[Senate Hearing 111-154] [From the U.S. Government Publishing Office] S. Hrg. 111-154 PANDEMIC FLU: CLOSING THE GAPS ======================================================================= HEARING before the AD HOC SUBCOMMITTEE ON STATE, LOCAL, AND PRIVATE SECTOR PREPAREDNESS AND INTEGRATION of the COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS UNITED STATES SENATE ONE HUNDRED ELEVENTH CONGRESS FIRST SESSION __________ JUNE 3, 2009 __________ Available via http://www.gpoaccess.gov/congress/index.html Printed for the use of the Committee on Homeland Security and Governmental Affairs U.S. GOVERNMENT PRINTING OFFICE 51-781 PDF Washington: 2009 ---------------------------------------------------------------------- For Sale by the Superintendent of Documents, U.S. Government Printing Office Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; (202) 512-1800 Fax: (202) 512-2104 Mail: Stop IDCC, Washington, DC 20402-0001 COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS JOSEPH I. LIEBERMAN, Connecticut, Chairman CARL LEVIN, Michigan SUSAN M. COLLINS, Maine DANIEL K. AKAKA, Hawaii TOM COBURN, Oklahoma THOMAS R. CARPER, Delaware JOHN McCAIN, Arizona MARK L. PRYOR, Arkansas GEORGE V. VOINOVICH, Ohio MARY L. LANDRIEU, Louisiana JOHN ENSIGN, Nevada CLAIRE McCASKILL, Missouri LINDSEY GRAHAM, South Carolina JON TESTER, Montana ROLAND W. BURRIS, Illinois MICHAEL F. BENNET, Colorado 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 ENSIGN, Nevada MARY L. LANDRIEU, Louisiana GEORGE V. VOINOVICH, Ohio JON TESTER, Montana LINDSEY GRAHAM, South Carolina MICHAEL F. BENNET, Colorado Kristen Sharp, Staff Director Mike McBride, Minority Staff Director Kelsey Stroud, Chief Clerk C O N T E N T S ------ Opening statement: Page Senator Pryor................................................ 1 Prepared statement: Senator Ensign............................................... 23 WITNESSES Wednesday, June 3, 2009 Bernice Steinhardt, Director, Strategic Issues, U.S. Government Accountability Office.......................................... 2 John Thomasian, Director, National Governors Association Center for Best Practices............................................. 4 Paul E. Jarris, M.D., MBA, Executive Director, Association of State and Territorial Health Officials......................... 6 Stephen M. Ostroff, M.D., Director, Bureau of Epidemiology and Acting Physician General, Pennsylvania Department of Health.... 8 Alphabetical List of Witnesses Jarris, Paul E., M.D., MBA: Testimony.................................................... 6 Prepared statement........................................... 62 Ostroff, Stephen, M.D.: Testimony.................................................... 8 Prepared statement........................................... 69 Steinhardt, Bernice: Testimony.................................................... 2 Prepared statement........................................... 24 Thomasian, John: Testimony.................................................... 4 Prepared statement........................................... 48 APPENDIX Questions and responses submitted for the Record from: Mr. Thomasian................................................ 76 Dr. Jarris................................................... 83 Dr. Ostroff.................................................. 86 Map of ``Confirmed Cases Of Swine Flu Across The Globe,'' submitted by Senator Pryor..................................... 93 PANDEMIC FLU: CLOSING THE GAPS ---------- WEDNESDAY, JUNE 3, 2009 U.S. Senate, Ad Hoc Subcommittee on State, Local, and Private Sector Preparedness and Integration, of the Committee on Homeland Security and Governmental Affairs, Washington, DC. The Subcommittee met, pursuant to notice, at 2:05 p.m., in room SD-342, Dirksen Senate Office Building, Hon. Mark L. Pryor, Chairman of the Subcommittee, presiding. Present: Senator Pryor. OPENING STATEMENT OF SENATOR PRYOR Senator Pryor. I will go ahead and call our meeting to order. I want to thank everyone for being here today. This is the Subcommittee on State, Local, and Private Sector Preparedness and Integration and it is time for us to update our efforts on pandemic influenza. The Centers for Disease Control (CDC) has described pandemic flu as both inevitable and as one of the biggest threats to public health in the Nation. In October 2007, I chaired a hearing entitled, ``Pandemic Influenza: State and Local Efforts to Prepare.'' At that hearing, HHS, DHS, and State and local health officials testified. The witnesses cited efforts underway that included national strategies, plans, and exercises. Now less than 2 years later, we are faced with the reality of a pandemic threat. In late March and early April 2009, the first cases of a new flu virus, the H1N1, were reported in Southern California and San Antonio, Texas. So far, the CDC has confirmed 10,053 cases in 50 States and in the District of Columbia. This includes seven cases in my home State of Arkansas according to the CDC. The CDC reports that most of the influenza viruses being detected now in the United States are of the strain. Further, CDC's Dr. Anne Schuchat has said this will be a marathon and not a sprint, and even if this outbreak is a small one, we can anticipate that we may have a subsequent or follow- up outbreak several months later and we need to stay ready. One of the things we have talked about in this Subcommittee before is hurricane preparedness. Years ago, there was an exercise authorized and then for whatever reason, the money wasn't available to conduct the Hurricane Pam exercise, which was almost identical to the scenario we saw when Hurricane Katrina struck. We find ourselves today in somewhat of a similar situation in that we have had this flu scare already this spring and now it looks like, if flu behaves like it normally does, we will have a few months where it won't be that active, and then I hope I am wrong, but it looks like it may come back in the fall. We just need to make sure that we are ready, that we are doing everything that we can do, and that the State, local, and private sector are working together on this. So what I would like to do is introduce the panel and ask each of you to make a 5-minute statement. We may be joined by some other Senators. I know Senator Ensign has been trying to change his schedule to get here. We will keep the record open after the conclusion of the hearing for a couple of weeks and let Senators submit questions, and if there are follow-ups that we need to work with you on, we will do that. Let me introduce the panel. First, we have Bernice Steinhardt. She is Director of the Government Accountability Office's Governmentwide Management Issues. She has led the preparation of 11 GAO reports, the most recent, ``Sustaining Focus on the Nation's Planning and Preparedness Efforts.'' It synthesizes 23 recommendations that we should be working on now. Ten of them have yet to be acted on. Our second panelist will be John Thomasian. He is the Director of the National Governors Association's Center for Best Practices. Next, we will have Dr. Paul Jarris. Dr. Jarris is the Executive Director of the Association of State and Territorial Health Officials (ASTHO). Finally, we will have Dr. Ostroff. Dr. Ostroff is the Acting Physician General and Director of the Bureau of Epidemiology for the Pennsylvania Department of Health. What I would like to do is open it up, 5 minutes each, and then we will ask questions. Go ahead. TESTIMONY OF BERNICE STEINHARDT,\1\ DIRECTOR, STRATEGIC ISSUES, U.S. GOVERNMENT ACCOUNTABILITY OFFICE Ms. Steinhardt. Thank you very much, Senator Pryor. I really appreciate the chance to be here today. I wanted to talk to you about the report that you mentioned a moment ago that we issued this past February which synthesized the results of close to a dozen reports that we have issued since 2006. In that February report, we pointed out that despite the economic crisis and other national priorities that had become top priorities for the country, a pandemic influenza is still a very real threat and requires continued leadership attention. When the H1N1 virus emerged 2 months later, that warning was dramatically underscored. --------------------------------------------------------------------------- \1\ The prepared statement of Ms. Steinhardt appears in the Appendix on page 24. --------------------------------------------------------------------------- Before I go into the findings of our reports, I want first just to acknowledge the important progress that we have made in the last few years. In addition to the National Pandemic Strategy and Implementation Plan that was developed by the Federal Government, all 50 States and the District of Columbia now have pandemic plans, as do many local governments and private companies, and we have clearly benefited from all of this planning. But that said, there are still some significant gaps in our planning and preparedness. For one thing, the leadership roles in a pandemic, the ``Who is in charge?'' question, have not been clearly worked out and tested. Under the National Pandemic Plan, the Secretaries of Health and Human Services and the Secretary of Homeland Security are supposed to share leadership responsibilities along with a system of Federal Coordinating Officials and also Principal Federal Officials and the FEMA Administrator. And all of these positions may be vital in a pandemic, but how they will work together has not been tested yet. So in 2007, we recommended that HHS and DHS work together to develop and conduct national tests and exercises, and the Departments agreed with our recommendation, but since that time, there still has not been a national exercise for this purpose. Now that we have new people filling some of these leadership positions, the need to clarify these relationships in practice is only heightened. Beyond the lack of clarity on leadership roles, the National Strategy and Plan have a number of other missing pieces, and I will mention just a couple. First of all, key stakeholders, like State and local and tribal governments, were not directly involved in developing the plan, even though the plan relies on them in a number of instances to carry out some key elements of the plan. Second, there were no mechanisms described in the plan for updating the plan and reporting on its progress, and this issue of updating the plan is particularly timely since this is a 3- year plan and it was developed in May 2006. To fill these gaps, we recommended that the Homeland Security Council establish a process for updating the plan that would, first of all, involve key stakeholders and incorporate lessons learned from exercises and other sources. We made that recommendation in 2007, but the Homeland Security Council didn't comment on it, nor did they indicate whether they would act on it. But I would say that it is especially pertinent today as we try to learn from the experiences of the H1N1 outbreak. As we go forward, it is also essential for the Federal Government to share its expertise and coordinate its decisions with other levels of government and the private sector. A number of mechanisms were developed for these purposes, but they could be used even more, and I will mention one example. In a 2008 report that we did on State and local pandemic planning, we pointed out that an HHS-led assessment of State plans found many major gaps in 16 of 22 priority areas that included policies related to school closures and community containment. At that same time, a number of the State and local officials that we were talking to told us that they would welcome additional guidance from the Federal Government in these same areas, and I know the National Governors Association found many of the same kinds of issues. DHS and HHS at that time had earlier convened a series of regional workshops with State officials to help them with their planning efforts and we thought that the two Departments could use additional workshops to help States address the gaps in their pandemic plans. The two Departments, HHS and DHS, agreed with our recommendation, but they haven't held any additional meetings since then. In closing, I just want to point out that it's important to bear in mind that while the current H1N1 outbreaks seem to have been relatively mild, the virus could return, as you pointed out, Senator. It could return in a second wave this fall or winter in a more virulent form. So given this risk, the Administration and Federal agencies should be turning their attention to filling some of the gaps that our work has pointed out, while time is still on our side. Thanks very much. Senator Pryor. Thank you. Mr. Thomasian. TESTIMONY OF JOHN THOMASIAN,\1\ DIRECTOR, NATIONAL GOVERNORS ASSOCIATION CENTER FOR BEST PRACTICES Mr. Thomasian. Thank you, Mr. Chairman. As you pointed out, my name is John Thomasian and I direct the National Governors Association Center for Best Practices and I appreciate the opportunity to testify before you today on pandemic influenza and how we can close potential gaps in our capacity to respond. My comments today are based on the work we have done over the past several years with the States on pandemic planning that began in 2006 with a Governor's Guide. It included training workshops, nine regional training workshops for all 50 States and four territories in 2007 and 2008, and our work continues today as we assist the Governors' Homeland Security Advisors in responding to the recent outbreak. --------------------------------------------------------------------------- \1\ The prepared statement of Mr. Thomasian appears in the Appendix on page 48. --------------------------------------------------------------------------- I am going to focus on five key areas very quickly: Information sharing, interagency coordination, school closings, continuity of government and coordination with the private sector, and communication with the public. Each of these were identified as problems in our previous work and I will discuss how each of them were handled in the current outbreak. Information sharing--information sharing during the recent flu event demonstrated that systems worked much better than we anticipated. The flow of information between the Federal Government and the States was nearly constant during the initial weeks of the outbreak and case counts were updated daily. Morbidity and mortality figures were readily available. And the Federal Government did a good job pushing information down to State and local government. That being said, there is room for improvement. Both CDC and DHS began to hold independent daily briefings for State officials in the early weeks. These briefings often contained the same information and often contained the same Federal officials. But States were never sure if all the information was new, so they put time aside for all the briefings. As a result, State officials spent several hours each day monitoring conference calls instead of response activities. In the future, DHS and CDC should hold a single daily briefing with States on all essential information. Interagency coordination--when we held our workshops in 2007 and 2008, many State teams were meeting for the first time. They were not clear on their own responsibilities, much less those of their Federal counterparts. Three years later, with additional planning and exercises, the situation has improved. I think the Centers for Disease Control and Department of Homeland Security worked well together during the recent outbreak and provided a relatively seamless portal to Federal resources and technical assistance. At the State level, homeland security agencies began coordinating immediately with their health departments and many States enacted emergency declarations and other orders to begin mobilizing broader State resources, if needed. Looking ahead, we must recognize that good interagency coordination deteriorates without practice. To maintain performance, States must be given encouragement and resources to conduct preparedness exercises with multiple agencies and levels of government. This is a capacity that will go away over time. School closures--school closure policy was a topic of intense discussion at each of our national workshops with little consistency in approach. It was not a surprise, therefore, when the recent outbreak led to a patchwork of school closure decisions. One issue was that the Centers for Disease Control's written guidance suggested that closures should be based on laboratory-confirmed cases, while public comments by some Federal officials suggested decisions should be based on suspected or probable cases or even when students had a family member with the disease. Also missing was advice to parents and students on actions to be taken outside of the classroom to limit the spread of the disease. In many cases, dismissed students simply recongregated at shopping malls or other venues to share potential infections. More precise advice will be needed from CDC in the future to help States and districts implement a more consistent approach to school closure. Guidance should also address prevention actions beyond school grounds. Continuity of government and coordination with the private sector on critical services--in our workshops, we asked States to envision a rate of absenteeism that could approach 40 percent. To cope with this possibility, States needed to develop detailed continuity of government plans and work with the private sector to ensure the availability of critical goods and services. This mild outbreak simply did not test these contingencies. They remain among the unknowns of our preparedness and should be revisited before we enter the next flu season. Finally, communication with the public. In the recent outbreak, government and the media did a good job informing the public on the spread of the disease and what individuals should do to avoid infection. However, the Federal Government did not adequately explain the type of response options they had at their disposal, what was being considered or rejected, and why. This led to a great deal of confusion in the early stages regarding what might happen next. To address this gap, the public must be given information on the appropriateness and implications of specific actions, such as quarantine, social distancing, travel bans, school closings, and the use of personal protective equipment. In conclusion, the spring outbreak has so far resulted in less than 9,000 confirmed cases nationwide. In contrast, we must remember that a severe pandemic would produce tens of millions of infections. Before the onset of the next influenza season, we should take the time to address the weaknesses this initial outbreak exposed. We should clarify the guidance on school closures to ensure consistency. Information exchange should be improved so that responders can allocate their time more efficiently. The public must be educated on the benefits and costs of mitigation strategies. And States should be encouraged and supported to conduct periodic pandemic exercises with Federal agencies, local governments, and the private sector. Thank you, Mr. Chairman. I am pleased to answer any questions later. Senator Pryor. Thank you. Dr. Jarris. TESTIMONY OF PAUL E. JARRIS, M.D., MBA,\1\ EXECUTIVE DIRECTOR, ASSOCIATION OF STATE AND TERRITORIAL HEALTH OFFICIALS Dr. Jarris. Mr. Chairman, thank you for the opportunity to speak. I would like to make a couple of points that have not been made before. --------------------------------------------------------------------------- \1\ The prepared statement of Dr. Jarris appears in the Appendix on page 62. --------------------------------------------------------------------------- One is that this is not over. We still have an outbreak and an epidemic going on in this country. Just over the last day, the cases have increased to 11,000, which is a tremendous undercount, and your State of Arkansas is now nine rather than seven. You have been relatively spared, but other States have been hit much harder, including New York and currently Massachusetts has a dramatic outbreak ongoing. So this has never gone away. It is really not a matter of if it comes back in the fall. It hasn't left yet. The question will be, when it comes back in the fall, will it have evolved to a more severe pandemic or epidemic than the epidemic we are having right now? Furthermore, it is not just another seasonal flu, as we hear people saying. This is not the time of year you have a flu outbreak. That is one of the ways we search for new viruses and find them. Second, this is primarily young people being affected. The average age of individuals being affected is between 11 and 19 years old. The average age of someone in the intensive care unit is 23 years old. And the average death rate is in the 40s. That is not seasonal influenza, which largely affects the elderly and otherwise people with immune compromise. So this is a novel virus, and what we have to understand is we do not know how this is going to behave. In 1918 at this time, it was behaving very similar to this. Now, whether or not it will come back as severe a category four or five in the fall, we simply don't know. But the prudent thing is to plan for a range of an outbreak consistent with what we have now all the way to a severe pandemic worldwide. The World Health Organization is right now considering whether to raise it to a pandemic level six, but frankly, that is not that important to this country because we already have an epidemic ongoing. Pandemic just means the epidemic has spread around the world. We have it already. The response to date, I believe, has been a good response. The Federal Government, State government, and local governments have acted in concert with each other and as a National Government response. Harvard did a study which showed 80 percent of Americans were satisfied with the response. Eighty- eight percent were satisfied with the information they were getting. That was the result not only of the Federal Government giving us guidance, but the State public health officials and homeland security officials going back to the Federal Government to say, here is what is happening on the ground and giving them situational awareness. We also have learned that there is much to be done with our planning. There were many assumptions made which proved not to be true. There were many planning plans that were made which were not nearly granular enough. So now that we are in a response, much more so than just a drill, we have learned about the shortcomings in our planning and what has to be happening. We have now a window of 12 to 16 weeks before this thing would escalate, as the 1918 virus did, before the return of the seasonal influenza, which will come on top of this current influenza outbreak. The reason I say it is not scalable, there has been about a 25 percent cut in State and local emergency preparedness funding over the last several years. We have had about a 20 to 25 percent cut in hospital preparedness funding. And the single appropriation of pandemic influenza funding in 2006 was completely spent by August 2008. There is no money from the Federal Government to state and local government, public health, to respond and plan for the fall and we simply have no alternative. So we must take advantage of this window of opportunity now to protect the American people. And let me give you the orders of magnitude here because frankly, I think we are all having a little bit of sticker shock when we think about what it will take to respond and protect the American people. For one, we are asking for $350 million, another bolus, if you will, of planning money to carry the State and local governments not only through the response right now, but to plan and work on transitioning from planning to implementation for the fall. But importantly, there has been much talked about vaccine, the single most effective thing we can do to protect our population. Our plans call for protecting the entire U.S. population. That is 300 million people. We do believe that it will be two doses per person. By the time we know different, it is too late to produce the extra doses. So if conservatively that is $5 per dose, we are talking about $6 billion just to buy the vaccine. Now, vaccine isn't a good luck charm. It has to be given to people. We can give you the numbers and the information, but conservatively, it is $15 a dose to provide vaccine under the government-run program. That is less than the private sector. But much of the workforce giving this will be private sector. So we are talking about $15 billion to give those 600 million doses. So just there alone, we are in the $14 to $15 billion range. So we really have to come to grips very rapidly with how serious are we as a Nation in protecting the people of the United States and will we make those resources available now or will we stare the American people in the eye come the fall and say, when we had an opportunity, we didn't do it. Thank you, sir. Senator Pryor. Thank you. Dr. Ostroff. TESTIMONY OF STEPHEN OSTROFF, M.D.,\1\ DIRECTOR, BUREAU OF EPIDEMIOLOGY AND ACTING PHYSICIAN GENERAL, PENNSYLVANIA DEPARTMENT OF HEALTH Dr. Ostroff. Thank you, Senator. Influenza is unquestionably one of the most unpredictable public health issues we face. Just when you think you understand what is going on, it always throws you a curve ball. --------------------------------------------------------------------------- \1\ The prepared statement of Dr. Ostroff appears in the Appendix on page 69. --------------------------------------------------------------------------- For several years, we have been focused on the emerging threat of bird flu in Asia, and rightly so. It is highly lethal, it has continuously circulated for 6 years, and it has devastating consequences for agriculture. Most of our planning assumptions have been based on a scenario that a pandemic would start in Asia, that it would be noticed there, and that we could delay its introduction and spread. And then out of nowhere, a new virus lands right on our doorstep, isn't noticed until it is already here, and renders many of our planning assumptions irrelevant. Fortunately, so far, its public health impact as measured by illness and death has been modest, but its overall impact has been anything but. It has caused tremendous disruption to individuals, families, schools, and communities, and we don't know what the future holds for this virus. Like the other States, we in Pennsylvania immediately ramped up our disease monitoring and response as soon as we learned of this new flu strain. Over the last 2 months, despite the fact that we have not had that many cases in Pennsylvania, it has been enormously labor intensive and challenging to address the myriad of issues that it presents. We have established a State-wide task force that includes our public health and emergency response partners. We have partly activated our emergency operations center. And we set up an internal health department task force. We have reached out to the education and agriculture sectors, migrant centers, medical societies, the rich array of academic centers in our State, the pharmaceutical sector, and the State's major vaccine manufacturer. And most importantly, we have closely integrated our work with that of our network of district and local health departments who form our front-line eyes and ears through daily group phone calls to discuss cases and disease clusters. We have greatly relied upon the excellent work done by the CDC, including their guidelines, lab support, the pharmaceutical stockpile, and their technical back-up. We in the States have had an ongoing dialogue with CDC about all aspects of this event, and sometimes we have disagreed, like in the school closure area. But CDC has been very willing to listen and change course when appropriate. Some aspects of our response have gone quite well. These include risk communications, disease monitoring and investigation, and applying control measures to limit disease spread. Other areas have been more challenging, especially lab support, where backlogs quickly developed when specimens had to go to CDC. We in Pennsylvania continue to individually count, investigate, and respond to each identified case of illness due to this new virus. With less than 300 cases, even this has been very resource intensive and has strained our disease investigators and our laboratory. Like most States, we have been impacted by the economic situation. We have hiring freezes in place and our bench strength is not very deep at all. Because in general we don't count individual cases of seasonal influenza, many of the most heavily impacted States are now no longer doing it for this new flu strain, either. Instead, they only count severe cases and those in special circumstances, like health care workers and pregnant women. This makes the national numbers that you are hearing now being reported very tough to interpret, since States are counting cases differently. In Pennsylvania, because many parts of the State have still been minimally affected by this virus, we think it is important to understand where the virus is, how it is spreading, and who it is affecting, so we will continue to count until it is no longer feasible for us to do so. So far, many aspects of our preparedness efforts have not been engaged. As examples, we have not dipped into our pharmaceutical stockpile. We have not mass distributed vaccines or antivirals. We have not handled large numbers of sick or dying people. And we have not implemented full community mitigation efforts, and hopefully we won't have to do so. But it is important to be prepared in case we need to. So we in Pennsylvania have just initiated a process to review our efforts to date and see what has gone well and where we need to improve. We are also embarking on a planning effort to prepare for what the virus has in store for us in the coming months. This includes doing better monitoring, planning for distribution and administration of stockpile material and vaccines, and dealing with health care surge needs. The flu is just one of a long line of emerging infectious disease threats. Others include SARS, MRSA, West Nile, foodborne outbreaks, and vaccine-preventable diseases. All of these highlight the need for a robust and a well-trained public health workforce and for flexible resources that allow us to best apply the resources that we have where they are needed. At the State and local level, the same people address all these problems in the field and in the lab. While our preparedness resources have helped, they do not cover nearly all of our needs and our resources for emerging infections have dwindled in recent years. Despite these problems, all of us are firmly committed to continue to address this new flu virus while continuing to confront the other public health threats that we face. I will be happy to answer any questions. Senator Pryor. Thank you. Let me start with you, Ms. Steinhardt. In your GAO report, you have several criticisms of the state of affairs right now. One of those is that the roles are not very clear between State, Federal, local, and who makes the decisions on certain things. What would you recommend that State and local officials do to clarify their roles? Ms. Steinhardt. Well, the important thing, and this is the lesson that we learned, I think, most vividly from Hurricane Katrina, the important thing is to test and exercise. It has often been said that you don't make friends in the middle of a disaster. People need to know each other and figure out how they are going to work together in advance of a true emergency, and that is what needs to happen here, as well. Senator Pryor. OK. I notice that the GAO, the NGA, and the ASTHO have reports that say that you need more guidance in school closures, you mentioned, and several other areas, like private sector workforce, situational awareness, etc. Do you think the Federal Government could distribute policies on these issues by this fall or is it too late for this year? Ms. Steinhardt. I would hope that the Federal Government could do that. As my fellow panelists have said, there is a lot that we are still learning about this virus. But certainly there is more--some of those lessons learned can and should be shared with States and local governments, as well. Senator Pryor. Mr. Thomasian, in your experience in terms of defining roles and some of the gaps that Ms. Steinhardt has identified, how has the Federal Government been to work with? Mr. Thomasian. In the past Administration, I would say the lead agency was clearly HHS. Secretary Leavitt took it on himself. Under his watch, he was going to try to avoid not having these roles defined. So I think we got one strong but one siloed lens looking at that. Senator Pryor. He wanted to not define the roles? Mr. Thomasian. No, he did want to define the roles, but since he represented a single agency, he had certain boundaries. Senator Pryor. I see. Mr. Thomasian. So I think we got halfway there. I think we still have a ways to go. I was pleased to see that the Department of Homeland Security worked well together with HHS during this initial crisis. Again, we have not been fully tested, so all the roles have not been fully defined or explored and the tensions have not been exposed to a large degree. But it was an initial good first step. So I do believe they have tried to do a good job and I will reiterate my panelist assertion that the best way to define a role is to initially put some aspects down on paper, but you have to exercise. You have to test it. Relationships need to be built. Senator Pryor. OK. Let me follow up on that. When the National Response Framework and the National Pandemic Implementation Plan were being put together, there was a lot of criticism that the Federal Government did not work with and talk to the State and local governments effectively. Now they have been working on the First Responder Health Surge Capacity Action Directive. Have they been working with the States and with the local folks as they are putting that together? Mr. Thomasian. They are. We work very closely, I should say, with the Governors' Homeland Security Advisors. In fact, we have formed an association within our association called the Governors' Homeland Security Advisors Council, and it is our understanding they are working together with them. Again, though, it does take a while for all this to trickle down through the States. This has been a constant refrain from the Governors' Homeland Security community, that the Federal Government needs to fully advise and work through issues with the States. I believe we are on the right path. It is too early to tell that it is taking place in all cases, though. Senator Pryor. Dr. Jarris, did you have any comments on that? Dr. Jarris. Yes. I think it is worth questioning the model. The model that the Federal Government will sequester itself and develop guidance for the Nation is a model that doesn't work well. There is a certain amount of expertise, whether it is scientific or law enforcement, in the Federal Government. But actually, the people who implement this guidance are at the State and local levels, and what we fail to appreciate is the expertise in implementation. So a model that will work much better is if Federal, State, and local all work jointly on guidance. Right now, what we do is we play ping-pong. The Federal Government comes out with something, lobs it over the table. We say it doesn't work. We lob it back. We don't have time for that in 14 to 16 weeks. What worked well in this response to date is that we really were working together, information flowing up and down, modifying what each other was doing. Now we seem once again to be flipping back into the old model of the Federal Government will come up with guidance for the fall. It simply won't work. For example, school closure. That is primarily a public and political decision to close schools. It is not fundamentally a science-based decision. So what we need to do is to work with the mayors, the governors, and those who make the school closures, and the health officials who will make recommendations to them, to truly understand all the issues there so we can do, if you will, a cost-benefit analysis. There is no way that the Federal Government guidance can come out without true involvement of the local and State officials making these decisions and have it work. Senator Pryor. So are you recommending that we get some sort of summit together? Dr. Jarris. Well, a summit would be helpful, but an ongoing working relationship would be far more helpful. Senator Pryor. And does that not exist right now? Dr. Jarris. The tendency is for Federal Government to develop guidance. There may be input sought, but then it goes back into a sequestered environment and the guidance comes out. And I think it is much more efficient, actually, if we could sit down as Federal, State, and local and jointly work on guidance. Senator Pryor. OK. This is a little bit of a follow-up to something I think you said in your opening statement. There are a lot of assumptions about the flu and the H1N1 did not really follow those assumptions. Dr. Jarris. Yes. Senator Pryor. It didn't start in Asia. It didn't go from a bird population to human population. What do you recommend, or how do you recommend that we build in flexibility to all this planning so that if a different scenario presents itself, like H1N1 has so far, it doesn't really follow the textbook example, how do you build in the flexibility? Dr. Jarris. Yes. I think with a novel virus, it is a mistake to assume there is a textbook. They all operate differently. So really what we need is to have much more robust planning. It is not just a matter of scientifically planning for it. We need to have modelers in there. We need to have systems engineers come in and figure out what is going to happen. So, for example, we should plan for a best case, a worst case, and a most likely case scenario and hope that covers the bases. Of course, something out of the blue will happen. But, for example, if we look at the vaccination campaign for the fall, we will have an initial bolus of vaccine coming out probably sometime around October, but we don't know how fast it is going to grow. That vaccine will come out with an initial bolus. We don't know how much that will be. It will then come out with weekly numbers, so a certain amount per week. We don't know how much that will be. That will be distributed on a per capita basis to the country and we have to go down a priority list, which incidentally the priority list we have is for H5N1, not H1N1. So you see how many unknowns there are here. What will the adjutant do? We haven't gone through the safety studies yet. We actually don't know if it is one dose or two doses. So there are so many complexities here and we will not know ahead of time enough information to make the decisions. So at the outset, we have to come up with operational assumptions and plan around those assumptions with different scenarios. Senator Pryor. And you had mentioned the costs of providing a vaccine to every American. What is your overall estimated cost on that? Dr. Jarris. Well, we don't quite know again, what the vaccine is going to cost. It hasn't been developed yet. We don't know the cost of the adjutants that may be in it. So probably between $5 and $10 a dose, $10 is what it normally costs for regular seasonal flu. And we assume 600 million doses, so we are talking somewhere in the $6 billion range. It could be more, could be less. But then we actually have to give the vaccine, and we estimated this a number of ways. We had dozens of States and local health departments who did a cost basis for them to give a vaccine. Medicare pays $18 to $20. Medicare pays costs. We checked with Visiting Nurse Associations. We checked with private sector. So the ranges are anywhere from about $12 to $30. We picked $15, which we think is a reasonable dose. So $15 times 600 million, we are talking about another $9 billion. Senator Pryor. And how does that square with your thoughts on planning, though, because at some point, you have got to pull the trigger on the vaccine, about whether you are going to go with this particular vaccine or not. And if the strain changes, like down in the Southern Hemisphere it could be a different strain this fall or whatever the case may be. So when is that point where you have to pull that trigger? Dr. Jarris. There is seed stock developed now, it is my understanding--and I am not Dr. Fauci--that the variation has not been tremendous around the world yet. So we think we will have a vaccine that will probably cover all the options unless there is a major mutation. So that seed stock will then have to go into production. At the same time, we need 2 to 3 months to do the scientific testing for safety, for response, for dosage, and things like that. So we will have to make a decision soon to purchase--we have already put a purchase order in for this country--not only because we need the lead time to develop the vaccine, but because other countries are already in line, Great Britain, France, things like that. So in order to put our place in line, we are going to have to make a purchase decision very soon. Now, it is one decision to purchase. That, we will have to do early. It is another decision to give it. We are going to have to look in the fall, based on the safety studies, to say, OK, given what we know, we have this vaccine. Should we actually give it to people? And I think we have to carefully consider that, because all vaccine has side effects and we will have to weigh the severity of the illness in the fall versus potential side effects of the vaccine. So that is a later decision, I would guess, that is going to be made probably in the August to September time frame. Senator Pryor. Mr. Thomasian, let me ask you a follow-up to what Dr. Jarris was talking about. We have talked about a lot of different scenarios about administering a vaccine and how to distribute it around the country, around the various States. From your standpoint, how should that be done? Should you let the various States make that decision on how it is distributed, or should there be one national policy that the States just follow? Mr. Thomasian. Well, the way it is currently laid out is the States have prepared plans on how they would distribute vaccines and antivirals and they have priority lists that match up to a good extent to the Federal senses of priority. So I don't think there is a huge variation out there. So I would say, let the States administer it with a joint discussion between the Federal Government and the States on the type of priorities. I am saying that because I am assuming, and I think it is safe to assume, that we would not have vaccines for everybody, so we would have to be focusing on the essential service individuals and the most vulnerable populations. Otherwise, I think we can probably go to the open market distribution of the vaccines. Senator Pryor. Dr. Ostroff, do you have any thoughts on that? Dr. Ostroff. Specifically about the vaccine? There is obviously a lot of unknowns, I think, as Dr. Jarris pointed out. Senator Pryor. And let me just interrupt there. It seems to me that you can do a lot of planning and you can be prepared in some ways, but because the vaccine needs so much lead time, that is sort of a separate question that just makes it hard to figure out what the best way to go is, but go ahead. Dr. Ostroff. Well, I think a couple of other points just to consider--one of them is, I think as Dr. Jarris rightly pointed out, we shouldn't look at the current situation as being in the past tense. We in Pennsylvania, our numbers have gone up by a third just since I put my testimony together this weekend, so it is quite active right now in Pennsylvania. It shows no signs of abating. I think that we all anticipated that it would dampen down over the summer months. The virus may not have read the textbook and may decide not to do that. The other thing that we have to remember is that in 1918, which is the model that we have all been looking at, the virus came back very early. It came back in September and it came back with a vengeance in September. It didn't wait until the usual winter influenza season. And so in terms of our thinking about what to do related to vaccine, I think that we have to really put our decision making on the fast track about what to do because by the time we make decisions over the next couple of months, the virus may have jumped out ahead of us and it could come back in a form that is more severe than it currently is. The other, I think, issue to also keep in mind is that we are relying quite heavily on antiviral drugs. The antiviral drug of choice, if you look at the seasonal strain that was just floating around the country, that was resistant to that particular drug. And so if this particular virus decides to get together with that one and transfers its resistance, then that is a program for our assumptions and planning. And so I think as far as the vaccine, I am not sure that we have a lot of time to be able to make these decisions. I think the virus is telling us, because right now, virtually all influenza in the United States--and again, it is a very unusual time to be seeing this disease--is this virus. And so it may not be an option, the regular one versus this one. I think that we have to look seriously at what the virus is telling us right now and make our decisions relatively quickly. Senator Pryor. OK. Given all the circumstances that we are in right now and also given the fact that in the supplemental appropriation that is working its way through the Congress and hopefully will get to the President's desk in the next couple of weeks, we put $1 billion in there for pandemic flu issues and preparedness. Do you have an idea on how that money should be prioritized, what the most critical needs are to get us ready for this? Dr. Ostroff. Well, there are a lot of needs and I think many of them have been pointed out. Again, we have not been fully exercising the full gamut of things that we would need to do for a full-fledged pandemic. I think that we do need to very quickly come up with our plans as to how we would distribute the vaccine. I think when the vaccine becomes available, there is not going to be enough for everybody and we are going to have to make decisions about how to prioritize who gets it and who doesn't, and we generally do that based on what we see about the patterns of disease. I think that we have to work out much better than we did how to distribute antiviral medications. In addition to that, I do think that we have to very quickly figure out what we are going to do about the medical surge issues, because again, most of us haven't had to exercise that part of our pandemic plan. And the last thing that I will say is that for us, if there is a lot of disease, both being able to monitor what is going on as well as do the diagnostic work in our laboratory--I mean, Pennsylvania is a large State. We are the sixth largest State in terms of population. We only have 300 cases, and it has been all we could do to be able to count what we are seeing and to make the diagnoses in our laboratory. We are sort of relying on two people in our laboratory to do all this work, and if one of them gets the flu, then we are down by 50 percent. So we need to, I think, pretty quickly figure out how we deepen our bench strength between now and the fall because I think that these will all be serious gaps for us. The last thing that I will say is that in terms of the Federal guidance, one of the things I think that is important-- and I have a fairly unique perspective, because I worked at the CDC for 20-some years, so I was on the giving end rather than the receiving end for all that time period--is that we don't like it to be so prescriptive that there is not a lot of wiggle room. We in Pennsylvania, as far as school closures, we set up our policy right from the very beginning. We have held to that policy all along. We didn't think that the initial recommendations from the CDC were quite correct and we didn't think the revised recommendations were quite correct, either. So we don't want them to be so prescriptive that it looks like we are not following what other people are doing. Each State has to take that guidance and interpret it and translate it to their local circumstances. That is what is being done in Arkansas and that is what we are doing in Pennsylvania. Senator Pryor. Let me ask about this medical surge question that you brought up. It is really just for the panel at large. Given the economic downturn and given that certain hospitals, first responders, you name it, there have been some layoffs and some cutbacks, a lot of cities and counties and States are having to do cutbacks and this can be very painful. But it seems to me this is the worst time that they could be cutting back on these type of health-related services, but the reality is what it is. So any advice for this fall? Dr. Jarris. Dr. Jarris. Yes. It is an excellent question, Senator. We have looked at the State and local public health agencies, and due to the budget constraints in the States, we have lost over 11,000 positions in the last year and that pace is continuing. Given an outbreak, and we have already seen this in the last several weeks, we have taken a drastically diminished workforce and put them on two shifts from one shift. There is only so much people can do, and that really strained the system. On top of that, of course, we have had certain States who have actually run out of places to build the pandemic response so they are actually ramping down in the face of an escalating outbreak. So this is again the reason why we need some Federal assistance to mount the response and protect the American people. Senator Pryor. Mr. Thomasian, do you have any thoughts on that? Mr. Thomasian. Well, it is an excellent point. I will say that in our work at NGA, we projected even after the recovery dollars are spent that States will be facing over the next 2 years somewhere between $170 and $230 billion in deficits across the States, so it is a tough time. It is very difficult to build a government around a peak event that may not occur. I do feel, though, that if further resources were available to States, there are some critical areas that would certainly help. It may not address all the surge capacity, but certainly one is laboratory capacity is sorely needed in the States. Also, assistance again on exercising. Clearly, States will need to build as much capacity as they can afford to do in these areas, but honestly, I think this is an area that we have not been tested in and we will probably find that we will be sorely behind if a large event does come. Senator Pryor. Yes, Mr. Steinhardt. Ms. Steinhardt. Just to add to the comments that have already been made, looking at vaccine production, at best, at least from my understanding, if we begin today, we are looking at November for the initial production lines for this virus. So we still have this long period between now and then in which communities have to be able to respond to the continuing epidemic or a resurgence in a more virulent form. And so the kind of planning, the kinds of activities that have to take place before we even have a vaccine are really our first--need to be our first considerations here. What kinds of capacities do we need to build into communities? And I think as we look at priorities for funding and allocations of funding, we need to keep that very much in mind. Senator Pryor. OK. As I understand it, the World Health Organization is deliberating whether to move this from a Phase Five to a Phase Six. First, I don't understand the complete significance of that. And second, I guess, Dr. Ostroff, if they move from a Phase Five to a Phase Six, what does that mean for the United States? How does that change things here? Dr. Ostroff. I think in practical terms, it really doesn't change very much for us. Our planning, our thinking, our activities are all predicated on what we think the appropriate things to do in the United States are. I do think that part of the difficulty and why World Health Organization (WHO) has been having such struggles around this particular issue is that when you move to Phase Six, it sort of trips off a whole lot of activities in other parts of the world, some of them appropriate and some of them inappropriate based on their particular circumstances. And so I think it does make a difference. I think that we have seen many countries do things that, in terms of entry and exit screening, etc., that may not necessarily be the best application of resources and if this would give them further reason to do some of those things, then I think it would be somewhat problematic. But in terms of the way that we would approach what needs to be done here in the United States, I don't really think it makes that much of a difference, which level they define it as. Senator Pryor. Dr. Jarris. Dr. Jarris. Yes. I would agree with my colleague that in terms of our response in the United States, within our borders, it probably doesn't change what we do because we have the epidemic. But as a global leader, it may very well change what we do. One is as this continues to spread around the world, which it has been, and frankly, it is almost academic whether they declare it Phase Six or not because I think they met the criteria a month or more ago but there have been political discussions. But the issue is what role will the United States play in terms of a health diplomacy role worldwide if we have outbreaks hitting undeveloped countries or developing countries who do not have an infrastructure for public health and we see many more deaths because some of these countries have high rates of HIV, what will the United States do? Will we feel a responsibility to go and assist these nations? And what is our responsibility to the rest of the world with regard to things like vaccine and antivirals? If we were producing antivirals with our domestic capacity only for the United States, we might produce it one way without the vaccine sparing adjutants. However, the whole world needs the vaccine, and if we need to help other parts of the world, we probably do have to put adjutants to stretch the supply that we can produce even further. So I would suggest that our political leadership involved and scientific community involved with global health issues will have some significant questions to address in terms of the U.S. leadership. Senator Pryor. That is fair enough. Let me ask about this map that we have here.\1\ You can see the confirmed cases around the world. When you see a map like this and when you look at the numbers, the quantity of this around the world and the fact that it is spread out geographically, from a scientific perspective, does that increase the chance of mutation or does that have any bearing on the chances of mutation? --------------------------------------------------------------------------- \1\ The map referred to by Senator Pryor appears in the Appendix on page 93. --------------------------------------------------------------------------- Dr. Jarris. Every infection increases the chance. Viruses do mutate rapidly, and as they travel around the world and are exposed to different populations of humans, of animals, there is an increased chance of resortment. So yes, the more it spreads, the more the chance of resortment. Now, one thing to consider is since this is a novel virus, there isn't a heavy evolutionary pressure on it to evolve. In and of itself, it is making people sick and surviving. So we can't conclusively say whether it will resort or not. The great fear, of course, is that it does mix with someone with an H5N1 or mix with a seasonal influenza that is Tamiflu-resistant and then we are in trouble. But that really is another one of the unknowables. Senator Pryor. Mr. Thomasian, let me ask you about the Medical Reserve Corps. Can the States activate that, and what is that process? Mr. Thomasian. I am not completely familiar with the activation process. I believe they can, but I would have to get back to you on that. Senator Pryor. Dr. Jarris, did you---- Dr. Jarris. Yes. There is a Medical Reserve Corps that has been very helpful in certain limited disasters around the country. What we have found in areas severely hit, in Texas and Louisiana during their hurricanes, though, is the Medical Reserve Corps are people who have other jobs, and so when you are mounting a sustained response, they can't be counted on to be there day in and day out in shifts, so the doctors have to go back to their office to practice and nurses have to go back to the hospital or the health departments to their shift. So what Texas has found, in fact, is that although they welcome them and like to work with them, they have actually had to go out and contract for paid professionals to come in and work for them because then you have performance standards that you can maintain. That again will be important with the vaccinations in the fall as well as if we have to do mass dispensing of Tamiflu. We are going to have to hire in contract nurses or hospital nurses or VNA nurses, which means with them having other jobs, time-and-a-half, weekend pay, and things like that. Senator Pryor. OK. Let me ask this. I am getting down to the end of my questions, and like I said, we will keep the record open and some other Senators will probably have other questions. But given the last few months where the flu was first discovered in North America and it was almost wall-to- wall coverage there for several days on the cable news channels, etc., how did the media do and how did the public health officials and the elected officials do in getting the word out to the public and communicating the nature of this? Can you all grade that? Is that one of the lessons learned that we can improve? Mr. Thomasian. Well, in my comments, I addressed--I think I would give them high marks. I would give the Federal officials and the public officials at the State and local level high marks for communicating to the public and communicating to the media, and the media did a good job, I think, reporting on the nature of the disease and where it was. Again, I think where the breakdown began in some areas was, well, so what do we do? What is the appropriate government response? And I think there was some initial hesitancy at the opening to talk about issues like quarantine and why you should and why you shouldn't use it and issues like travel bans so that we got into this situation for a while where there was a discussion of, should we block the borders in Mexico, and that percolated for a few days. But initially, I do think that the communication was very good and I think the public had a sense that this disease was existing out there, it wasn't a disaster, and they were getting up-to- date information. Senator Pryor. Does anybody else want to add to that? Dr. Jarris. There was a study done by Harvard University, a sample of the American people, and as I mentioned briefly before, 88 percent of Americans that were surveyed expressed satisfaction with the information they were getting. So I think we did a good job. I think it was clear, and Dr. Besser should be commended. He did a wonderful job, the Acting Director of the CDC. The one place I think we are falling down right now is we have shut it down. I mean, you can't find anything in the media anymore. We should be using this time to let people know that now is the time to prepare. Now they should figure out in the fall if their kids' school is canceled, how are they going to take care of the kids? How are they going to telecommute? What if their elderly parent gets sick? We are missing an opportunity now, ahead of time, to have people think about the fall. Ms. Steinhardt. If I can add to that---- Senator Pryor. Yes, go ahead. Ms. Steinhardt [continuing]. I think I would agree that the response and the communications were first-rate. But I think from our experience, looking at what happened several years ago when we first began to see cases of bird flu and outbreaks of H5N1 virus in humans, there was an enormous amount of attention, and then it fell off, and for most of the public, it seemed as though this issue went away completely. Unfortunately, what the public loses interest in, government often loses interest in, as well. I think within the public health community, members of the public health community never lost sight of this problem, but otherwise, we let other issues take priority, and we know this from conversations we had with people in the private sector. Other food safety issues, whatever the issue of the day was, that is what took attention. So we need to, I think, somehow keep sight within government of our priorities and what the real dangers to the public are, whether it is covered in the media or not. Senator Pryor. Dr. Ostroff. Dr. Ostroff. Yes. I will just add a couple of comments, because I agree with everything that was said. I think that over the last few years, it has been ingrained in the public's mind that when something happens related to flu, it is going to be like the big bang. When that didn't quite happen right at the very beginning, I think there was a tendency for everyone to shrug their shoulders, saying, what is the big deal here? What you heard was a lot of descriptions of this as being mild. Flu is never mild, and we tried very vigorously to say that this is not a mild disease now and it could be even more severe in the coming months. And so I do think that there is a segment of the population who feels that this was sort of like oversold to them when, in point of fact, I think that many of us are very concerned about what we are seeing right now and we are awfully concerned about what is going to happen in the fall. So I do think that I would echo the comment that we have to continue to reinforce the message that what you have seen so far might not necessarily be what you see later on. But having said that, I would fully concur. I think that the Federal officials, in particular, did a fantastic job conveying information to the public. It was a transitional group of people, and given the circumstances and the amount of attention that this initially got, I think they did a wonderful job. Senator Pryor. Let me follow up on that. Ms. Steinhardt, you may be the best one to ask. There is sort of a lull period right now in terms of public awareness on this. If it comes back this fall, the lull will be over. A lot of people will be looking back and saying, why didn't we do something different? What would you recommend right now to the private sector in terms of the things they can be doing? It sounds like the government is going to continue to plan and work and try to coordinate, and there is a lot of work that we have talked about that needs to be done, but we haven't talked a lot about the private sector yet. Do you have any suggestions for the private sector? Ms. Steinhardt. Well, I have suggestions for the government in working with the private sector. We have this system of coordinating councils for critical infrastructure sectors. In fact, in work that we did here, we found that they could be used much more than they currently are. There are a lot of questions that the private sector has within these critical sectors that they have about how government policies are going to work. How are States and the Federal Government going to handle State border closings? These are vital issues for commerce. And those discussions should be happening today between private sector and government. We are not in this alone and these are issues that have to be resolved in tandem, and that is one area where we certainly would urge greater attention. Senator Pryor. I have one last follow-up question. It is really a two-part question. I want to ask each of you this, and that is what is the single most important step that we can take to increase our preparedness in the next 3 months, from now until the fall? What is the single most important step we can take, and how do you suggest that we do it? Dr. Ostroff. Dr. Ostroff. Well, I wish I could tell you that there was a single step, because there isn't. There is a series of steps that I think we need to deal with. Senator Pryor. Is there one thing, though, that---- Dr. Ostroff. Well, I think that the two areas that I really think that we need to focus on is we need to get our house in order for issues related to vaccination because we know for influenza that is the single best preventive measure we have available. And I do have concerns that we will see more morbidity and certainly more mortality for this as we go along and I do think we have to think about how we deal with medical surge issues. Senator Pryor. And so you are thinking vaccine, even though it could mutate, but you are saying, place your bet on what you know---- Dr. Ostroff. I think not placing your bet on what we currently know would be a significant mistake. Senator Pryor. OK. Mr. Jarris. Dr. Jarris. Limited to one, it is a very difficult question because there is so much that has to be done. But I would think that if I was in the shoes of Congress and the Administration, the single most important thing to do is to appropriate sufficient resources in the next 2 weeks with this supplemental. There is so much that needs to be done. We don't have time to catch up later. Earlier, you asked how to prioritize the $1 billion, and that is a very difficult question because just the vaccines are $15 billion. Senator Pryor. That sounds like a lot of money, but it is not---- Dr. Jarris. Yes, in the old days. But frankly, if we appropriate less than what is needed, for example, the $15 billion for vaccines, and we need more than that, then the question that makes sense would be, well, if we appropriate $1 billion, which one-fifteenth of the American public are we willing to vaccinate and which fourteen-fifteenths are we not willing to vaccinate? Senator Pryor. Mr. Thomasian. Mr. Thomasian. Thank you. Well, this is an excellent question and I will take mine beyond the public health arena. The one thing that we need to keep in mind is that this was not really a test. This was not really even a pop quiz. When we did our workshops, we asked States to envision a scenario where 90 million people came down with the disease and we had 1.5 million people needing intensive hospital care and an estimated 1.9 million deaths. And I would have the States, if they received resources for exercises and further planning, to consider how they would maintain continuity of society under those situations. How would public safety react? How would we handle the high degree of absenteeism in both State government as well as our critical services, such as food services, electricity, etc. So I would use these intervening months to examine what would happen if this became the true pandemic and the scenarios that we thought we would be looking at under the 1918 scenario and go beyond the public health aspects and look at the public safety, as well. Senator Pryor. OK. Ms. Steinhardt. Ms. Steinhardt. Well, I would certainly support that. I would say this is our time now to take a look at what our plans are, what our plans have been, what we have learned from what has happened over this last month. What assumptions do we need to revisit? This is our opportunity to learn from a real live test, and it is also our opportunity to actually pull in the results of a number of different tests that have happened over the last few years. I don't think we have learned nearly as much or incorporated the lessons learned from the various tests and exercises that have been done around the country and incorporated that into our thinking, but now we have this opportunity to just take that pause and think about what we know and what we need to change in our plans going forward. Senator Pryor. Good. I want to thank all four panelists. I hope I didn't grill you too much. We are going to leave the record open, as I mentioned, and I know Senator Ensign and others will submit some questions for the record. We would appreciate you getting those back to us within 14 days. Thank you very much for your attention, and I appreciate all the work you have done in your various capacities. You are playing a very important role in saving American lives and we just appreciate everything you are doing. So with that, we are going to conclude the hearing and leave the record open for 14 days. Thank you. [Whereupon, at 3:14 p.m., the Subcommittee was adjourned.] A P P E N D I X ---------- PREPARED STATEMENT OF SENATOR ENSIGN While the media attention for the H1N1 virus has subsided, this hearing is no less important. Health officials believe that this virus could come back stronger during flu season this fall, and we have to be prepared for that. Right now, Federal officials are beginning to track this virus as it heads to the southern hemisphere to gain a better understanding of what it does in populations that are just entering the winter flu season. I am hopeful that whatever characteristics are identified will help us in our preparedness efforts. While the number of confirmed cases of H1N1 in Nevada is on the low end at 102, a combination of guidance from the Federal Government and decisions made at the local level helped mitigate the spread of the disease. Two weeks ago, in Washoe County, Nevada, surveillance procedures revealed an increased absenteeism rate at Mendive Middle School. Local health district officials awaited word from the State laboratory as to whether or not the children were sick with H1N1. Upon confirmation, the Joint Health and Education Authorities Influenza Oversight Committee met quickly and decided to close the school. The decision was made when only five tests had come back positive for H1N1; however eight additional cases from the school have since been confirmed. State officials have noted that the guidance on school closures has been successful and the closure of Mendive is an excellent example of how the policy worked. Today we will hear from a number of witnesses who will help us understand how States have responded to this virus over the last month. Their testimony will highlight successful responses and areas that need improvement. As with any emergency, lessons learned can be invaluable. Ideally, the discussion we have here today will provide information for States as they update their State preparedness plans to address the potential for a more potent strain of H1N1. Approximately 36,000 people die as a result of influenza each year. Should this virus re-emerge as a stronger strain than we are seeing today, citizens should continue to exercise precaution and personal responsibility. While we can't predict the severity of a possible mutation, we can do our best to minimize its effects. 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