed in

eggs—to a cell-based solution? Where are we on that? We need a

lot of eggs to develop vaccines, Mr. Chairman.

Dr. SOSIN. It is a process of development. There are new platforms for vaccine development. They are pretty early. They are not

replacing egg development at this point in time. I can’t give you

particulars as it relates to the H1N1 vaccine development, how

much would be egg and how much in cellular techniques. If that

is something that you would like more information on, we can provide that to you.

Mr. CUELLAR. I would like to get that. Real quick because I am

out of time, I have just a quick question to one of the other four

gentlemen. Again, understanding the strains—I think you articulated that pretty well—how much more do you think public health

departments can handle right now with the H1N1 outbreaks occurring? You have those strains.

I guess whoever provided the pictorial here, I guess this is pretty

much what we are looking at where we have that up. We are down

here in this current situation and I guess to get up here it is going

to take a lot of effort. I assume there is a lot of strain in what you

all do. I think that is the message that we are getting loud and

clear. Dr. Birkhead or anybody who wants to answer?

Dr. BIRKHEAD. No, that is right. I think public health departments across the country at the State and local level have been operating almost 24/7 now for the last month. It has eased up a little

bit but it is not going away. We need to arrive at a new normal

for going forward. But if this gears up at all in the fall and we are

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having to do vaccination at the same time, it is not going to be sustainable without more resources.

Mr. CUELLAR. I think the chairman was correct. I think we are

trying to get some input from you all. We might not grant all the

wishes but we certainly want to know what you think we ought to

be addressing.

Thank you to all of you. I appreciate your time and effort for

being here. Thank you, Mr. Chairman.

Chairman TOWNS. Thank you very much. I thank the gentleman

for his questions. Congressman Kucinich.

Mr. KUCINICH. Thank you very much, Mr. Chairman. Mr. Allan,

does Cuyahoga County currently have the ability to handle a pandemic? Do we have the health infrastructure to be able to do that?

Mr. ALLAN. I think, Congressman Kucinich, that Cuyahoga

County has a wealth of certainly health care capacity. I think that

in the H1N1 response, it is important to note that the current activity relative to this virus is sort of uneven around the country

right now. Certainly in New York there is a lot of activity, as Dr.

Birkhead pointed out, and we have been reading in the newspapers.

I think if we start to move forward on a pandemic of higher severity, we are going to be stressing the system. The current level

of severity that we are dealing with was sporadic activity in Ohio

and in the greater Cleveland area is something that we think we

can maintain activity on in terms of control.

Mr. KUCINICH. You are saying we have the health infrastructure

to maintain public health support for a pandemic?

Mr. ALLAN. I am saying that in terms of a pandemic of this low

severity that we are seeing, we can deal with it locally. If it begins

to become more severe, we are going to have some serious problems.

Mr. KUCINICH. Well, you have said in your testimony that not

knowing if the virus will shift or drift, we are looking into the fall

of 2009 and beyond, you have a To Do list. Your To Do list notes

that if funding levels continue to drop as anticipated, we will be

unable to advance our detection, preparedness, and response. Now

detection is an essential part of being able to get ahead of a pandemic, right?

Mr. ALLAN. Right.

Mr. KUCINICH. Can you put a dollar figure on what Cuyahoga

County needs in order to adequately advance detection preparedness and response capacity to a level that would be necessary if a

more severe virus were to emerge?

Mr. ALLAN. Well, we were back in 2005 somewhere around $2.2

to $2.5 million in terms of our funding level for the county. That

involved both the city and the county. That allowed us to advance

our plans, I think substantially. We have seen cuts, which means

now we are losing people. That means the To Do list is still sitting

there. In fact, as people step away, the To Do list may get longer

for us to accomplish.

So from our end, we think a relatively modest investment nationally in public health relative to other national issues can go a long

way. If we look at a situation where we are going to be having to

vaccinate folks to a new virus, also dealing with seasonal flu vacVerDate 11-MAY-2000 10:40 Feb 18, 2010 Jkt 000000 PO 00000 Frm 00083 Fmt 6633 Sfmt 6633 U:\DOCS\54388.TXT KATIE PsN: KATIE
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cination, dealing with a potential escalation of severity in the fall,

that confluence of things right now we are not prepared to address.

Mr. KUCINICH. What about if there were an increase in incidents? Would you have the infrastructure at this moment to be

able to keep up with testing suspected carriers of a virus?

Mr. ALLAN. Well, that testing in Ohio specifically ties back into

some rapid detection work that is being done in the hospitals. Then

the activity all flows through the State health department. So it is

a question of capacity of the State health department. If we saw

a significant increase, I know that there were some early delays as

people were dealing with the volume. But it is a question of State

level capacity. We have one lab in Ohio and it all goes through Columbus.

Mr. KUCINICH. One lab?

Mr. ALLAN. One lab to handle this incident, yes.

Mr. KUCINICH. Do you have direct contact with the CDC?

Mr. ALLAN. Our contact occurs through the State health department.

Mr. KUCINICH. I think, Mr. Chairman, it would be interesting to

canvass the State health departments to see about their contact

with the CDC. Because if something is getting out of control in an

area, in a county as large as Cuyahoga, it seems to me that the

large counties, which in some cases are bigger than some States,

should have a quicker connection to CDC since we are talking

about the fact that a virus by its very nature can spread in any

direction at any time.

Did you want to say something, Dr. Birkhead?

Dr. BIRKHEAD. Yes. Let me just comment from New York State

and New York City’s point of view. We do have direct access to the

scientists at CDC. With the school situations going on and now

looking also at more hospitalized cases, we have been able to have

conference calls directly with the folks at CDC.

Mr. KUCINICH. You know, Mr. Chairman, I think one of the

things that we might want to do is to ask the CDC about these

large metropolitan areas. Instead of going through States, large

metropolitan areas should have the ability to contact the CDC directly. My time has run out, but I want to make sure metropolitan

areas will have the ability to respond appropriately to any threat

of a pandemic.

Chairman TOWNS. Thank you very much. Congressman Lynch.

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

this hearing along with the ranking member. I want to thank the

witnesses for their willingness to help the committee with its work.

Dr. Sosin, thank you for your service to our country. I appreciate

that.

We had a hearing here last week centrally dealing with the vulnerability of some of our employees. I happen to chair that subcommittee. Right now, we have a situation where we have a lot of

our folks on the borders—Customs and Border Patrol folks, ICE,

Transportation Security officers—and they are on our country’s

borders as well as at our major ports of entry. I would say on average many of these officers probably screen and some of them come

in direct physical contact with 3,000 passengers or travelers per

shift.

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Up until recently, even through this crisis, H1N1 pandemic, they

were instructed by their supervisors at the Department of Homeland Security and other agencies that they were not to wear masks.

They basically had these masks, not very threatening, but apparently the Department of Homeland Security felt that the public

might be overly alarmed if the border patrol officers and transit security officers wore something like this. These are N95 masks, just

for the record. They were told, as a matter of fact, to take off these

masks when a few of them took the initiative to protect themselves.

And this is where the CDC comes in.

The Department of Homeland Security said they were relying on

a determination by CDC that masks like this and repeated applications of Purell were medically unnecessary for our border security

folks and transportation security officers even though they are in

physical contact—they are wanding, checking passports, and coming into physical contact—on a regular basis with these folks.

Again, they use the term ‘‘medically unnecessary.’’ Meanwhile, we

have instructions from CDC saying folks should cover their

mouths, wash their hands, and avoid unnecessary travel to Mexico.

So now I have hundreds, actually thousands of border folks, security officers—and the Laredo facility is part of this, the busiest

checkpoint in our country—and even though we have that concern

out there, meanwhile our people, the U.S. transit security officers

and border patrol people, are looking across the Laredo checkpoint

and the Mexican folks on the other side, the Mexican security officers all have these masks on. But we are being told that it is medically unnecessary.

The World Health Organization has already taken it to a Level

V, which means a global pandemic is imminent. I just find it mystifying why we have the World Health Organization saying we are

at Level V going to Level VI on a global pandemic, we have schools

shutting down all over the place, and in the meantime we have

these officers who are actually screening 3,000 travelers a day. The

epicenter of this thing was in Mexico City. Infection counts in

Texas, California, and Arizona are off the charts. They are something like 400 percent of the national average.

And here we are not letting our folks wear these masks because

it might alarm the public. I am just wondering, where is the sense

of that policy?

Dr. SOSIN. Thank you, sir. This is challenging decisionmaking. It

is not strictly a science-based decision.

Mr. LYNCH. Apparently.

Dr. SOSIN. The specifics of the Department’s of Homeland Security decisions and the interactions with CDC are ongoing and

evolving. So that is one piece. The challenge here is establishing

level of risk versus level of response that is feasible and appropriate. Whether it is ever appropriate to forbid people to use protective equipment or not is an issue that I do not want to touch

on. But whether it should be required or recommended is the challenge that CDC has been trying to produce in its guidance.

Let me say that the crux of the CDC position, as reflected in the

National Institute for Occupational Safety and Health, which is a

part of CDC, is that when in doubt, we offer guidance which protects the worker. When in doubt whether influenza can spread

82

through airborne mechanisms and we have a severe situation, we

err on the side of protecting the worker. The challenge here—the

WHO phases are not severity based—and the challenge in this entire outbreak has been whether this is more severe than what we

see in seasonal flu and therefore whether we should take more extreme measures than we typically take in seasonal flu.

As you know, the Border Patrol or border agents do not wear

masks during flu season. So that question of, are they at risk of

more severe illness than they would be under comparable circumstances, has been the most challenging part of this. We continue to watch for evidence of severity, for evidence of uniqueness

and needs for protection. We continue to offer guidance which is at

minimum permissive of that type of protection and, when felt to be

appropriate, specific guidance to use.

All I can say is that this continues to be a discussion. I know

over the last 2 days decision briefs about health care workers,

which is another work force of great concern, and the use of respirators like those in 1995 continue to be worked through so that

we have practical, feasible, manageable guidance which also protects the worker.

Mr. LYNCH. OK. I appreciate your attempt to answer that question. I really do. And it is not your decision so I am not laying it

on you.

Mr. Chairman, could I ask Dr. Jarris to take a crack at that?

It seems that I have a Level V pandemic which, according to the

World Health Organization, is a strong signal that a pandemic is

imminent and that the time to finalize the organization, communication, and implementation of plan mitigation measures is very

short. OK, so I have the World Health Organization telling me this.

We have people sick all over the place. I would hate to be the

3,000th person that this security officer frisks and wands because

he is likely to be contaminated at this point and he is contaminating all the way down the line. This is Government bureaucracy at

its worst. We just need to move the ball forward here and inject

a little bit of common sense into the situation.

Dr. JARRIS. Congressman, I think your question is a very valid

one. It is an example of the types of things we have been wrestling

with for the last 3 weeks and why we have not gotten sleep in the

last 3 weeks. There are many, many examples of issues like this

where we, as Dr. Sosin said, because it started in North America

we did not have the 2-months to figure out how this transmitted

from one person to another. Was it aerosol? Was it a droplet? We

simply did not know that. We did not know how transmissible it

was. Was the border guard at risk or not at risk? What did it take

to actually transmit this? We did not know that. How severe was

it?

Initially, given what was going on in Mexico, we weren’t very

concerned. It looked as if it was not that severe. But we still do

not quite know that. So we were in a situation of trying to make

decisions in the face of tremendous uncertainty, always balancing

what is the prudent thing to do against what is the disruption to

society.

Two weeks ago I was in a committee in which we were being encouraged to close the border. In retrospect, I think we would have

83

said that probably was not the right thing to do. But there certainly were people feeling strongly that, well, why wouldn’t we do

that. So this is what we are struggling with.

This is an indication of why we now need to go back, given that

we have had these plans which have been obviously imperfect, and

we can give you many other examples of imperfect situations, and

dedicate the time and the resources this summer to figure out what

are we going to do in the fall if this comes back bigger, what are

we going to do in the fall if this comes back more serious, and we

need to be prepared. We need to address some of the issues of: How

do we look at CDC guidance, OSHA guidance, and NIOSH guidance, and which one actually applies in a given situation because

they may be different.

Mr. LYNCH. Right. I appreciate your remarks and I appreciate

the perspective that you provide. You do say, properly I think, that

we have to figure this out by the fall. I think everybody on the

panel has said we could have a situation in the fall. Meanwhile,

our Border Patrol people and transit security officers cannot use

masks. It seems rather silly to me. But we will see how that goes.

Mr. Chairman, I have abused my time and I want to yield at this

point. Thank you very much.

Chairman TOWNS. Thank you very much. Let me thank all of you

for your testimony. I appreciate your thoughts and insight, and I

appreciate the interest of all the Members who attended today.

Before we adjourn, I would like to emphasize the continuing need

for attention to be given to the issue of State and local pandemic

readiness. As we have seen in recent weeks, an outbreak can strike

at any time and potentially take a heavy toll. We must be prepared

in order to protect the lives of our citizens. We do not wait for a

house fire before we make sure that our fire department has fire

engines and water hoses. Likewise, we cannot wait for a pandemic

before we make sure our public health departments have trained

responders and a mechanism in place to provide vaccines and

treatments.

The question becomes one of the next steps. The House passed

funding for State and local pandemic preparedness in the fiscal

year 2009 Supplemental Appropriation Act just last week. Congresswoman Tammy Baldwin has recently introduced a bill, House

of Representatives 805, of which I am a proud cosponsor. This bill,

Strengthening of America’s Public Health System, would provide

Federal support for improving public health agencies’ infectious

disease surveillance and reporting.

What kind of sustained support can the Federal Government provide given today’s harsh economic circumstances? How can States,

localities, the Federal Government, and other entities leverage the

resources that we already have in order to increase our public response capabilities?

Please, please let the record demonstrate my submission of a

binder with documents relating to this hearing. Without objection,

I enter this binder into the committee record.

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The record will remain open for 5 days for any additional comments. Thank you very much.

Without objection, the committee stands adjourned.

[Whereupon, at 4:30 p.m., the committee was adjourned.]

[Additional information submitted for the hearing record follows:]

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