|Archived hearing: Oct. 3 2007 at 2:30 PM
Homeland Security and Governmental Affairs
State, Local, and Private Sector Preparedness and Integration Subcommittee
To hold hearings to examine pandemic influenza, focusing on state and local government efforts to prepare.
What follows is NOT a transcript, but a report (by me, typing!) of the statements (I tried to be as accurate as I could) and then a brief summary of key points in the Q and A. I do not intend to do a report on the second panel!
Senator Pryor (AR): ...thank everyone for coming.... and talk about something as important as a flu pandemic make sure we are prepared.....
We hope that day never comes but we hope that this country is prepared if that day should come. .....
For most American idea of flu pandemic is abstract. When we hear about on the news it seems to be In birds; other side of world; I think for a lot of people in this country, even though they know it is a potential threat it is not real; we as leaders and planners we need to be sure we're ready in the event it does come.
I think the thing that concerns the experts about a flu pandemic - when you look at bird flu around the world- the numbers are startling. How rapidly it spreads through avian population; also look at humans:
329 humans infected 201 passed away - so that's 61% of the people who've ever had it have died from it. So that's very alarming numbers. See this chart here - confirmed cases w/age and outcome; disturbing numbers. Not one of those that just hits young and old people. If you get it you have a real chance of not surviving contact with bird flu.
So the concern would be if mutates into a contagious human disease - the consequences could be very dire. Don't want to talk like a science fiction - but some of the scenarios that people talk about really cause great concern.
The number of Americans who could not survive this, what it could do in terms of overwhelming our Health Care, infrastructure , restrictions on travel, maybe having to institute quarantine or martial law. Have to think things through
Other thing that we see is that a flu pandemic is problematic for government because so many different sections of the government that have to deal with it. Just on the federal level you look at DHS, HHS, Homeland Security, other agencies that would have to deal with it.. Also fed - state - local issue - not just political leaders-health officials, first responders, lot of local officials that have to make very critical decisions in a short period of time. That's why we keep coming back to PLANNING and hopefully being able to test our planning and being prepared.
So today Senator Sununu and I wanted to encourage dialog, make sure everyone's talking like they should be, everyone's planning like they should be.
Senator Sununu may have a statement when he arrives We will have one or more senators who come in through out the course of this - lots of votes going on right now.
First we have Rear Admiral Craig Vanderwagon who serves as Asst Sec for Preparedness and Response at HHS: His office is charged with leading the nation in the prevention, response and reduction of adverse health effects of public health disasters.
He is the department senior advisor to the secretary for the matters relating to bioterrorism and public health emergencies. He'll be discussing progress his office has made as well as efforts they are making in coordinating public health awareness across all levels of government
Our second panelist will be Dr. Tillman Jolly: He's the associate chief medical officer/ office of Health Affairs at DHS. Extensive background in emergency medicine and medical operations planning and consulting, in addition to practicing emergency medicine and serving on medical staff of 5 Superbowls and US Open Golf championship.
Today will report on progress of DHS office of health and affairs and coordinating with relevant DHS departments as well as other federal, state and local agencies.
You spoke of partnerships - there is a partnership between legislative and executive branches that has to be strengthened and built upon.
The Assistant secretary is the responsible party for HHS in coordinating coordinating medical and public health responses.
It was established 10 months ago with Dec. 19 2006 with the signing of the law, Pandmemic and all hazards preparedness act. Transfer of authorities related to development of medical counter measures.
Various authorities, partnerships with CDC etc.
Hospital preparedness plans, various authorities related to medical reserve corps. Many new authorities related to countermeasures..
And in Aug. we assumed leadership in our office for pandemic flu for HHS.
As you know PF could be quite catastrophic even will effect all sectors society; involves planning, interoperability wide variety of sectors public safety, commerce, all have a role in preparing for pandemic flu.
About 1.5 years ago Congress and the executive did lay out a plan how we would try and address issues with panflu, a strategy. That strategy was based on a theory of victory. Not expectation that we could stop dead in tracks but could delay emergence and reduce # of people who became ill ill.
1)Development of vaccine capability
2)antiviral capability - production capability was at that time small
3) Community mitigation strategies - commitments to them
4)Development of surge capacity - additional facilities space and people with skills.
We've made pretty good progress and I think will hear from state and local colleagues about the progress they've been making. I will report, I made numerous visits to states. I was in NC last week. NC last year did 87 exercise involving seven thousand people in preparing for pandemic flu; So there's a great deal of activity going on at community level where it really needs to be, in a pandemic flu.
This really highlights the shared responsibility that prevails particularly as we look forward to future steps. Early in this course, the last year or two, the federal governments and state governments have been lead players -earlier vaccine, infrastructure, antiviral, initial planning and training. These were roles for fed and state.
The next steps will build on successes - inc antiviral prophylaxis - but this will require wider application of shared responsibilities among businesses, Health Care industry individuals and families.
There are new developments that need to be taken advantage of: We need cheaper ventilators, less labor intensive ventilator for the kind of respiratory support we may need.
Additional guidance for augmentation of CMG: using respirator protection such N95 respirators. Science doesn't give us a clear answer but we will need to find solutions to these gaps, and we'll need to find them in concert with state local business and individual colleagues.
In summary: our office is functional. Pandemic and All Hazards act is being implemented. Panflu preparedness has moved pretty smartly. We've made pretty good progress - not only in panflu but on a variety of hazards. Gaps still exist, additional steps will and must be taken, must be in context of shared responsibility.
We will continue to consult state local and private businesses as we address this next set of gaps. Without that consultation we will not have an effective plan and a comprehensive capability to respond when the nation needs us.
13:00 Dr. Jolly:
Thanks you for the opportunity to testify to day to discuss our efforts in overall pandemic preparedness..(More thanks).
Pandemic is unique. It is likely to come in waves, pass thru communities of all sizes across the nations of the world simultaneously. The pandemic may last as long as 18 months. An unmitigated pandemic (and I emphasis unmitigated) could result in 200,000 to 2,000,000 deaths in the US depending on its severity.
Further, an influenza pandemic could have major impacts including our nation's Critical infrastructure/Key Resources based on illness and related absenteeism.
DHS has been and remains actively engaged with its federal state local territorial and tribal private partners alongside HHS to prepare our nation and the international community for an influenza pandemic.
As outlined in the implementation plan, DHS is responsible for the coordination of the overall domestic federal response during an influenza pandemic including: implementing policies that facilitate compliance with recommended social distancing measures, developing a common operating picture for all federal departments and agencies; insuring integrity of nation's infrastructure and domestic security; and entry and exit screening for influenza at our borders.
In working with out partners, such as HHS, State Department, and USDA, DHS has developed and implemented a number of initiatives and outreaches for continuity of operations planning for all levels of government and private-sector entities.
I'll highlight a few noteworthy accomplishments and responsibilities under the implementation plan:
DHS produced and released the Pandemic Influenza Preparedness, Response, and Recovery Guide for Critical Industries/Key Resources. The guide has served to support business and other private sector in pandemic planning, by complementing and enhancing, but not replacing, the existing COOP planning efforts With that in mind DHS and its partners developed a guide to assist businesses whose existing COOP plans generally do not include plans to protect human health during a pandemic.
As a next step - leading the development of specific guides for each 17 CI/KR sectors using the security partnership model.
In coordination with other fed depts and agencies, DHS is developing a coordinated govt wide planning form.
Initial analysis of response requirements for federal support has been completed.
From this analysis a national plan defining the fed concepts for coordinating response and recovery operations during a pandemic has been developed, and will be undergoing interagency review.
Utilizing this planning process the coordinated federal border management plan has been developed and is also under review. This process included a wide range of partners.
DHS has also conducted or participated in fed or state pandemic exercises and has held work shops and forums with critical resources Key Resources Owners and Operators.
Consistent with the role, under Homeland Security Presidential Directive 5, Secretary Chertoff pre-designated Vice Admiral Vivian Crea, Vice Commandant of the Coast Guard, as the national PFO for pandemic influenza and has pre-designated 5 regional PFOs and 10 deputy PFOs.
Likewise our partners have pre-designated infrastructure liaisons, fed coordinating officers, senior officials for health as well as defense coordinating officers.
Vice Admiral Crea and the regional PFOs have participated in multi agency training and orientation sessions regarding pandemic duties.
Additionally the PFOs have begun outreach both national and in their regions, and have participated nationally in their regions and advanced a more formalized program which has been developed by DHS.
On an ongoing basic DHS participates in interagency working groups to develop guidance including Community Mitigation Strategies, Medical counter measures,
Vaccine Prioritization, and Risk communication strategies.
In closing significant progress has been made in national preparedness for pandemic influenza.
DHS looks forward to continuing its partnerships with fed state local territorial and private sector stakeholders to complete the work of pandemic preparedness and to further the nation's ability to respond to all hazards.
Thank you for the opportunity to testify on behalf of the Dept of Homeland Security.
Senator: Roles and responsibilities, who's in charge? Study done HSC national Strategic influenza Plan responsibilities in a crisis are split between HHS and DHS ; HHS for health, DHS in emergency. Panflu crisis is BOTH - have the 2 departments worked it out?
Jolly: (DHS): We all feel comfortable. Every crisis has health implication. Under HSD #5 Secretary of Homeland Security responsible for overall incident coordination. HHS is responsibility for specific public health and med response - very large in this situation.
Vanderwagon: (HHS) agree there are 15 useful emergency support fuctions, health is one, has a big role HHS health messaging and interventions are our responsibility but under under overarching responsibilities of DHS.
Senator: same report said only been 1 Only been 1 national multi-jurisdictional exercise - do you all have plans for further national multi-jurisdictional exercises that would coordinate all the various levels that would need to be coordinated?
Jolly (DHS) Do have plans. Number of state and local exercises, quite important, ongoing plans in coming months....complex set of exercises, one won't do it. HHS also had exercises to do that.
Senator: What's your time frame? Working now?
Jolly (DHS) ? Beginning the planning of those now. Important to develop strategic plans first, coming months will exercise them. Cabinet level down.
Senator: Something that is part of the nature of a pandemic flu. Generally ... disaster ...Stafford act gets triggered and neighboring states help, regional approach. But in a flu epidemic, governors might be reluctant to send people to nearby state to help - may be next, may be spreading virus back and forth. How do you adjust overall planning for that contingency? This just behaves differently from other disasters.
Vanderwagon (HHS): Secretary Leavitt in 2005 went to every state and his message was pretty much the same - you need to be prepared to take care of yourself; that circumstance is highly likely. In our work with local and state - how much capacity can we fill internally, not relying on EMAC or fed system Very difficult if talking about facilities and personal. Very important to build from base to make localities as self sufficient as you can.
Senator: Making progress?
Vanderwagon: Yes, what are objective measures: medical reserve corp 120,000 individuals more. States have local programs. Pre-identified volunteers with skill sets needed to fill roles that localities have identified as being in need in an event like this that the states and localities have identified.
Senator: Stay with that line of question: how a flu pandemic behaves across the country... Los Alamos national lab scenario - 10 Avian Flu people get off plane in LAX - spreads across country; runs course through country. Do you all generally agree that that is a realistic model? Fair model?
Jolly (DHS): probably fair. Lot of models. Largely based on history 1918,
Vanderwagon (HHS) : unmitigated, unintervened upon event unfolding. Modelers - given this as the base - what can we do? CMS ST Louis in 1918 - respiratory protection and social distancing - could reduce by 50%. Using social distancing practices could give us 70% more conservative 50% - without adding antivirals or vaccines in play..
Resp. protection, social distancing, reduced by 50% the number of cases and mortality. CMStrategies could give us 70% or 50% reduction. Without adding antivirals or vaccine.
Senator: You are saying HHS, DHS, state and local may take steps to make sure we don't see rapid spread?
Vanderwagon (HHS): that's the planning most communities are doing. Looking to invest in new vaccines (next months or two) that may reduce production time for vaccine from 20 weeks down to 8 weeks. Number of strategies technologies will allow us to play so we can put more tool sin the hands of communities. If they use just the CM they'll get a certain reduction. Add more, may be able to reduce rate of spread.
Senator: quick Q about vaccines - in terms of vaccine as I understand it, med and scientifically you need samples of the real strain; once you get those samples it'll take come time to develop vaccine, enough vaccines
Vanderwagon (HHS): in the stockpile we have significant number of doses based on H5N1 in Asia. But if that's not the particular strain, we'll have to produce a different strain. Right now production time is about 20 weeks right now to full production of a vaccine.
Other things on the horizon positive picture. Testing: With adjuvants - augment to increase immune response - we may have 20fold more vaccine which would give us enough probably to cover everyone in the country if it was H5N1 as we've developed a vaccine for that this point. Lots of technological activities give us HOPE we could intervene and slow this down dramatically..
Senator: in terms of Health Care infrastructure -see a map like that look at LA medical infrastructure could be totally overwhelmed. Is that part of our planning, to allocate respurces - concrete limitations on hospital beds? Figuring out other arrangements, bring in more medical professionals, to the area.
Vanderwagon (HHS) : States using hosp. preparedness grants and their own funds have been increasing their fiscal commitment as much as feds have. Stand up portable hospitals. Rate limiting step is number of people ill or not ill and available. 40% absentee rate in Health CareWorkers can't provide care so volunteer work force is being pre-identified.
Early cases - many exercises are targeted on early - what can we bring to the fight?
Once it goes to half a dozen communities, we'll back off - looking at a broader based population. If we can slow it down in LA, great for us. If it's in 20 cities go to plan B - local capacity plan.
Jolly (DHS) key is reduce up front reduction - employ mitigation strategies VERY EARLY; modeling shows key is doing it early, can make a difference reduces the load and spreads out the load.
Senator: Does that include economic load? Hospitals are overwhelmed, percentage of uninsured - will this financially burden our health care system?
Jolly: number of potential effects - part of modeling.
Vanderwagon: and this goes to how we work in synch. Leavitt can declare a public health emergency, sets in effect waivers, hospitals can take care of people and be reimbursed. If taking additional burdens can get paid 150% of existing Medicare rate; Katrina had additional funds available.
Senator Akaka: One of 2007-08 flu season strains is type A- H3N2 - linked to 1969 Hong Kong pandemic flu - killed 2 million people worldwide. Outlook for the upcoming season, are we prepared?
Vanderwagon: vaccines produced 6 months before flu arrives - prognosticators tried to pick; didn't get right one. Will see virus don't have full protection - vaccines will provide "pretty good coverage" from it.
Jolly: every year some are more closely matched than others - major issue is get people vaccinated. Supply this year is good - challenge is to get public vaccinated early.
Akaka: concern that avian flu attacks chicken and eggs - you produce the vaccine - may be problems producing enough vaccine?
Vanderwagon - invested 3.2 billion to convert from egg based to cell based technologies; 5 manufacturers that are converting over to cell based - major investments. Next - trying to target recombinant vaccine to shorten prodsuction by half - based on European studies - trying to get around older approach.
Jolly - poultry industry taken great strides for bio security.
Akaka: HHS and DHS are leaders but GAO recently testfieid thht their respective roles haven't been clarified. Has HHS and DHS communicated to state and local their roles?
Jolly (DHS): clear delineation. HHS is manager of overall incident; all of our interaction of states; leaves HHS with large role of managing infrastructure?. (sic)
Vanderwagon: worked with Crea as she develops overarching plan, we nestle into place.
Akaka: current flu vaccine may not give us protection this season. What will fatalities be this season?
Vandewagon(HHS) no epidemiological studies of changes. We'll have to see how it projects into our population.
Akaka: HHS responsible for strategic national stockpile. 6.1 billion appropriated for Tamiflu Relenza and vaccines. Status, update of stockpile for Hawaii?
Vanderwagon: at the time strategy was marked out, only produceing 15 million per year; so strategy was only for treatment. We have purchased on plan 37 million; states purchased 15 million. Up to 81 million by end of 2008. We're on plan, making good progress.
Other: looking for alternatives, diagnostics;
Senator: vaccines again. WHO says worldwide pandemic flu vaccine capability 1.2 million does TOTAL. Agree?
Vanderwagon: More capacity. We have taken delivery into the stockpile of 15 million doses of vaccine, our purchases a lone.
Senator: tell me about our stockpiles, shelf life, etc. status of stockpile
Vanderwagon: Talking about Pre Pandemic H5N1 vaccine, 2 or 3 varieties; we have 26 million doses by the end of this calendar year - 3 year shelf life - have to think about how to sustain investment?.
Then we have 37.5 million antivirals antivirals on plan will purchase another 15 million... states will purchase another ....to meet goal
Should we consider use of these in a prophylactic way (high risk environment?)
We know from seasonal flu 15% to 30% of HCW will get sick - should we use antivirals for them? For people home taking care of someone there? Is that local responsibility? Individual resp? business resp? Working through with our stakeholders.
Senator: hinted at ways to have larger capacity? Retrofitting domestic production plans?
Vandewagon- Productin capactity - explaned 6 million dollars; 133 million into facilities retrofitting 10 million vaccine production; antigen sparing agents when added to vaccine may make vaccine more potent - reducing amount you need to get a good response. From 90 down to 3 micrograms; we're not betting on 3 but if we can go down to 15 or 20 mcg we'll have more vaccine by adding the adjuvants - in clinical trials to establish safety and efficacy.
Senator: What's the criteria to decide which producers receive vaccine contracts?
Vanderwagon: simple - US licensed; want domestic production capability. 5 or 6 firms in the hunt. Building infrastructure base across the base - we'll have supply we need.
Senator: last thing - certain stockpile - planning on go out and get MORE in a rapid fashion, are we doing advance pricing contracts to be ready with manufactures
Vanderwagon: recently conducted gap analysis - some industries have no further production capacity to provide surge products (inc. N95 respirators) - rely on off-shore material supply - complex market analysis - trying to prioritize against high demand like respirators.
Vanderwagon (HHS) Dialog is absolutely necessary - we have a challenge to meet the nation's needs.