[Senate Hearing 110-465]
[From the U.S. Government Publishing Office]
S. Hrg. 110-465
PANDEMIC INFLUENZA: STATE AND LOCAL EFFORTS TO PREPARE
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HEARING
before the
AD HOC SUBCOMMITTEE ON STATE, LOCAL,
AND PRIVATE SECTOR PREPAREDNESS
AND INTEGRATION
of the
COMMITTEE ON
HOMELAND SECURITY AND
GOVERNMENTAL AFFAIRS
UNITED STATES SENATE
ONE HUNDRED TENTH CONGRESS
FIRST SESSION
__________
OCTOBER 3, 2007
__________
Available via http://www.gpoaccess.gov/congress/index.html
Printed for the use of the Committee on Homeland Security
and Governmental Affairs
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COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS
JOSEPH I. LIEBERMAN, Connecticut, Chairman
CARL LEVIN, Michigan SUSAN M. COLLINS, Maine
DANIEL K. AKAKA, Hawaii TED STEVENS, Alaska
THOMAS R. CARPER, Delaware GEORGE V. VOINOVICH, Ohio
MARK L. PRYOR, Arkansas NORM COLEMAN, Minnesota
MARY L. LANDRIEU, Louisiana TOM COBURN, Oklahoma
BARACK OBAMA, Illinois PETE V. DOMENICI, New Mexico
CLAIRE McCASKILL, Missouri JOHN WARNER, Virginia
JON TESTER, Montana JOHN E. SUNUNU, New Hampshire
Michael L. Alexander, Staff Director
Brandon L. Milhorn, Minority Staff Director and Chief Counsel
Trina Driessnack Tyrer, Chief Clerk
AD HOC SUBCOMMITTEE ON STATE, LOCAL, AND PRIVATE SECTOR PREPAREDNESS
AND INTEGRATION
MARK L. PRYOR, Arkansas, Chairman
DANIEL K. AKAKA, Hawaii JOHN E. SUNUNU, New Hampshire
MARY L. LANDRIEU, Louisiana GEORGE V. VOINOVICH, Ohio
BARACK OBAMA, Illinois NORM COLEMAN, Minnesota
CLAIRE McCASKILL, Missouri PETE V. DOMENICI, New Mexico
JON TESTER, Montana JOHN WARNER, Virginia
Kristin Sharp, Staff Director
Michael McBride, Minority Staff Director
Amanda Fox, Chief Clerk
C O N T E N T S
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Opening statements:
Page
Senator Pryor................................................ 1
Senator Akaka................................................ 10
Senator Sununu............................................... 15
Prepared statement:
Senator Obama................................................ 33
WITNESSES
Wednesday, October 3, 2007
Rear Admiral William C. Vanderwagen, M.D., Assistant Secretary
for Preparedness and Response, U.S. Department of Health and
Human Services................................................. 3
B. Tilman Jolly, M.D., Associate Chief Medical Officer for
Medical Readiness, Office of Health Affairs, U.S. Department of
Homeland Security.............................................. 4
Paul K. Halverson, DrPH, MHSA, FACHE, Director and State Health
Officer, Arkansas Department of Health......................... 16
Christopher M. Pope, Director, Homeland Security and Emergency
Management, State of New Hampshire............................. 18
Yvonne S. Madlock, MAT, Director, Memphis and Shelby County
Health Department, Memphis, Tennessee, on behalf of the
National Association for County and City Health Officials...... 20
Alphabetical List of Witnesses
Halverson, Paul K., DrPH, MHSA, FACHE:
Testimony.................................................... 16
Prepared statement........................................... 56
Jolly, B. Tilman, M.D.:
Testimony.................................................... 4
Prepared statement........................................... 49
Madlock, Yvonne S., MAT:
Testimony.................................................... 20
Prepared statement........................................... 75
Pope, Christopher M.:
Testimony.................................................... 18
Prepared statement........................................... 66
Vanderwagen, Rear Admiral William C., M.D.:
Testimony.................................................... 3
Prepared statement........................................... 34
APPENDIX
Questions and responses for the Record from Dr. Jolly............ 84
Chart submitted for the Record by Senator Pryor.................. 90
PANDEMIC INFLUENZA: STATE AND LOCAL EFFORTS TO PREPARE
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WEDNESDAY, OCTOBER 3, 2007
U.S. Senate,
Ad Hoc Subcommittee on State, Local, and
Private Sector Preparedness and Integration,
of the Committee on Homeland Security
and Governmental Affairs,
Washington, DC.
The Subcommittee met, pursuant to notice, at 2:35 p.m., in
Room SD-342, Dirksen Senate Office Building, Hon. David Pryor,
Chairman of the Subcommittee, presiding.
Present: Senators Pryor, Akaka, and Sununu.
OPENING STATEMENT OF SENATOR PRYOR
Senator Pryor. I call the Subcommittee to order. Senator
Sununu is on his way, but he wanted us to go ahead and get
started, so he will join us and probably have some questions in
a few moments.
Let me thank everyone for being here and welcome everyone
to the Senate and specifically to our Ad Hoc Subcommittee on
State, Local, and Private Sector Preparedness and Integration.
I know everybody is busy, has a lot going on, but to come and
talk about something as important as a flu pandemic, I think it
is a very important part of the process to make sure that we
are prepared. We hope that day never comes, but we hope that
this country is prepared if that day should come.
I would especially like to welcome Dr. Paul Halverson.
Thank you for coming up from Arkansas and I look forward to
hearing from you in the second panel.
Let me just make a few opening comments and then I would
like to jump right in with our first panel. The first thing I
would say is that for most Americans, the idea of a flu
pandemic is abstract. When we hear about it on the news, it
seems to be pretty much in birds and on the other side of the
world. I think for a lot of people in this country, even though
they know it is a potential threat, it is not real, and I think
we, as leaders and as planners, need to make sure that we are
ready in the event that it does come.
The thing that concerns the experts about a flu pandemic is
when you look at bird flu around the world, the numbers are
startling. How rapidly it spreads through an avian population
is very alarming, but also when you look at the humans who have
been infected--there have been 329 infected with bird flu and
201 have passed away. So 61 percent of the people that have had
it have died from it. Those are very alarming numbers.
You can see this chart here with the confirmed cases by age
and outcome and you see some very disturbing numbers there
because it is not one of those diseases that hits young people
and old people.\1\ If you get it, you have a very real chance
of not surviving contact with bird flu.
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\1\ The chart referred to appears in the Appendix on page 90.
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So the concern would be is if you have a flu with these
characteristics and it mutates into a contagious human disease,
the consequences could be very dire. I don't want to talk like
a science fiction movie here, but some of the scenarios that
people have talked about really cause great concern. The number
of Americans who could not survive this, what it could do in
terms of overwhelming our health care infrastructure, the
restrictions on travel, maybe having to institute some sort of
quarantine or martial law, there are a lot of ramifications of
this that we need to think through and be prepared for in the
event that it does come.
The other thing that we see is that a flu pandemic is
problematic for the government because there are so many
different levels of the government that have to deal with it.
Just on the Federal level, you look at DHS, HHS, Homeland
Security, and other agencies, but it is also a State and local
issue, as well. Health officials are involved, as are first
responders. It is a lot of local officials that have to make
very critical decisions in a short period of time.
That is why we keep coming back to planning and being able
to test our planning. Today, Senator Sununu and I wanted to
encourage dialogue and make sure that everybody is planning
like they should be, and we are working through this in
preparation for that day, if it ever comes.
With that, let me go ahead and introduce our first panel.
Again, Senator Sununu may have an opening statement in a few
moments. We will have probably one or more Senators in addition
to Senator Sununu that come in throughout the course of this
hearing. We have votes and a lot of other committee hearings
going on right now, so it is a pretty hectic day in the Senate.
But let me go ahead and introduce our first panel. First we
have Rear Admiral William Vanderwagen, who serves as Assistant
Secretary for Preparedness and Response at the U.S. Department
of Health and Human Services. His office is charged with
leading the Nation in the prevention, response, and reduction
of adverse health effects of public health disasters. He is the
Department's senior advisor to the Secretary for matters
relating to bioterrorism and public health emergencies and he
will be discussing the progress his office has made as well as
efforts they are making in coordinating public health
preparedness across all levels of government.
Our second panelist will be Dr. Tilman Jolly. He is the
Associate Chief Medical Officer of the Office of Health Affairs
at the Department of Homeland Security. Dr. Jolly brings an
extensive background in emergency medicine and medical
operations, planning, and consulting. In addition to practicing
emergency medicine and serving on the medical planning staff of
events, including five Super Bowls and the U.S. Open Golf
Championship, he has spoken and published extensively on these
subjects. Today, he will report on the progress of the DHS
Office of Health Affairs in coordinating with relevant DHS
Departments as well as other Federal, State, and local
agencies.
Admiral Vanderwagen, would you like to go ahead and start,
please.
TESTIMONY OF REAR ADMIRAL WILLIAM C. VANDERWAGEN, M.D.,\1\
ASSISTANT SECRETARY FOR PREPAREDNESS AND RESPONSE, U.S.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Admiral Vanderwagen. Thank you, Mr. Chairman, and it is a
real pleasure to be here. I think you spoke to partnerships and
I think there is a partnership between the Legislative and the
Executive Branch that has to be strengthened and built upon.
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\1\ The prepared statement of Admiral Vanderwagen appears in the
Appendix on page 34.
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Let me submit my written testimony for the record and I
will speak for a few minutes and summarize.
As you noted, the Assistant Secretary for Preparedness and
Response is the responsible party for Health and Human Services
(HHS) in coordinating medical and public health responses. It
was established about 10 months ago, December 19, 2006, with
the signing of a law, the Pandemic and All Hazards Preparedness
Act, that transferred many authorities to our responsibility,
including NDMS, the hospital preparedness programs, enrollment
of volunteers, and so on, various authorities related to the
Medical Reserve Corps, partnerships with the Centers for
Disease Control (CDC), etc., and many new authorities related
to the development of medical countermeasures, and that would
include such things as vaccines, anti-virals, diagnostics, etc.
And in August, we assumed leadership in our office for pandemic
flu for HHS.
As you noted, pandemic flu really could be quite a
catastrophic event and it will affect all sectors of our
society, and it involves planning and interoperability between
a wide variety of many sectors in this country. Public safety,
energy, transportation, commerce, labor, all have a role in
addressing the issues and preparing for a pandemic flu.
About a year and a half ago, Congress and the Executive
Branch did lay out a plan for how we would try and address
issues with pandemic flu--a strategy. That strategy was based
on a theory of victory that was not with the expectation that
we could absolutely stop dead in its tracks this disease, but,
in fact, we could delay its emergence and we could reduce the
number of people who became ill with this disease. And the
critical elements of that strategy was the development of
vaccine capability, anti-virals for treatment, and recall at
that time production capability for anti-virals was relatively
small. In addition to that, there were commitments to community
mitigation strategies and the development of surge
capabilities, including additional facility space and people
with skills who could be employed in addressing this illness as
it hits in many communities around the Nation.
We have made pretty good progress, and I think we will hear
from some of our State and local colleagues today about the
progress they have been making. I would report to you, sir,
that I made numerous visits to States. I was in North Carolina
last week and in North Carolina last year, they did 87
exercises involving about 7,000 people in preparing for a
pandemic flu. So there is a great deal of activity that is
going on at the community level where it really needs to be,
particularly in a pandemic flu.
This really highlights, as you suggested, the shared
responsibility that prevails, particularly as we look forward
to future steps. Early in this course, the last year or two,
the Federal Government and State Governments have been the lead
players. Vaccine infrastructure development, anti-viral
infrastructure development, expanded bed capacity, initial
planning and training, these were all roles for the Federal and
State Governments. The next steps will have to build on the
successes, including anti-viral prophylaxis, but this will
require wider application of shared responsibilities among
businesses, the health care industry, individuals, and
families.
There are new developments that need to be taken advantage
of. We need a cheaper, less labor-intensive ventilator for the
kind of respiratory support we may need. We need additional
guidance--and we are working on these issues--additional
guidance is needed for augmentation of community mitigation
strategies using respiratory protection, such as M-95
respirators. The science doesn't give us a clear answer on many
of these issues, but we will have to find solutions to these
gaps and we will have to find them in concert with our State,
local, business, and individual colleagues.
In summary, our office is functional. The Pandemic and All
Hazards Preparedness Act is being implemented. Pan flu
preparedness has moved along pretty smartly and we have made
pretty good progress, not only in pan flu, but on a variety of
hazards. Gaps still exist and additional steps will and must be
taken, but they must be done in the context of shared
responsibility. We will continue to consult with our State,
local, business, and private sector partners as we develop
actions to address this next set of gaps. Without that
consultation, we will not have an effective plan and a
comprehensive capability to respond when the Nation needs us.
I thank you for the opportunity to be here today.
Senator Pryor. Thank you. Dr. Jolly.
TESTIMONY OF B. TILMAN JOLLY, M.D.,\1\ ASSOCIATE CHIEF MEDICAL
OFFICER FOR MEDICAL READINESS, OFFICE OF HEALTH AFFAIRS, U.S.
DEPARTMENT OF HOMELAND SECURITY
Dr. Jolly. Mr. Chairman, thank you for the opportunity to
testify before the Subcommittee today to discuss our efforts
toward overall pandemic flu preparedness. Before I begin, I
would like to take the opportunity to thank you and the Members
of the full Committee on behalf of Secretary Chertoff for your
continued willingness to work alongside the Department to
provide leadership in protecting and ensuring the security of
our homeland. I would also like to thank our partners at HHS
and others with whom we work every day.
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\1\ The prepared statement of Dr. Jolly appears in the Appendix on
page 49.
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A pandemic is unique. It is likely to come in waves,
passing through communities of all sizes across the Nation and
the world simultaneously. But then it may last as long as 18
months. An unmitigated pandemic--and I emphasize unmitigated--
could result in 200,000 to two million deaths in the United
States, depending on its severity. Further, an influenza
pandemic could have major impacts on society and the economy,
including our Nation's critical infrastructure and key
resources, as you have said, based on the illness and related
absenteeism.
DHS has been and remains actively engaged with its Federal,
State, local, territorial, tribal, and private sector partners
alongside HHS to prepare our Nation and the international
community for an influenza pandemic. As outlined in the
implementation plan, DHS is responsible for the coordination of
the overall domestic Federal response during an influenza
pandemic, including implementing policies that facilitate
compliance with recommended social distancing measures,
developing a common operating fixture for all Federal
departments and agencies, and ensuring the integrity of the
Nation's infrastructure, domestic security, and entry and exit
screening for influenza at our borders.
In working with our partners, such as HHS, the State
Department, and USDA, DHS has developed and implemented a
number of initiatives and outreach to support continuity of
operations, planning for all levels of government and private
sector entities. I will highlight a few noteworthy
accomplishments and responsibilities under the implementation
plan particular to DHS.
DHS produced and released the ``Pandemic Influenza
Preparedness, Response, and Recovery Guide for Critical
Infrastructure and Key Resources.'' The Guide has served to
support business and other private sector pandemic planning by
complementing and enhancing but not replacing their existing
continuity planning efforts. With that in mind, DHS and its
partners developed the guide to assist businesses whose
existing continuity plans generally do not include strategies
to protect human health during emergencies like a pandemic. As
a next step, DHS is currently leading the development of
specific guides for each of the 17 critical infrastructure and
key resource sectors using the security partnership model.
In coordination with other Federal departments and
agencies, DHS is developing a coordinated government-wide
planning forum. An initial analysis of the response
requirements for Federal support has been completed. From this
analysis, the national plan defining the Federal concept for
coordinating response and recovery operations during a pandemic
has been developed and will be undergoing interagency review.
Utilizing this planning process, a coordinated Federal border
management plan has been developed and is currently also under
review. This process included a wide range of partners.
DHS has also conducted or participated in Federal and State
interagency pandemic influenza exercises and held workshops and
forums with critical infrastructure key resources owners and
operators. Consistent with this role under Homeland Security
Presidential Directive 5 (HSPD-5), as it is known, Secretary
Chertoff pre-designated Vice Admiral Vivien Crea, Vice
Commandant of the Coast Guard, as the National Principal
Federal Official (PFO), for pandemic influenza and has pre-
designated five regional PFOs and 10 deputy PFOs. Likewise, our
partners have pre-designated infrastructure liaisons, Federal
coordinating officers, senior officials for health, as well as
defense coordinating officers. Vice Admiral Crea and the
regional PFOs have participated in multi-agency training and
orientation sessions regarding preparedness duties.
Additionally, the PFO teams have begun outreach both nationally
and in their regions in advance of a more formalized exercise
program which is being developed at DHS.
On an ongoing basis, DHS participates in interagency
working groups to develop guidance, including community
mitigation strategies, medical countermeasures, vaccine
prioritization, and risk communication strategies.
In closing, significant progress has been made in national
preparedness for pandemic influenza. DHS looks forward to
continuing its partnership with the Federal interagency, State,
local, tribal, territorial, and private sector stakeholders to
complete the work of pandemic preparedness and to further the
Nation's ability to prepare for, respond to, and recover from
all hazards.
Thank you again for the opportunity to testify today on
behalf of the Department of Homeland Security and I would be
happy to answer any questions you might have.
Senator Pryor. Thank you, and I appreciate again both of
you being here and your testimony. We will submit your written
testimony for the record.
Let me ask just on the front end about roles and
responsibilities, basically who is in charge, and I guess the
way I would--did you say that he is in charge? Is that what you
are saying? [Laughter.]
That is like the old ``Far Side'' cartoon. But I guess what
I might do is ask this of both of you, and if one wants to
answer or one wants to add something to the other, that would
be great.
There was a study done, an evaluation done by GAO not too
long ago, of the Homeland Security Council's National Strategic
and Pandemic Influenza Plan. Basically, it says that
responsibilities in a crisis are split between HHS and DHS with
HHS taking responsibility for health issues and DHS directing
in ``emergency situations.'' But since a pan flu crisis is both
by definition, do you all feel comfortable that the two
departments have worked it out in terms of that happens if a
decision is made that we have a flu pandemic coming? Who wants
to take that?
Dr. Jolly. I will begin. I believe we both do feel
comfortable and all of our teams feel comfortable. Pandemic
influenza is unique, but in fact, every crisis has health
implications and HHS has an important role to play in public
health and medical response to almost any crisis you can name.
Under Homeland Security Presidential Directive 5 and under
other authorities, the Secretary of Homeland Security is
responsible for the overall incident coordination, and that is
well accepted throughout the government, and the Secretary of
Health and Human Services is responsible for the specific
public health and medical responsibility, which is quite large
in this situation.
Senator Pryor. Do you want to add anything to that?
Admiral Vanderwagen. No, I would just affirm what he said.
There are 15 useful emergency support functions. Health is one
of them. In this case, it has a big role. I think the health
messaging and the health interventions and so on are our
responsibility, but it is under the overarching direction of
DHS.
Senator Pryor. This same report I referred to a few moments
ago talked about how there only has been one national multi-
jurisdictional exercise as kind of a run through on our
response, and as I understand it, I guess that was done before
there was a National Response Plan. Do we have plans for
further national or multi-jurisdictional exercises that would
coordinate all the various levels and people that have to be
coordinated?
Dr. Jolly. We certainly do have plans for those and that
report does discuss that exercise initially done. Since then,
there have been a number of exercises at the State and local
level and those are quite important to exercise those roles,
and we do have ongoing plans in the coming months for exercises
of our Principal Federal Official structure and the interagency
structure and then the national structure. It is a complex set
of exercises. I don't think that one exercise of the structure
would do it, but a complex set, and yes, we will be advancing
with those and HHS has also had exercises to inform that
process.
Senator Pryor. What is your time frame on doing those? Are
you doing those now?
Dr. Jolly. We are beginning the planning of those now. We
have been working through--as I said in my testimony, one of
the important things to develop those exercises is to develop
strategic and then operational plans that you would then
exercise rather than just designing the exercises off a
scenario. And so those are being completed now and we hope that
in the coming months--I don't have a specific date scheduled
that I can announce, but we hope that in the coming months, we
will start that process and build to an exercise that goes from
the cabinet level down.
Senator Pryor. OK. Let me also ask about something that is
part of the nature of a pandemic flu epidemic. Generally when
there is a national disaster or regional disaster, the Stafford
Act gets triggered and States help neighboring States and there
is often a regional approach. But I can see in a flu epidemic
or pandemic where governors, for example, might be reluctant to
send his or her people to a nearby State to help because they
may be next, and plus they may be spreading the virus back and
forth across State lines. So to me, that seems to be something
that is--I don't know if I would say unique, but certainly a
characteristic of a pandemic--a flu pandemic. How do you adjust
your overall planning for that contingency, that this just
behaves differently than most national disasters?
Admiral Vanderwagen. Well, let me speak to the health
segment of that, and you may recall that Secretary Leavitt back
in 2005 started--he went to every State for a summit on pan flu
and his message was pretty much the same, and that is you need
to be prepared to take care of yourself because the very
circumstance you just described is highly likely.
So I think in our work with the States and localities, the
notion here is how much capacity can we build locally and
within a State in order to fill as many gaps as we can
internally, not relying on the EMAC or the Federal system as a
means to fill gaps. Very difficult, particularly if we are
talking about facilities and personnel which will be in short
supply in just about every location. But it is the best way we
can plan, and that is try and build from the base of making the
localities as self-sufficient as you can in the event.
Senator Pryor. And do you feel like we are making progress
along those lines?
Admiral Vanderwagen. Yes. What are some objective measures?
The Medical Reserve Corps, which is a way of organizing
community-based volunteers into identifiable teams, has
expanded up to over 650 units and 120,000 individuals, and that
is just one approach to organizing volunteers. States have
local programs, as well. We are seeing a real increase in pre-
identified volunteers with skill sets needed to fulfill roles
that the States and localities have identified as being in need
during an event like this.
Senator Pryor. Let us stay with that general line of
questioning--how a flu pandemic behaves and how it unfolds
across the country. In this chart here,\1\ the one with the
black background, that is a scenario that the Los Alamos
National Lab came up with where 10 avian flu individuals get
off the plane at LAX, Los Angeles, and then you can see the
sequence of how it spreads across the country and runs its
course through the country. Do you all generally agree that is
a realistic model? Does that model ring true to you, or is that
fair?
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\1\ The chart referred to appears in the Appendix on page 90.
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Dr. Jolly. I think it probably is fair. There are a lot of
modelers who have done a lot of models based on where the first
case is or where first clusters are and how it spreads,
depending on the disease characteristics and travel
characteristics and behavioral characteristics. I think that is
a reasonable assumption of one possibility of a model and how a
disease might spread that is largely based on history from 1918
and the other couple of pandemics of the last century.
Admiral Vanderwagen. Let me add one other comment to that.
Senator Pryor. Yes, go ahead.
Admiral Vanderwagen. I think that is an unmitigated or
unintervened-upon event that we see unfolding there, and again,
the modelers, given this as the base, what can we do to
intervene, the community mitigation strategies that were
employed, for instance, by St. Louis in 1918----
Senator Pryor. Where they basically quarantine the city and
more or less quarantine----
Admiral Vanderwagen. Respiratory protection and slow down,
get social distancing, and so on, they were able to reduce by
50 percent the number of cases and the mortality associated
with it, and so the community mitigation strategies using
fairly simple community social distancing practices, could give
us--some people in the modeling world say as high as 70
percent. We operate on a more conservative notion that it will
reduce it 50 percent, and that is without adding anti-viral
prophylaxis and without really having a vaccine in play.
Senator Pryor. OK. So you are saying that HHS, DHS, State,
and local people might take some steps to make sure that we
don't see the rapid spread across the country?
Admiral Vanderwagen. Yes. That is the planning that most
communities are doing, and in fact, now we are looking to
invest in new vaccines, and we should make that investment here
in the next month or two, that may reduce the production time
from 20 weeks, which is the current production time for a
vaccine, down to 8 weeks. So there are a number of strategies
that technologies will allow us to bring into play so that we
can put more tools in the hands of communities. If they use
just the community mitigation without these other
interventions, they will get a certain reduction. And as we are
able to give them more tools, like faster turnaround on vaccine
production, anti-virals for prophylaxis, we may be able to
reduce the rate of this spread even more significantly.
Senator Pryor. And let me ask this quickly about vaccines.
I want to leave plenty of time for Senator Akaka to ask
questions. But in terms of the vaccine, as I understand it,
medically and scientifically, you need samples of the real
strain, and so once you get those samples, then it is just
going to take you some time in order to develop enough vaccine
to get it out to the public. Is that right?
Admiral Vanderwagen. Yes. In the stockpile, we have a
significant number of doses of pre-pandemic vaccine based on
the current H5N1s that have been present in Asia. But you are
absolutely right. If that is not the particular strain, we will
have to produce a different vaccine and production time right
now is about 20 weeks from identification of the specific virus
to the time that you are in full production of a vaccine.
There are other things on the horizon that make this a very
positive picture, and that is testing that currently shows that
with adjuvants, that is things that augment the ability of the
vaccine to increase your immune response, we may have 20-fold
the amount of vaccine that we currently have in the stockpile
by adding adjuvants to the existing vaccines, which would give
us enough probably to cover everybody in the country if it was
an H5N1 as we have developed the vaccine for at this point.
There are lots of technological activities that in the next
year or two give us much hope that we can intervene and slow
this thing down very dramatically.
Senator Pryor. Let me ask one more question before I turn
it over to Senator Akaka, and that is in terms of our health
care infrastructure, when I see a map like that, I look at the
Los Angeles area. To me, it seems the Los Angeles area medical
infrastructure could be totally overwhelmed, whereas in other
parts of the country, they are not feeling any stress from this
at all. Is that part of our planning, to figure out how to
allocate those resources nationally? Do you just have some
concrete limitations on the number of hospital beds available?
I guess part of the planning, I hope, would be figuring out
other arrangements to take care of people outside of a hospital
context, but also to bring in more medical professionals into
that area. How is the planning going there? What are the
recommendations there?
Admiral Vanderwagen. I think that States using the Hospital
Preparedness Grants and their own funds--States have been
increasing their fiscal commitment to these activities as much
as the Federal Government have--are investing in expanded bed
capacity in the form of stand-up portable hospitals so that
they have that mobility for a variety of events, but they can
certainly use them within a pan flu environment. The limiting
step in many of these things is going to be the number of
people who are ill or not ill and are available in the
community. If you have a 40 percent absentee rate, for
instance, in health care workers, it is going to be tough for
them to provide the care. That is where the volunteer workforce
is being pre-identified.
Yes, where we see the cases coming early in the
environment, and this is where many of these exercises are
targeted, we are seeing it emerge in Location X. What can we
bring to that particular fight? That is a high priority. Once
it goes to a half-dozen or so communities, then we would
probably back off with some of that extra push because then we
are going to be looking at a broader-based problem. If we can
slow it down in L.A., better for us. But if it is in 20 cities,
well, it is already on the spread. Then we need to go to Plan
B, which is the local capacity plan.
Dr. Jolly. And I would add the key in this is really up
front trying to reduce the burden on the health care system.
The health care system is under stress now and would be under
more stress, and the more we can employ community mitigation
strategies broadly across the community very early, and the
modeling shows that the key is doing it early when you can
really make a difference to really reduce the load and spread
out the load on the health care system to improve everyone's
outcome.
Senator Pryor. Does that also include the economic load?
Have you thought about these hospitals, because they are going
to treat people and if they are totally overwhelmed, and given
the percentage of uninsured, etc., just special circumstances,
is this going to financially, not ruin, but greatly burden our
health care system?
Dr. Jolly. I think there are a number of potential effects,
economic being one, and supplies and others that are all part
of the mix and they are part of the modeling and part of the
exercises.
Admiral Vanderwagen. And this goes to how we work in sync.
What Secretary Leavitt can do is declare a public health
emergency behind Secretary Chertoff's leadership on the
Incident of National Significance. If we declare a public
health emergency, that sets in effect many waivers. That gives
the hospitals many opportunities to take care of people and be
reimbursed in ways they might not otherwise be reimbursed.
Second, hospitals that are part of the National Disaster
Management System in disasters, if they are taking additional
patient burdens, can get paid at about 115 percent of the
existing Medicare rate. So that helps to over-compensate. And
then there are always supplemental requests. In Hurricane
Katrina, for instance, we had some additional funds identified
to support the facilities in Louisiana and Mississippi that
were under dire economic stress.
Senator Pryor. Senator Akaka.
OPENING STATEMENT OF SENATOR AKAKA
Senator Akaka. Thank you very much, Mr. Chairman. I am glad
to be here with you and with our witnesses. You know that I
share your concerns about the possibility of pandemic influenza
outbreak not only in our country but around the world, and also
because of the prediction that was made by WHO in 2004 about
the concern about A H5N1 outbreak and how deadly it would be
and what a disaster that would be.
So I was glad to note that last month, the Department of
Homeland Security conducted a National Preparedness Month
campaign and 1,700 State and local-level organizations
participated in that, and this week, Senator Pryor and I have
had respective hearings in our Subcommittees on pandemic flu.
So I am glad that we are giving it that kind of focus.
Admiral it is good to see you.
Admiral Vanderwagen. [In Hawaiian.]
Senator Akaka. Aloha. According to the CDC, Admiral, among
the three flu strains it is preparing for in the 2007 and 2008
season, one is type AH3N2. This strain is linked to the 1968
Hong Kong pandemic flu, noted as the deadliest flu in the past
30 years, which killed two million people worldwide. What is
the outlook for this upcoming season, and are we prepared for
this type of influenza?
Admiral Vanderwagen. Well, as you know, vaccines are
produced, or they have to begin production about 6 months
before the season actually arrives, and so the folks who are
prognosticating these things, looking at the epidemiology, try
and pick those virus strains that are most likely to appear.
Sometimes you don't get absolutely the right one. One of the
things that we are seeing in the Southern Hemisphere right now
is a virus that we may not have full protection from. We think
that the influenza viruses that we have will provide pretty
good coverage for it, but we are seeing in the Southern
Hemisphere a pretty tough influenza season.
As you know, in a routine year, 36,000 people die in the
United States from this seasonal influenza. So while we worry
about pandemics, seasonal influenza is not a white event,
either.
Dr. Jolly. If I could, I would add that some years are more
closely matched than others, as a physician, in the influenza
vaccine, but I think our major issue is to really get the word
out and get people vaccinated who need to be vaccinated and
have them--I believe we have 130 million doses available for
this coming year, so our supply is good and our challenge is to
get the public vaccinated early and aggressively.
Senator Akaka. There is a big concern about whether we will
be able to have the vaccine. Is there any concern that as avian
flu attacks chickens and eggs, and I understand that the eggs
play a part in this vaccine or are used to produce this
vaccine, that these may be problems producing enough vaccine?
Is that true?
Admiral Vanderwagen. Well, as you know, sir, we received in
the supplemental about $5.6 billion. We have invested about
$3.2 billion of that already and much of that has gone into
helping companies convert from egg-based to cell-based
technologies. I think we have five or so manufacturers now that
are converting over to cell-based production capability, and
that would be useful both for seasonal flu, but also in a
pandemic event. That is one of the major investments. Our next
investment, we are trying to target a recombinant vaccine that
will shorten the production time by half, at least it appears
that it will do that based on European studies. So we are
trying to get around this egg-based older approach to vaccine
production.
Dr. Jolly. I would add that our poultry industry has taken
great strides toward biosecurity in general and this subset of
the industry that produces these eggs is a very secure subset
and that is a key part of keeping that supply open.
Senator Akaka. Admiral and Dr. Jolly, HHS and DHS are the
Federal leaders in pandemic emergency response, but GAO
recently testified that their respective roles haven't been
clarified. Have HHS and DHS communicated to the State and local
jurisdictions around the country the roles and responsibilities
of each agency?
Dr. Jolly. As we have stated in the prior hearing, I think,
when GAO was there and also in our statements, there is a
fairly clear--a very clear delineation of roles of HHS as the
manager of the overall incident, and that is being manifested
in all of our interactions with the States and also through the
work of our Principal Federal Official group and their support
group as they move throughout the States and regions. That
leaves HHS with a large role of managing emergency support
function, the public health and medical.
Senator Akaka. Admiral, do you want to comment?
Admiral Vanderwagen. I fully agree. I think we have worked
very closely with Admiral Crea as she has tried to develop the
DHS overarching response capability and we nestle into that
with our health piece. But she has got a broader
responsibility--public safety, transportation, energy, etc.
Our's is the health link.
Senator Akaka. Admiral, you mentioned that the current flu
vaccine may not give us sufficient protection this season. If
this is the case, have you made any new predictions about the
number of possible fatalities this season?
Admiral Vanderwagen. I don't have any epidemiologic
projections of any change in our seasonal usual. We have seen
some different behavior, some increased infectivity in the
Southern Hemisphere and we will just kind of have to see how
that projects into our population.
Senator Akaka. Admiral, HHS has responsibility for
overseeing and administering the Strategic National Stockpile
of anti-viral drugs and vaccines. Congress appropriated $6.1
billion over 3 years for HHS to work with States on building a
stockpile of Tamiflu, Relenza, and available vaccines. Can you
give us a status update of the stockpile for Hawaii?
Admiral Vanderwagen. [In Hawaiian.] I couldn't answer
specifically with Hawaii. I can get that for the record for
you, sir. I didn't do my full homework, I guess.
I think that where we are--you may recall that the
acquisition of anti-virals, the strategy was to purchase enough
anti-virals, and at the time that the strategy was marked out
they were only producing 15 million regimens a year, so the
notion was, let us buy enough to treat the percentage of people
we think may get infected, not prophylaxis, treatment. We have
purchased on plan in 2007 about 37 million treatment courses
and the States have purchased about 15 million. We were on plan
to purchase the balance up to a total of 81 million treatment
courses by the end of 2008, and we are on plan to get that
done. I think we are making good progress.
Our other investments, as I spoke to you, are about
increasing our vaccine production capability, looking for
alternatives to the existing anti-virals so that if we develop
resistance, we have another drug to work with, diagnostics so
that we can determine is it just seasonal flu or is it an avian
flu. Those investments have gone a long way to building an
infrastructural base that gives us more options in the future.
Senator Akaka. Thank you so much for your responses.
Senator Pryor. Thank you, Senator Akaka. We appreciate your
time on this.
Let me follow up, if I may, with you, Admiral, about
something we got into just a few minutes ago and that is the
vaccine. I would like your comments on the World Health
Organization report that says that worldwide production
capability for pandemic flu vaccine would be 1.2 million doses
total. I am wondering if that is consistent with your
understanding or if you think that there is more worldwide
capacity than that.
Admiral Vanderwagen. I think there is much more capacity
than that. We have taken delivery this year alone into the
stockpile something on the order of magnitude of about 15
million doses of vaccine. So just for our purchases alone, we
are purchasing a lot more than that.
Senator Pryor. I was going to ask you that, because you
mentioned the stockpile a few moments ago and I think you
mentioned that you had some stockpile of the flu that you have
seen mostly in Asia that you are already stockpiling. Tell me
about our stockpiles. What is the shelf life of the vaccine?
How long can we stockpile them before we have to replenish? If
you don't mind, give us the status of our stockpile.
Admiral Vanderwagen. Sure. With regards to vaccines, and
now I am talking about a pre-pandemic vaccine, H5N1----
Senator Pryor. Right.
Admiral Vanderwagen [continuing.] There are two or three
different varieties of that that have been identified in South
Asia, Indonesia and Vietnam. We have about 26 million doses. By
the end of this calendar year, we will have 26 million doses of
vaccine based on those viruses. They have about a 3-year shelf
life to them. It is just biologicals. They only last for a
fixed period of time, which leads to the question about
sustainability that I think, over time, this is going to be the
issue that we are all going to have to confront, State, local,
Federal, is how will we sustain some of these investments that
we have made when they run out of shelf life or the equipment
becomes obsolete, etc.
I have mentioned to you the 37.5 million doses of anti-
virals that we have. We will purchase another 13 million or so
up to 50 million on the Federal side. The States have 15
million. They will purchase another 3 to 4 million to meet that
treatment goal. Right now, we are entertaining, with the
production capability that the anti-viral manufacturers have
for Relenza and Tamiflu, should we consider the use of these in
a prophylactic way, that is for people who are in high-risk
work environments--hospital workers. We know from seasonal flu
that 15 to 30 percent of health care workers in hospitals that
have influenza load will get sick.
Should we be using anti-virals for prophylaxis for those
kind of folks, people who are home taking care of somebody with
pan flu? Should we recommend using the anti-virals in a
prophylactic mode there? That will have implications for
acquisition, purchasing, and is that a local responsibility? Is
it an individual responsibility? Is it a business
responsibility? These are some of the issues that we are
working through right now with our stakeholders.
Senator Pryor. And you also hinted--maybe I misunderstood
what you said earlier, but maybe hinted that you were looking
at ways to have a larger capacity. I read something recently
about maybe retrofitting some domestic production plants. Could
you give us a status report----
Admiral Vanderwagen. Production capacity, I spoke to
adjuvants, and I will come back to that in just a minute, but
production capacity has expanded significantly with the
investments we have been able to make with the $6 billion that
Congress gave us. That has been a major part of our investment.
We have put about $133 million into facilities retrofitting. We
have put about $10 million into international vaccine
production.
Antigen spearing, which is what I mentioned earlier,
antigen is the part of the virus that is in the vaccine that
stimulates your immune system. These antigen spearing agents,
when added to the vaccine, may make that vaccine more potent,
in effect reducing. Right now, it takes 90 micrograms to get a
good response when we give the vaccine, but these adjuvants,
some of them have demonstrated efficacy down to three
micrograms. We are not betting on three micrograms, but if it
gets us a 10- or a 20-fold increase, down to 15, 20 micrograms,
or below that, we are going to have a lot more vaccine
available to us fairly quickly just by adding these adjuvants.
Those are in clinical trials right now to establish their
safety and their efficacy.
Senator Pryor. On the vaccines, what is the criteria that
HHS uses to decide which producers receive vaccine production
contracts? Are you limited based on patents and brand names,
what is out there, or are these more like generics that it is a
competitive bid? How does that process work?
Admiral Vanderwagen. Our basic criterion is very simple. We
want U.S.-licensed manufacturers because we want domestic
production capability. We have five or six firms in the hunt.
They have different approaches and so on, but we believe that
by building the infrastructural base across the market base, we
are doing a better job of assuring that we have the domestic
production capability that we may need in this event rather
than relying on international suppliers.
Senator Pryor. And the last thing on that is we have a
certain stockpile. Are we planning on, assuming we have a
pandemic like the chart shows there, being able to go out and
get quite a bit more in a very rapid fashion, and if that is
the plan, are we doing advance pricing contracts or are we
working with the manufacturers to be ready in the event that
terrible day comes?
Admiral Vanderwagen. Well, the material is plentiful and we
have recently conducted some gap analysis and we don't believe
that--some of the industries don't have any further production
capacity available to them and we are going to have to work out
how we could expand their production capacity if they are going
to provide a surge product in high demand. That would include
such things as M-95 respirators. Other products rely heavily on
offshore raw materials. They may have production capacity
domestically, but they have offshore materials supplies. This
gets to be a pretty complex market analysis and will take
continued dialogue with our industry partners to achieve
reasonable solutions. We are trying to prioritize it against
the highest priority demands, such as ventilators and other
respiratory care materials.
Senator Pryor. Senator Sununu, did you have any questions
of this panel?
OPENING STATEMENT OF SENATOR SUNUNU
Senator Sununu. No, I don't. I just appreciate the
testimony. Sorry to have arrived a little bit late. I will
submit a written introductory statement for the record, but I
want to give an opportunity for all the panelists to have some
time, so I thank you, Mr. Chairman, and thank both of our
witnesses on the first panel.
[The prepared statement of Senator Sununu follows:]
PREPARED STATEMENT OF SENATOR SUNUNU
Good afternoon. I would like to thank all of the witnesses who have
agreed to testify before today's hearing, and would especially like to
thank Homeland Security and Emergency Management Director Christopher
Pope from my home State of New Hampshire who will provide testimony on
our second panel.
Director Pope came up through the ranks in the Concord, NH fire
department having served as a Firefighter, Paramedic, Lieutenant,
Acting Captain, Battalion Chief, and Division Commander before becoming
Chief. As Chief, Director Pope was responsible for 117 employees and a
regional dispatch enter that handled 20,000 emergency calls per year.
Additionally, he developed the Emergency Management Master Plan for
Concord. Director Pope's strong background in public safety
administration and emergency management is an asset to New Hampshire
and I am pleased that he could be with us today.
This afternoon, this Subcommittee looks into the issue of Pandemic
Influenza Preparedness at the State and Local level. While we know that
we can never be truly prepared for a pandemic outbreak, it is important
that our State and local partners have the resources they need from the
Federal Government to be ready. This hearing is an important step in
opening those lines of communication. I look forward to hearing from
both our Federal and State partners.
Senator Pryor. I want to thank both of you for being here.
We may submit some written questions and we will leave our
record open for a little while in order to do that back and
forth. Thank you.
Admiral Vanderwagen. The dialogue is absolutely necessary,
Mr. Chairman. We have a challenge together to meet the Nation's
needs. Thank you for your interest.
Senator Pryor. Thank you.
As the first panel is leaving, I will ask the second panel
to come forward. Let me go ahead and introduce them. First, we
will hear from Dr. Paul Halverson, Director of Health for the
Arkansas Department of Health and State Health Officer. Dr.
Halverson has an extensive background in public health, having
served as a member of the Senior Biomedical Research Service at
the Centers for Disease Control and also as the Director of the
Division of Public Health Systems Development and Research.
Next, we will have Christopher Pope, the Director of
Homeland Security and Emergency Management for the New
Hampshire Department of Safety. He has a solid background in
public safety administration and emergency management. He
served as the fire chief there in Concord and he has developed
an emergency management master plan. As a former fire chief, he
brings a unique perspective on the role of first responders in
a health crisis.
And our third panelist will be Yvonne Madlock, Director of
the Memphis and Shelby County Health Department and a Board
member of the National Association for County and City Health
Officials. She has a strong background in public health,
particularly in dealing with issues at the local and county
level.
Dr. Halverson, welcome, and if you want to give your
opening statement. Thank you.
TESTIMONY OF PAUL K. HALVERSON, DrPH, MHSA, FACHE,\1\ DIRECTOR
AND STATE HEALTH OFFICER, ARKANSAS DEPARTMENT OF HEALTH
Dr. Halverson. Thank you, Senator, and thank you, Senator
Pryor and Senator Sununu for the invitation to appear today.
This is a very important time, I think, for our State and also
our Nation as we work together in putting together a plan and
to exercise that plan in preparation for a pandemic.
---------------------------------------------------------------------------
\1\ The prepared statement of Mr. Halverson appears in the Appendix
on page 56.
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As Senator Pryor mentioned, I serve as a member of Governor
Beebe's cabinet and am responsible for public health in
Arkansas. We have nearly 5,000 employees and contractors in 95
local offices and in 75 counties in Arkansas. The Arkansas
Department of Emergency Management has the primary
responsibility for emergency response generally, but the
governor has designated the Arkansas Department of Health to
have lead responsibility for pandemic influenza preparedness
and response.
Arkansas is a great small State with approximately 2.8
million people. We have six metropolitan areas with a
population of over 55,000, but the majority of our State is a
collection of small towns and villages. Although we are home to
Wal-Mart, the largest retailer in the world, approximately one-
third of our workforce is employed by small business. Most
small businesses cannot withstand the impact of lost workers
and the workers cannot afford to miss work. We have 84
hospitals that are part of our Hospital Preparedness Program
and 10,897 licensed beds and approximately 2,000 active
physicians. According to the CDC-anticipated attack rate of
around 35 percent, we would have over 500,000 people clinically
ill, over 11,000 hospitalized, and over 3,500 people would die
in the event of a pandemic that is being forecasted.
One of the biggest challenges facing our State is the
ability to sustain basic needs, such as electricity, food,
water, and other services during an emergency because many of
our smaller communities lack the resources and manpower to
support these services. Federal funding and guidance have
provided our State with the ability to provide critical
infrastructure and make extensive progress in preparedness
efforts in our State. We have taken an early proactive position
in regard to pandemic preparedness, enacting planning
strategies designed to protect Arkansans from any threats to
public health, really an all-hazards approach from the public
health perspective.
Hurricane Katrina was an example of our ability to respond
to over 75,000 evacuees that came to our State, and we believe
because of our preparedness, we were able to meet the challenge
of that great influx of individuals.
We have conducted 233 pandemic briefings and over 97
exercises, working with over 9,000 people in Arkansas,
including county, State, and our work with CDC. We are working
closely with State and county government organizations, first
responders, police, sheriffs, hospitals, and a variety of
private sector partners. Partnership really is the key. It will
allow us to be successful as we work together to make the most
of our resources.
With the support of our legislature, we have been able to
purchase our maximum allotment of anti-virals and personal
protective equipment. We convened an expert panel on
recommendations regarding priority use of anti-virals and
vaccine when it becomes available. We have worked to develop a
medical reserve corps with volunteer physicians and nurses and
other health professionals and our state-of-the-art laboratory
has been designated by CDC for testing avian flu.
Surveillance really is very critical in our State and every
State and we work very closely with the CDC as well as sentinel
sites and physicians in the monitoring of Medicaid claims data
as a part of our approach towards surveillance.
There are a number of things that we have done to respond,
including mass flu vaccination campaigns, and we will again
this year be working to try to exercise those plans and believe
that the whole idea of exercising is critical to our success.
We have also focused on special populations with physical
disabilities and partnered with the Governor's Commission on
People with Disabilities and the Arkansas Association of the
Deaf, and we are developing a List Serve for our deaf
population, 60 to 80 percent of whom use Blackberries and
cellular telephones to communicate.
There are a number of issues, and I will talk about those
briefly. Our hospitals in Arkansas have worked carefully with
the Department to address issues around capacity, but we really
do need to focus on our ability to be prepared in terms of not
just the materials, but the people necessary to achieve that.
In our urban areas in particular, we have shared staffing that
really needs to be sorted out because people who will work in
multiple facilities will only be able to work in one generally
and we need to work in terms of that.
Funding is also very important to us. In a small State like
Arkansas, it is critical to have stable and sustainable
funding.
And last, let me just mention that, again, our working
together in partnership with State, Federal, and county
governments is really crucial to our continued success.
Thank you so much and I appreciate the opportunity to be
here this morning.
Senator Pryor. Thank you. Mr. Pope.
TESTIMONY OF CHRISTOPHER M. POPE,\1\ DIRECTOR, HOMELAND
SECURITY AND EMERGENCY MANAGEMENT, STATE OF NEW HAMPSHIRE
Mr. Pope. Good afternoon, Mr. Chairman, Senator Sununu. My
name is Christopher Pope and I do serve as the Director of
Homeland Security and Emergency Management in the State of New
Hampshire. I was appointed by Governor Lynch just over a year
ago following a 30-year career in the fire service, functioning
as a local responder both in EMS and fire and hazardous
materials response.
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\1\ The prepared statement of Mr. Pope appears in the Appendix on
page 66.
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Each State has characteristics which make it unique in
terms of pandemic planning. I wish to point out a few of these
unique factors about New Hampshire which impact our public
health and our all-hazard planning efforts.
First, while New Hampshire is small geographically, it sits
in a compact region of States in the Northeast. The cities of
New York, Boston, Hartford, Providence, Portland, Albany, and
Montreal all exist within a shorter driving distance from New
Hampshire's Emergency Operations Center than the distance
separating Los Angeles from San Francisco. This means that
evacuation surge secondary to any natural or human-caused
disaster in this densely-populated region will significantly
impact our State.
Second, we share a border with Canada, which is important
both due to the potential of the illegal entry of those intent
on committing harm, but also because local citizens routinely
cross the border every day to conduct business. As we all know,
State and foreign borders do not stop floods, terrorist events,
or pandemics.
Third, Portsmouth, New Hampshire is an active seaport with
significant critical infrastructure that supports not just the
economy of the State, but that of the entire region.
Fourth, New Hampshire is a major tourist destination in all
four seasons of the year.
And finally, New Hampshire has a very small county
government presence within the State. There are no county
emergency management directors. There are no county public
health officials or county emergency operations centers. Prior
to recent pandemic planning initiatives, all 234 communities
within our State reported to one central government agency on
all matters related to natural disasters and public health
crises.
These unique factors have caused New Hampshire to take a
slightly different approach to public health planning and
response. For example, a Memorandum of Understanding was signed
between the New Hampshire Department of Safety and the New
Hampshire Department of Health and Human Services to allow
collaboration in the area of emergency preparedness by actually
embedding Department of Health and Human Services staff in the
Division of Homeland Security and Emergency Management. Our
bioterrorism unit exists within the Department of Safety rather
than within our Department of Health and Human Services. This
forces these two key State agencies to work closely together,
thus building a strong partnership.
The Director of Public Health, the State epidemiologist,
the chief of our public health lab, our grants manager, our
bioterrorism chief, and I, along with several other staff, meet
twice per month to review public health planning efforts and
further our strategic planning.
Because of the lack of a county public health structure, it
became evident for the need to develop a regional approach to
respond to a pandemic. Thus, New Hampshire developed 19 what we
refer to as All-Health Hazard Regions (AHHR) covering all 234
of our communities. As of late summer, 14 AHHRs had completed a
pandemic influenza annex to their all-hazard public health
plan, with the remaining five nearing completion. The AHHRs
have identified acute care centers, neighborhood emergency
health centers, point of dispensing distribution centers, and
mass quarantine centers, and they have already developed or are
in the process of developing plans on how these would be
operationalized.
All 19 AHHRs have conducted tabletop exercises of their
all-health hazards plan for public health response. Pandemic
Phase 1 and 2 funds were distributed to AHHRs to support
enhanced regional response plans, including community medical
surge. These efforts have increased the capability and capacity
of the health care system with these regions. Several of these
regions have purchased medical supplies to support acute care
centers to reduce the likelihood that hospitals will be
expected to provide them. Because of the number of exercises
that have occurred, community-based partners and health care
system partners have demonstrated they have a better
understanding of the real capacity of hospitals.
My submitted written testimony details a list of cross-
cutting lessons learned from the many exercises conducted in
New Hampshire. It further lists a large number of
accomplishments subsequent to these exercises. It also delves
into details related to our building of interstate and
international regionalization initiatives. Two I will mention
quickly.
The Northeast States Emergency Consortium (NESEC), is a
group of the six New England emergency management directors and
those from New York and New Jersey cooperatively working to
deal with emergency management issues and now public health-
related issues, as well.
The second group, International Emergency Management Group
(IEMG), exists with those same States and our friends in the
Eastern Provinces, including Quebec, New Brunswick, Nova
Scotia, Prince Edward Island, Labrador, and Newfoundland.
I would like to briefly relate to you some feedback that we
have received from our State partners and our local communities
in terms of what the Federal Government, and State Government,
for that matter, working together can do to improve our
efforts.
One, the need to support for small towns to update and
develop their local emergency operations plan, either directly
to the community for hiring of a consultant or other staff
member, and to require the plans be all-hazard.
Earmarked funding for disability agencies and organizations
to participate in planning and exercises. For example,
interpreters for the deaf and hard of hearing individuals to
participate in a 90-minute planning meeting can cost between
$200 and $250.
Cooperative funding between DHHS and Homeland Security to
fund Points of Distribution where communities share a border
with other States or Canada. It is difficult to prepare a plan
and fund for POD activations without these cross-border
fundings.
These are but four of many recommendations that we have and
many I have submitted as part of my written testimony.
Finally, I would say that local government, States, and the
private sector have made great strides in their preparedness
and response capabilities in public health crises. However, we
are still not at the acceptable level of readiness that our
citizens expect and deserve. States and local governments
continue to need funding and leadership from the Federal
Government as we continue to build these capabilities.
I wish to thank the Members of this Committee for inviting
me here today to report these findings and I also wish to
publicly thank the many local public health and emergency
management officials who provided me with input for this
report. Together, we commit to you to continue to knock down
the stovepipes and continue to foster a cooperative environment
between the myriad public and private entities that will be
called upon to serve our citizens in times of disaster. Thank
you very much.
Senator Pryor. Thank you. Ms. Madlock.
TESTIMONY OF YVONNE S. MADLOCK, MAT,\1\ DIRECTOR, MEMPHIS AND
SHELBY COUNTY HEALTH DEPARTMENT, MEMPHIS, TENNESSEE, ON BEHALF
OF THE NATIONAL ASSOCIATION FOR COUNTY AND CITY HEALTH
OFFICIALS
Ms. Madlock. Good afternoon, Senator Pryor and Senator
Sununu. On behalf of the citizens of Memphis and Shelby County
and on behalf of local public health agencies across the United
States, I appreciate the opportunity to come and share with you
some comments on the state of pan flu preparedness at the
public health level, local level, across the Nation.
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\1\ The prepared statement of Ms. Madlock appears in the Appendix
on page 75.
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My name is Yvonne Madlock. I am Director of Memphis and
Shelby County Health Department and I have worked there for the
last 12 years. Along with my staff, I have been deeply engaged
in pandemic flu preparedness planning activities.
As a part of our work, we have had an increasing number of
opportunities over the last several years to work closely with
our colleagues throughout the Mid-South Region and particularly
with our colleagues in Arkansas. I would like to tell you about
the successes we have had as we have prepared our community and
our region for what we perceive to be the inevitability of
pandemic influenza.
We believe we have done a good job in coordinating with
Federal, State, and community entities in developing a strong
and comprehensive local plan for pandemic response, and I would
believe that most local public health departments have had
similar experiences. Key to our success in coordinating has
been our ability to bring elected officials, key community
leaders, and stakeholders together to learn and engage in
pandemic flu planning.
More specifically, we have established 20 Points of
Distribution, what we call PODs, and the mechanisms for
distributing and administering vaccines and medications to a
large population, in our case, an MSA of more than 1.2 million
people in just a few days. This spring, we had a great turnout
in learning from our pan flu exercise, where more than 86
persons from across the region representing public health,
local elected officials, police and fire and emergency medical
services, public schools and college, the airport authority,
and community organizations and businesses.
The following is a list of some of the things that we
learned as a result of those experiences. First, we learned
there is still work to be done in the area of public education.
As Senator Pryor referenced earlier, many people are either
under-informed or misinformed about the reality and the threat
of flu and the need to plan for self-sufficiency. Delivering
this message is challenging, particularly in this age of short
attention spans when headlines compete for our attention moment
by moment.
Second, we are very concerned about business continuity
planning. Pandemics are not like hurricanes or tornadoes. They
are not a single incident that happens over the course of a few
hours or even a few days. Sustaining life as we know it and its
necessary business processes over weeks, months, and maybe even
years with a shrunken workforce is one of the major challenges
and consequences of pandemic flu that we all face and that I
believe has not yet been adequately addressed.
Third, the exercise emphasized for us the distinct role of
local responders. For instance, the Strategic National
Stockpile is a Federal and State resource, but its deployment
will be a local responsibility. Memphis and Shelby County
residents will look to the local health department and to local
government to distribute vaccines and medications in a quick
and efficient manner. They will look to us for specifics on the
epidemic in our community, where to go for assistance, and how
to protect themselves and their families.
All disasters are local and response is dependent upon the
knowledge, the skills, the resources of local responders
representing multiple disciplines. But local does not mean
isolated. Regionalism in planning is critical. Disasters,
whether manmade or naturally occurring, do not respect
political or geographic boundaries. National policies and
guidance, written into funding opportunities that encourages
and supports multi-State planning, minimalizing credentialing
challenges, encouraging inter-governmental agreements, would be
very helpful.
For example, Memphis is located in the extreme Southwest
corner of Tennessee and really serves as the metropolitan hub
of a three-State region, a mostly rural set of counties that
surround us for almost 120 miles in either direction. So in
terms of disaster planning, as Memphis goes, so goes the multi-
State region that surrounds us. Adequate cross-jurisdictional
planning can mean the difference in our ability to immunize our
MSA in 48 hours or not.
At the local level, our uniform public safety partners have
learned the value of public health in protecting communities in
emergencies. We need to translate those lessons learned locally
to the Federal level. The Federal Government can help by
insisting that local public health be at the table at the
local, State, and Federal levels as planning is done and
funding allocations are made.
Again, I thank you very much for the opportunity to come
before you today and for your interest in this very important
issue to the health of all of our Nation.
Senator Pryor. Thank you. What I would like to do is go
ahead and lead off with a few questions, then turn it over to
Senator Sununu. It looks like we may have a vote here in the
next 10 or 15 minutes, but we will just play it by ear and see
how it goes.
The first thing I have for all three of you is just a
general statement on the working relationship that you all have
with the Federal Government. Is there sufficient two-way
communication between your offices and the Federal Government?
Is the Federal Government providing resources and accessibility
on a variety of fronts? Dr. Halverson.
Dr. Halverson. I appreciate the question because I think it
really is important. As we talked about earlier, this is about
a partnership and if the partnership is not effective, our
response will not be, either. And I think, at least from
Arkansas's perspective, we have a very positive relationship
between the Department of Health and the Department of Health
and Human Services and CDC in particular.
One of the things that CDC has done specifically to address
this issue is the development of what is called the Senior
Management Official. That is an individual from the Director's
Office at CDC who works in Arkansas on our executive staff and
provides a responsibility as a liaison. That has been
incredibly important to us as we have been able to use that
individual to work with us to address issues that we have from
time to time.
The issue of Homeland Security, I think, and the Department
of Homeland Security is a relatively new partner for us. We did
attend a briefing recently that described the partnership
between the Department of Homeland Security and HHS and the
State and local health departments and how it will work.
Frankly, it is too early to tell. This is really about
relationships and I think that our strong working relationship
and history with HHS has been very positive. I have a lot of
hope for what could be a strong partnership with the Department
of Homeland Security, but we really need to work that out and
develop those relationships, as well.
Senator Pryor. Mr. Pope.
Mr. Pope. I would certainly echo Dr. Halverson's comment.
And frankly, it is refreshing to see people at the Federal
level who work as hard and just are as dedicated as we sense
these folks are, and there is nothing that if you could not in
some way add an additional 10 or 20 hours to each day, I don't
think there are any problems we couldn't overcome.
One other comment that I would make is that States and
local governments tend to get a little bit frustrated with
short deadlines, quick turnaround times that are imposed upon
us by the Federal Government in order to comply with certain
grant requirements. That is a controversial issue at times, but
I will say that it is my opinion that it is those deadlines
which will--it needs to be a balance, but it is those deadlines
that keeps us making progress.
Senator Pryor. Good.
Ms. Madlock. Thank you. I would say that the relationship
as I perceive it between the Tennessee Department of Health and
the Federal level in the health sector is a very strong one.
Ours at the local level is a bit more by proxy and a bit more
indirect. But we do have a growing strength in that
relationship, and I think overtures and recognition of the
importance of direct communication between the Federal level
and the local level is absolutely growing.
On the flip side, when we go to Homeland Security, that
represents for us a new construct also and we really are
working in two different organizational constructs. While we
have a very well developed, historically developed State
structure for public health, the emerging structure for
Homeland Security is a new one and we are working with
different regions, different counties comprising those regions,
and beginning to learn one another, so that the opportunities,
I think, ultimately will be there for us to communicate a lot
more with Homeland Security at the local level than has emerged
or has grown or evolved to exist thus far directly with the
Department of Health and Human Services.
So it is a set of relationships that are different
depending upon the office we are working with and they are in
different States of evolution. But again, I think meetings like
this and other opportunities we have had bode well for the
potential for us to strengthen those relationships. I think
everyone wants that to happen and I think we all recognize that
is a critical element of success of planning.
Senator Pryor. Well, thank you for those answers. One of
the reasons I asked is because the two witnesses from the
previous panel stayed here to listen to what you all had to
say, and that is a good indicator to me that they are listening
and they are working with you. As Senator Sununu will tell you,
that is not always the case. A lot of times, the one panel will
just leave the room, but I am so pleased that the previous
panel stayed here to listen to what our local people have to
say.
At this point, I am going to turn it over to Senator Sununu
for his questions and I will have a few follow-ups. Thank you.
Senator Sununu. It is possible, Mr. Chairman, that they saw
your question and super simply were well prepared, but somehow,
I think that is probably not the case, having spent time with
Chris Pope and others who have been working on these issues. I
do get the sense that, partly because of the priority Congress
has made, but I think because of the dedication of people at
the local level, there is a good channel of communication.
I want to begin by asking Chris Pope about that regional
communication and regional coordination. You mentioned New
Hampshire's involvement with the Northeastern States Consortium
to help facilitate a better regional approach. Can you give
some specific examples of how that regional approach has had an
impact on New Hampshire?
Mr. Pope. Sure. Well, a practical example that I can give
you is in a non-public health scenario where we had an ice
storm, a severe ice storm in the Northeast that affected New
Hampshire, Vermont, Maine. I had tens of thousands of citizens
without power for more than a week, and there is a very
specific need to get a very basic line, electric company line
truck from the Eastern Canadian Provinces into New Hampshire,
Vermont, and Maine to help local utility crews restore power.
It is part of a mutual aid agreement, and without agreements
and conversation and planning ahead of time, those line trucks
will sit at a border because of credible homeland security
concerns and not get into the country as quickly as they are
needed.
So you meet ahead of time, you identify issues, you conduct
tabletop exercises, and you exchange business cards before a
disaster occurs, and this has been incredibly valuable.
Senator Sununu. Why is it important to be part of that
Northeastern Consortium even as you have the FEMA Region 1
structure in place on top of it?
Mr. Pope. Well, simply because we as the regional, either
the directors of the Eastern Canadian Provinces or the
directors in the New England Northeast States, we are driving
our agenda. FEMA is not driving our agenda. And by the way, we
attend meetings called by FEMA Region 1. We have got a terrific
working relationship with FEMA Region 1.
But there are times when we need to meet where we are in
control of our own agenda, we are talking about the issues that
are germane to us, and I think--and FEMA attends our meetings,
as well, as does DHS. So this has been a positive, very
positive thing. And by the way, we have had visitors from the
Southern U.S. border attend these meetings and interest from,
for example, Guam, who wants to build a similar relationship
with Japan, who would be their primary help in a disaster.
Senator Sununu. Dr. Halverson, you mentioned 96 exercises
that you have participated in. Have any of those extended into
a regional approach, and what are some of the key findings or
experiences that have come out of those exercises for you?
Dr. Halverson. Well, we do an awful lot on a regional
basis, and in particular as we think about some of our border
States between Tennessee and Texas. We have taken a little bit
different approach in the issues related to pandemic, however,
with guidance from CDC and the Department of Homeland Security
and Health. The issue here is that in the event of pandemic, we
really need to be planning what we can do as a State and not--
and frankly, it is a very difficult thing for us because it is
our standard operating procedure to work together on a regional
basis to create and share resources.
In this instance, we certainly are aware of what is
occurring, particularly in Texarkana, Texas, and Texas, and in
Memphis, West Memphis, and in those areas. We do the planning,
but we also are very deliberate in some of our work with
pandemic to be thinking about what are we going to be doing
collectively within the State. So our emphasis really has been
on a State level.
Now, from the perspective of counties, we are working
together, and we do an awful lot of work sharing between
counties within the State of Arkansas and we have a very
established regional approach within our State, sharing
resources, both people and material, to be able to work
together in that regard.
So again, for us, we do both regional approach but also be
thinking about what we have to do on our own.
Senator Sununu. Ms. Madlock, I have heard a lot of concerns
about a lack of surge capacity within our health care system.
Is this an issue in Memphis and Shelby, and what is being done
or what might be done to deal with a lack of surge capacity in
the event of a pandemic?
Ms. Madlock. I would say I think the information you have
heard, sir, is absolutely correct. I think the reality for most
health care systems across the United States, and it is
certainly true in Memphis and Shelby County, is that it is
working at capacity right now. We have limited bed capacity in
our community.
One of the things we realize is that we probably could
never build and create the full amount of beds and support
services that would be available to medically respond to a
pandemic as you see depicted here. And so one of the things we
obviously try to do is to create strategies that will provide
us distance of time and the luxury of time so that we can
minimize that medical impact as much as possible.
But in addition, we are working--we have a Medical Reserve
Corps in Memphis and Shelby County. I know that they exist
throughout the United States and I think they create great
opportunities for bringing in folks to work in non-traditional
roles that they may not assume on a regular day-to-day basis so
that they can aid the effort as much as possible.
So I think there are different approaches to responding to
that, whether it is to build capacity through the use of
volunteers, whether it is work to maximize the relationships of
hospitals and health care systems across regions, and we are
working to do that also, working with 19 hospitals in our
region to try and identify capacities of both equipment, beds,
workforce, etc., or to develop strategies of intervention so
that we can minimize the demand to the extent that we possibly
can.
Senator Sununu. Director Pope, have New Hampshire hospitals
taken a similar approach, a slightly different approach to
dealing with the question of surge capacity?
Mr. Pope. Our plan for the most part, and I am going to
over-simplify it, but it is essentially not to rely on the
hospitals for any kind of surge capacity for the same reasons
that were very well enunciated by Ms. Madlock. We have asked
our 19 AHHRs to go out, identify facilities in their
communities that meet certain requirements, characteristics,
that could function in an infrastructure capacity as an acute
care center, as a help center, or any of the other, a POD, and
we have actually started to exercise these locations as the
operational plans are being built out.
Senator Sununu. One of the things you mentioned in your
testimony that would be of value that the Federal Government
could provide is cooperative funding between DHS and DHHS to
support Point of Distribution centers for communities that
border other States, or in the case of New Hampshire, other
countries like Canada. Has the Northern States Consortium or
the International Emergency Management Group reached out to DHS
and DHHS and how have they responded?
Mr. Pope. That is the direction we have taken, and more
specifically the issue becomes, and I will give you a very
quick specific example. On the Western border of New Hampshire,
where we border Vermont, we have major medical centers,
including Dartmouth-Hitchcock on the Western part of the State.
So you will see people from Vermont coming in on an every day
basis to seek medical care, doctors' offices, into New
Hampshire. And that is unique compared to what might happen on
the Eastern border of our State with Maine, where we may
actually have people from New Hampshire going into Maine to
normally seek medical care.
So the issues are a little bit different, but the problem
we run into is we can't take Federal--we have had difficulty in
trying to fund exercises where it appears in any way, shape, or
form that the funds are going towards some activity or benefit
in another State. So we have had some challenges there and we
have asked NESEC to look into that with FEMA and DHHS/CDC.
Senator Sununu. Thank you. Thank you, Mr. Chairman.
Senator Pryor. Thank you. Dr. Halverson, you mentioned in
your opening statement about non-medical containment exercise.
Could you tell me what that is, why you did it, and what were
some of the lessons?
Dr. Halverson. Well, again, our issue, Senator, is that, as
Dr. Vanderwagen testified earlier, the issue early on is to
slow down the spread of this disease, and frankly, issues
around social distancing, the limiting of large crowds, the
early use of social distancing and limited quarantine, we think
are really important. They relate to our ability to more
effectively manage the spread of disease. So it really has been
our focus to try to create an interest not just in the use of
the anti-virals or the vaccine, but practical issues that
individuals could take to try to minimize their risk and
contain the exposure.
Senator Pryor. Let me ask you, Ms. Madlock, about Memphis.
We have seen this chart here with the map of the United States
where hypothetically something starts in Los Angeles, and we
appreciate that, but we also need to recognize that Memphis has
one of the busiest airports in the United States.\1\ Is it the
largest freight----
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\1\ The chart referred to appears in the Appendix on page 90.
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Ms. Madlock. It is the largest cargo airport in the world,
Senator.
Senator Pryor. There you go, the largest cargo airport in
the world. When I hear a statistic like that, I think it is
just as likely that something like this could start in the mid-
section of the country, in Memphis, Tennessee.
Memphis is such a regional city because it is right on the
Mississippi River and Arkansas is across the river. If you draw
a little circle around it, you are touching Mississippi, the
very Southern part of Illinois and Missouri. It has always been
that way. In Memphis, they call it the Mid-South, right?
Ms. Madlock. Yes.
Senator Pryor. I am curious about your sense about your
capability for early monitoring and detection of a flu problem.
In other words, theoretically, it could be some airport workers
or some pilots or whatever it may be. I know you have a lot of
people coming in from overseas because you are an international
airport, as well. Do you feel like your city and your State has
the tools necessary to do that early monitoring, to maybe try
to contain it there before it really becomes a pandemic?
Ms. Madlock. We are working on several fronts, and I think
you have highlighted both our pride and our great challenge in
the event a pandemic comes into the United States. We are
working on several fronts. One of those is to develop very
strong surveillance. We have recently been able to further the
development on three different levels and on three different
approaches.
One is the Syndromic Surveillance System, using the early
aberrant reporting system that was developed by CDC, which
allows us to receive electronically information from emergency
rooms throughout our region so that we can monitor and see if
we have unexpected rates or incidences of infections or
diseases that we would not otherwise expect.
In addition to that, we have a system in place utilizing a
surveillance system that provides us data from our public
school system, where we get reports from 49 different schools
to measure and monitor absenteeism rates.
We are also working with a program that I believe is a
national program also, but in the Mid-South region is looking
at the retail pharmaceutical sales of drug stores, pharmacies
throughout the Mid-South, so that we can see if we have had an
exceptional spike in sales of anti-diarrheals or cold and flu
medication.
Those are kinds of early warning signals that will allow us
to, as Dr. Halverson has mentioned and Dr. Vanderwagen
mentioned earlier, provide us with an opportunity for early
detection to slow down the spread. It is classic public health.
It is the attempt to identify a risk early enough so that
preventive interventions can be effective.
So those are some of the major thrusts that we have, and I
had another response, and as I went down that path I lost it,
but I will be happy to respond further to that question.
Senator Pryor. Great.
Ms. Madlock. I can submit you something in writing along
those lines.
Senator Pryor. That would be great. Let me ask the whole
panel about a patient care question, and that is, as I
understand it, in most day-to-day practices, doctors naturally
tend to treat the sickest people first, but with flu and when
you have a pandemic situation, there is at least one school of
thought that says you should treat those who are the most
likely to survive. Who makes that kind of decision? Do we have
a protocol? Is it a national protocol or a State-by-State
protocol, or city-by-city, hospital-by-hospital? How will that
be done? That is kind of a micro question, but I am curious
about how that works. Who wants to take that?
Dr. Halverson. I would be happy to start. Senator, I think
you have identified one of the most difficult questions that I
believe our physicians and health officials will face in the
event of a pandemic. In Arkansas, one of the ways in which we
have addressed this is by working very collaboratively with the
Arkansas Medical Society and ethicists and we have created the
opportunity to provide a consultation team to hospital ethics
committees to begin working now to begin to address those kinds
of questions that you have mentioned.
Whether it is the priority of treatment is a major issue.
The other issue relates to, for example, patients who are
currently on a ventilator and the ability at some point in time
to say that this person who has been on a ventilator for the
last 6 months or 8 months or more may not necessarily be able
to be sustained on a ventilator because there are other
patients that might benefit more.
These are difficult questions and ones in which we have
asked our hospitals to begin to address now prospectively.
Obviously, it is easier to face these issues today than it is
to deal with them in the heat of the moment. So again, it is
not going to make it a whole lot easier, but it will hopefully
begin to address those issues now.
Senator Pryor. Did either of you want to take that, as
well?
Mr. Pope. Well, I would certainly echo, and my background
is not epidemiology or medical ethics for sure, but we will,
from the State perspective, look for some guidance from the
Federal Government, broad guidelines. Absent those, we will
build our own protocols. We do have a group that we can pull
together, an ethics group. It may or may not be practical to do
that. It is best done ahead of time, obviously, and not after
the incident occurs.
Ms. Madlock. I certainly would agree with both gentlemen
who have spoken thus far on that issue. The other piece would
be that I think that is only one of the ethical issues that,
again, we at the local level will be looking for support from
our partners in the medical community as well as our partners
at the Federal level. I know that the Centers for Disease
Control is grappling with issues as to, for example, how do we
prioritize the distribution of a relatively scarce commodity,
such as the vaccine maybe in the early stages. So we have many
issues as to how do we utilize scarce resources in a time of
medical and public health crisis.
If I might, Senator, just as a point of privilege--not any
privilege, but a point of response to your earlier question in
regard to Memphis serving as a transportation hub for the
Nation, indeed the world, one of the things we are also working
on is the development of guidelines and protocols as to how do
we isolate, quarantine, or control the potential for an
infection to be introduced through that international travel,
and so we have convened the airport authority, our medical
community, our public health community, and local officials to
begin to talk about that very issue and to begin to develop
some really strong plans in that regard. We do recognize that
is a major point of vulnerability.
Senator Pryor. Let me ask one more question, and Senator
Sununu may have some more, as well, but on the issue of
quarantine, I think all the witnesses have mentioned
quarantine, all five of you, in different contexts. I know the
University of Michigan did a study looking at 43 of the cities
who were impacted by the 1918 pandemic and St. Louis, Missouri,
had the fewest deaths. One of the reasons they did is because
they closed schools, churches, and other community gatherings
for 10 weeks to 2\1/2\ months.
My question for the panel generally is do we have plans on
the shelf that we can pull out to do that and take such drastic
steps if we need to? I mean, have you all gone through the
planning of all the things that need to be done in order to do
that type of quarantine?
Dr. Halverson. Senator, I think that is an excellent
example of the reason why we need to work together in
partnership. As we speak, actually, we have a very strong
relationship with our Department of Education and the over 200
school districts in the State of Arkansas. One of the issues
that we are addressing is the authority to actually close
schools, and not close schools for a couple of weeks but
potentially for several months or maybe the entire term. As you
pointed out very correctly, it is really about being able to
move quickly and take decisive action to limit public
gatherings. Schools are one example. Churches are another.
There are a lot of factors relating to--and consequences of
taking that action.
So we are working with our Department of Education and
school superintendents. We have actually conducted a State-wide
planning meeting with our education leaders, and this is one of
the issues that we are addressing right now. We are in the
process of finalizing a draft on indicators for when we would
take action, who would do it, how we would notify people.
But there are a lot of other downstream issues, also,
Senator, relating to the credit for children, how the teachers
are going to be paid, who would pay the teachers, how to deal
with a lot of downstream effects of making that kind of a
decision. It is a very big decision, but we think it is
important to address it early on.
Senator Pryor. Let me ask this. Who makes that decision? Is
that made on the local school board level or is that made city,
county, or State?
Dr. Halverson. In Arkansas, and I guess each State may be a
little bit different, but as the State Health Officer, I would
have the authority to make that decision generally in
collaboration with the Director of the Department of Education
and with the governor. But we clearly have the legal authority
to actually close schools, and that would then be communicated
to the local school superintendents and principals. But we
really do want to see this as a collaborative decision, but we
are in the process right now of delineating roles and
responsibilities and action steps to make that very clear with
everyone.
Senator Pryor. Do you have any comments on that?
Mr. Pope. I would just add that the problem is highly
complex because in the case of private schools, for example,
you have students who may be coming from overseas. You may have
students coming from an area where there are already test-
positive cases. But I would also say that schools throughout
the Nation, especially in the Northern climates, close due to
weather events and other events, so they are fully aware of
what the consequences are as enunciated by Dr. Halverson when
you do close a school.
That said, we have exercised this particular issue. There
is a clear delineation as to who makes the call in our State,
and that doesn't mean it is an easy call, but we have an
educational annex to our State pandemic flu protocol.
Senator Pryor. Senator Sununu.
Senator Sununu. I have one last question for all of you to
address. You have all participated in different simulations,
tabletop exercises, also live exercises, drills, some on a
small scale, I know some on a very significant large scale
involving movement of materials and people to try to work
through all the issues associated with pandemic response. I
would like each of you to name the exercise or the program that
you have found to be the most helpful in revealing steps that
need to be taken, assessments that need to be made to improve
your level of preparedness. Why don't we start with you, Ms.
Madlock.
Ms. Madlock. Yes, happy to. We conducted a drill, an
exercise in late June of this year. It was an exercise of our
POD administration system. We tested our ability to convene all
of our partners and stand a POD up in a very brief period of
time and be able to work patients through the system and have
them immunized and back out again.
I found it to be incredibly valuable for a number of
reasons. One, it gave us an opportunity to work with all of
those partners that came from all different disciplines
throughout the community and the region.
Second, I think the thing that was particularly valuable is
that it gave our lay, not our lay, but our professional public
health employees across the board, a cross-section of those
employees, an opportunity to experience emergency response
activities. It is one thing to read about it. It is another
thing to learn about it. It is another thing to learn the
language of NIMS and be able to talk the talk. But to be
actually able to work in a different capacity and see the
importance, the critical importance that your role and your
showing up, your presence in an emergency situation can make
and be is vitally important. We also then gave those same
employees an opportunity to participate in the after-action
report development so that they gave input into what worked for
them, what else they needed to learn and know, and how it
changed their perspective of their roles.
So from the standpoint of interagency coordination and
internal organizational staff development, to be really ready
to respond, I found it to be incredibly valuable----
Senator Sununu. Roughly how many people participated?
Ms. Madlock. Oh, I would say probably about 100 of about
500 to 600 people on our staff.
Senator Sununu. Thank you. Director Pope.
Mr. Pope. I would point to two things quickly. One is, and
some of my peers may not agree with me, but the HSC compliance,
Homeland Security Exercise and Evaluation Compliance--these are
standards that exercises should follow when they are being
conducted and I think they force you to really look at your
weaknesses and what you need to do to improve.
The second thing is just exercising, getting to your full-
scale exercises where you are exercising various pieces. We had
a large 5-day pandemic exercise in New Hampshire this past
spring. We relocated SNS assets from Georgia to New Hampshire,
distributed them. We had hundreds of volunteers in five
different cities, communities, or three different communities
in New Hampshire actually going through and receiving a
theoretic anti-viral or whatever it happened to be.
First of all, it is very heartwarming to see the number of
volunteers and people that are actually doing this. This is the
battlefield, as far as I am concerned, and the work that is
being done is just--I can't say enough about it. But the
rewards will be there. Will it be perfect when it happens? No,
but if we continue to do this, we are going to see, I hope, a
much better outcome than we did back in the early part of the
20 Century, the last time this happened.
Senator Sununu. Dr. Halverson.
Dr. Halverson. Probably the most significant exercise for
us occurred mid-summer this year. We actually participated with
the CDC and created--we were corresponding with CDC in real
time using our videoconferencing equipment, stood up our
Emergency Operations Center for a couple of days, worked with
our hospitals and local health departments. So it really was
for us a test of our Federal, State, and local response. It
allowed us to deploy equipment that we don't normally use on a
day-to-day basis. It allowed us to test things. We found things
that didn't work. We found things that we needed to improve on.
And frankly, that was a great exercise for us.
Probably one of the most important things, though, that we
have identified is now working with our local communities and
having them have that same kind of experience. And so we work
very collaboratively standing up our EOC as necessary, then
working with the local community to test communications
systems, work with hospitals, and again, all coordination with
our Arkansas Department of Emergency Management, that is a
partnership for us, as well, and we communicate very frequently
in much the same way that Director Pope has mentioned that they
coordinate their efforts. We do in Arkansas, as well, and that
has been a good relationship.
But that Federal, State, local exercise, I thought was very
revealing, very helpful, and we did a full after-action review,
as well.
Senator Sununu. Thank you. Thank you all.
Senator Pryor. Senator Sununu, thank you for your
participation here today, and Senator Akaka, as well.
I want to say that we will leave the record open for 2
weeks. I know that some Senators will want to submit questions
to the panel. We appreciate you all getting those answers back
to us as quickly as possible.
I want to thank both panels, and again give a special thank
you to the first panel, who stuck around to hear the testimony
of the second panel and to continue the dialogue. It is very
helpful.
So I want to thank everybody for participating and this
hearing is adjourned.
[Whereupon, at 4:27 p.m., the Subcommittee was adjourned.]
A P P E N D I X
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PREPARED STATEMENT OF SENATOR OBAMA
I would like to thank the Chairman and Ranking Member for their
leadership on what continues to be an important health issue in our
country--pandemic flu.
As all of you know, we are facing the start of flu season here in
the United States, and by many indicators, our public health officials
and the medical community are better prepared than in previous years.
Recent reports from the Centers for Disease Control and Prevention
indicate that a shortage of flu vaccine is not expected, as production
has reached an unprecedented 132 million doses. This preparedness is
particularly good news, because improving our ability to respond to
seasonal flu will certainly enhance our ability to respond to other
natural and manmade disasters, including a top concern of mine--
pandemic flu.
The Centers for Disease Control has described pandemic flu as
inevitable and the biggest threat to public health in this Nation. And
we know that much work remains to be done with regards to pandemic
preparedness and response. The recent incident involving tuberculosis-
infected Andrew Speaker is one stark reminder. As serious as XDR
tuberculosis has been to contain and control, dealing with pandemic flu
will be many times more difficult.
We need only look back over the last hundred years to remind
ourselves of the speed and devastation caused by this potentially fatal
virus. The Spanish flu pandemic in 1918, the Asian flu pandemic in
1957, and the Hong Kong flu pandemic in 1968 are all harrowing
reminders. The Spanish flu pandemic was the most severe, causing over
500,000 deaths in the United States and more than 20 million deaths
worldwide. Obviously, with our global trade and travel, the United
States remains highly vulnerable to any pandemic; the recent
tuberculosis incident involving Andrew Speaker clearly indicates that
much work needs to be done in the area of surveillance and tracking the
whereabouts of infected citizens, especially those leaving and entering
our country.
Congress has a responsibility to be proactive in building this
Nation's defenses against all public health disasters. During my time
in the U.S. Senate, I have introduced two bills specific to this
challenge--one that speaks directly to the threat of avian flu and
another that speaks more broadly at improving our emergency response.
Briefly, the AVIAN Act of 2005 focused on pandemic preparedness and
response in the areas of surveillance, preventive and medical care,
core public health functions, information, and communication, with
emphasis on collaboration and cooperation at the State, national and
international level. More recently, I introduced the Improving
Emergency Medical Care and Response Act of 2007 which will improve the
coordination of emergency medical services, expand communication and
patient-tracking systems, and implement a regionalized data management
system.
Even though the last flu pandemic occurred almost 40 years ago, we
need only look as far back as 2005 to the events of Hurricane Katrina
to be reminded of our poor response to a large-scale emergency.
Preparing for flu outbreaks goes beyond just vaccine production, and we
must remain vigilant in our efforts towards refining and implementing
an effective and comprehensive preparedness strategy. I commend you for
holding this hearing today and I look forward to working with my
colleagues on this issue moving forward.
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