[Senate Hearing 111-154]
[From the U.S. Government Printing Office]
S. Hrg. 111-154
PANDEMIC FLU: CLOSING THE GAPS
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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 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
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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 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
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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
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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.
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\1\ The prepared statement of Ms. Steinhardt appears in the
Appendix on page 24.
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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.
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\1\ The prepared statement of Mr. Thomasian appears in the Appendix
on page 48.
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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.
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\1\ The prepared statement of Dr. Jarris appears in the Appendix on
page 62.
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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.
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\1\ The prepared statement of Dr. Ostroff appears in the Appendix
on page 69.
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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?
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\1\ The map referred to by Senator Pryor appears in the Appendix on
page 93.
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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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