[Senate Hearing 109-604]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 109-604
 
                       PREPARING FOR PANDEMIC FLU

=======================================================================

                                HEARING

                               before the

                       SPECIAL COMMITTEE ON AGING
                          UNITED STATES SENATE

                       ONE HUNDRED NINTH CONGRESS

                             SECOND SESSION

                               __________

                             WASHINGTON, DC

                               __________

                              MAY 25, 2006

                               __________

                           Serial No. 109-24

         Printed for the use of the Special Committee on Aging



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                       SPECIAL COMMITTEE ON AGING

                     GORDON SMITH, Oregon, Chairman
RICHARD SHELBY, Alabama              HERB KOHL, Wisconsin
SUSAN COLLINS, Maine                 JAMES M. JEFFORDS, Vermont
JAMES M. TALENT, Missouri            RON WYDEN, Oregon
ELIZABETH DOLE, North Carolina       BLANCHE L. LINCOLN, Arkansas
MEL MARTINEZ, Florida                EVAN BAYH, Indiana
LARRY E. CRAIG, Idaho                THOMAS R. CARPER, Delaware
RICK SANTORUM, Pennsylvania          BILL NELSON, Florida
CONRAD BURNS, Montana                HILLARY RODHAM CLINTON, New York
LAMAR ALEXANDER, Tennessee           KEN SALAZAR, Colorado
JIM DEMINT, South Carolina
                    Catherine Finley, Staff Director
               Julie Cohen, Ranking Member Staff Director

                                  (ii)

  


                            C O N T E N T S

                              ----------                              
                                                                   Page
Opening Statement of Senator Gordon Smith........................     1
Opening Statement of Senator Herb Kohl...........................     3

                                Panel I

Hon. Michael O. Leavitt, Secretary, U.S. Department of Health and 
  Human Services, Washington, DC.................................     4

                                Panel II

Nancy Donegan, director of Infection Control, Washington Hospital 
  Center, Washington, DC; on behalf of the National Hospital 
  Association....................................................    27
J. Steven Cline, DDS, MPH, chief, Epidemiology Section, Division 
  of Public Health, North Carolina Department of Health and Human 
  Services, Raleigh, NC..........................................    42

                                APPENDIX

Prepared Statement of Senator Hillary Rodham Clinton.............    55

                                 (iii)

  


                       PREPARING FOR PANDEMIC FLU

                              ----------                              --



                         THURSDAY, MAY 25, 2006

                                       U.S. Senate,
                                Special Committee on Aging,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10 a.m., in room 
SD-G50, Dirksen Senate Office Building, Hon. Gordon H. Smith 
(chairman of the committee) presiding.
    Present: Senators Smith, Kohl and Carper.

      OPENING STATEMENT OF SENATOR GORDON SMITH, CHAIRMAN

    The Chairman. Good morning, ladies and gentlemen. We 
welcome you to this hearing of the Senate Special Committee on 
Aging, and our hearing today is ``Preparing for Pandemic Flu.''
    We have heard a great deal in the last several years about 
emergency planning and response. The tragedies of September 11 
and Hurricanes Katrina and Rita showed us all just how 
vulnerable we can be to both man-made and natural disasters. 
Applying the lessons we learned from the past, we move forward 
with preparing to address the potential threats of tomorrow. 
While much may still be unknown about those threats, more and 
more indicators suggest that we may soon face a pandemic 
outbreak of a new influenza virus.
    One does not have to look far back into history to see how 
devastating a severe pandemic flu can be to our society. In 
1918, Spanish flu killed an estimated 2 percent of the world's 
population, mainly the young and the healthy. The milder Hong 
Kong flu outbreak in 1968 killed 34,000 in the U.S. alone, and 
caused between $71 and $166 billion in economic losses.
    We have been fortunate not to experience a catastrophic flu 
outbreak for many decades, but the emergence of the highly 
aggressive avian flu virus in the late 1990's has generated a 
sense of urgency among the world's public health officials.
    Just this week, a case of human-to-human transmission of 
the avian flu virus was reported in Indonesia. Reports such as 
these suggest that the next severe influenza outbreak could be 
looming on the horizon. In response to this threat, the United 
States has undertaken a significant effort to prepare for the 
next pandemic. Just recently, the Homeland Security Council 
released a lengthy pandemic influenza implementation plan. This 
report provides broad directives for all sectors of our society 
to follow in order to effectively prepare for the next flu 
outbreak.
    I commend the efforts of the administration to put forward 
a comprehensive framework for pandemic flu preparedness, but it 
is clear we have much yet to do. Biotechnology and 
pharmaceutical companies continue to search for a safe and 
effective pandemic flu vaccine. Hospitals and other facilities 
are developing plans to ensure they have the necessary supplies 
and staff to handle a significant influx of patients.
    As we move forward with this important work, it is 
essential that we keep the special needs of older Americans in 
mind. They may be more vulnerable to an infection due to 
preexisting health conditions or weakened immune systems. The 
more outreach we can do to the elderly in our communities 
before an outbreak occurs, the better protected they will be.
    I hope we can use today's hearing to delve more deeply into 
what needs to be accomplished to safeguard all Americans from 
the harms of a pandemic, but especially those most vulnerable, 
such as the elderly, the disabled, the chronically ill and 
children.
    I am very pleased to have my friend and our Secretary, 
Secretary Leavitt, with us here today, and I look forward to 
your testimony, Mike.
    The witnesses we have assembled represent many of the key 
parties that will be involved in the initial response to a flu 
pandemic. If we have learned anything from the past, it is that 
all levels of public and private sectors must coordinate their 
efforts to successfully respond to an emergency.
    While much is still unknown about the nature of the next 
influenza outbreak, we must press forward with implementing a 
comprehensive response effort. As Benjamin Franklin once said, 
an ounce of prevention is worth a pound of cure. That was true 
then and it still true, and it is certainly true as we look 
toward this horrible potential event.
    In light of today's discussion of pandemic flu 
preparedness, I am pleased to join one of my Senate colleagues, 
Senator Evan Bayh of Indiana, in filing the All Hazards Public 
Health Emergency and Bioterrorism Preparedness and Response 
Act. This important legislation will help State and local 
communities better respond to the unique public health threats 
they might face, and creates new tools to encourage much-needed 
public health workforce development. I hope the Response Act 
will help guide Congress' discussion of how future public 
health planning and response efforts can better safeguard the 
health and well-being of our citizens.
    So with that, I will turn to my friend and my colleague, 
Senator Kohl of Wisconsin.

           OPENING STATEMENT OF SENATOR HERBERT KOHL

    Senator Kohl. Thank you, Mr. Chairman, for holding this 
hearing.
    Experts no longer ask if such a pandemic could occur. 
Rather, they question when it will occur. Earlier this month, 
the White House unveiled its plan for responding to a flu 
pandemic. This plan is a constructive first step with at least 
many serious questions unanswered, like which Federal agencies 
and officials will take the lead in responding to an outbreak 
emergency.
    I am concerned that we are not prepared to care for the 
complex needs of our Nation's seniors, in particular. The 
elderly are among our most vulnerable members of society and 
they are far too often overlooked or even ignored in emergency 
preparedness plans.
    Hurricane Katrina illustrated how we failed the seniors who 
need us most. Last week, we chaired a hearing in this Committee 
where we heard that 71 percent of those who died during Katrina 
were over the age of 60. We need to learn the lesson of those 
deaths and make sure that any strategy to prepare for pandemic 
flu incorporates the unique needs of seniors.
    We need to do a better job in telling older people what 
supplies and plans they need to have in place in the event of a 
national emergency like pandemic flu. As a start, my office has 
developed a tip sheet, and HHS and DJS should follow with 
pamphlets, public announcements and specific direction for 
seniors and the agencies that serve them.
    We also must direct States and local governments to include 
in all planning, training of first responders and practice 
exercises for national emergencies. Communities need plans to 
locate and help seniors who live at home if a flu pandemic 
occurs.
    Federal, State and local governments are making progress in 
preparing for potential outbreak, but I believe we need to do 
more. Even if we are spared from a flu pandemic, the work that 
we do today will serve us all well in the event of any national 
emergency. We look forward to hearing from our panels today 
about the direction our Nation should follow and what it will 
take to deal with pandemic flu, including steps we must take to 
care for our seniors.
    Again, Mr. Chairman, I thank you for this hearing and we 
look forward to hearing from our witnesses.
    The Chairman. Mr. Secretary, thank you for being here, and 
your staff and others. We appreciate all that you and your 
Department have done. We have seen you a lot on TV, and you 
obviously know the subject well.

     STATEMENT OF HON. MICHAEL O. LEAVITT, SECRETARY, U.S. 
    DEPARTMENT OF HEALTH AND HUMAN SERVICES, WASHINGTON, DC

    Secretary Leavitt. Senator, thank you for holding the 
hearing. It is an important subject.
    Pandemics happen. They are part of the biologic world. They 
are a biologic fact of life. They are part of the microbial 
world of viruses and bacteria that are constantly mutating, 
constantly finding ways to survive in more and more hosts.
    The history of pandemics isn't so much the history of 
public health as it is humankind. As you pointed out, we have 
periodically throughout history had pandemics. You can go all 
the way back to the city of Athens in 430 B.C. and see the 
evidence of 25 percent of that great city's population being 
wiped out by a pandemic disease. It not only changed the city's 
health, but it changed their future. It affected their 
politics, it affected their prosperity. It changed the city in 
an irretrievable way.
    That has been true almost entirely every century. We would 
see evidence of two or three of these. The 14th century may be 
the best-known--Black Death. Twenty-five million people across 
Europe died. Again, it did not just affect the health; it 
affected the culture and it affected the politics and the 
prosperity of that entire region.
    You mentioned the fact that we have had 10 pandemics in the 
last 300 years. We have also had three of them in the last 100. 
You mentioned 1968 and 1957. They were what the scientists 
refer to as relatively small events by pandemic scale. They 
were highly efficient viruses; that is to say they spread 
quickly, but they were not particularly virulent. Not many 
people died.
    1918 that you also referenced, on the other hand, was both 
efficient--it spread fast--and it was virulent. Lots of people 
died, and that, of course, is the type of event that we need to 
be prepared for. We hope and pray it will not occur, but that 
is the level at which we need to prepare.
    We are today concerned properly, in my judgment. Scientists 
fear that the H5N1 virus that is spreading across the world on 
the backs of wild migratory birds could, in fact, be the spark 
of the next pandemic. No one knows with certainty, but the 
warning signs are there. We are seeing the capacity for this 
virus to jump the species barrier, clearly going from birds to 
people. We are also now seeing, and have throughout the history 
of this virus, very limited and highly inefficient transmission 
between people. You mentioned the circumstance in Indonesia. I 
am happy to respond during the questions if you would like to 
know more about that.
    We are concerned not only because it is widespread; we are 
concerned because of its genetic similarity to the 1918 virus. 
It is clear by the course of events over the last several years 
that this is a aggressive killer once it gets into people, and 
so there is reason for us to be concerned. For that reason, the 
President has asked that we mobilize the country.
    I have been moving throughout the country, having summits 
in every State, including Wisconsin and Oregon; in fact, almost 
every State now. Tomorrow, I will be in New Hampshire. It will 
be our 51st summit. We are doing summits in both the 
territories and in the States. These have been rallying events. 
More than 20,000 public leaders from the health community, from 
local political leaders, from schools, from businesses have 
come for the purpose of being able to begin community planning.
    It is part of a comprehensive plan. There is no single 
action that prepares a community for this kind of an event. It 
requires our working on vaccines, on anti-virals, developing 
stockpiles, on having community preparedness. At the very 
foundation of preparedness, however, is a prepared community. 
The fundamental message of our summits has been this, that any 
community that fails to prepare, with the expectation that the 
Federal Government or even the State government can get to 
every community and rescue them at the last moment, will be 
sadly and tragically, mistaken not because any of us lack a 
will or because we lack a sufficient wallet, but because there 
is no way that a government can get to 5,000 communities at the 
same time.
    That is one of the peculiar and very important distinctions 
of a pandemic. It is highly local. It happens everywhere at the 
same time, but it is a highly local event. The truth is we are 
overdue for a pandemic.
    The Chairman. Mike, to that point, could I ask you a 
question, because it really is what is on my mind? It is local. 
Obviously, even hurricanes are somewhat local, and 9/11 was 
local, but are there lessons from those response efforts that 
local communities are drawing lessons from that specifically 
related to the flu pandemic?
    Secretary Leavitt. Senator, in your statement you mentioned 
some of the disasters we have endured as a Nation. There are 
many lessons to be learned. One of the lessons is that you have 
to think about the unthinkable because it happens. Another 
important lesson in my mind is that what you do before an 
emergency is far more important than what happens after in 
terms of being able to prevent injury and damage.
    But perhaps the most important will be the difference 
between a pandemic and any other natural disaster. Katrina was 
a devastating weather disaster. It covered Louisiana, 
Mississippi and a piece of Alabama, but at least it was 
constrained to that area. A pandemic would not be.
    In Katrina, we had people literally come from all over the 
country to help. That could not occur in a pandemic because 
people would be in their hometowns looking after their 
families, their community, in a way that would prohibit it.
    We also learned, I think, that most emergency events, if 
you will, like a hurricane or a bioterrorism event, are 
constrained as to time. The event occurs and then we move into 
recovery. That is not the case with a pandemic. It goes on for 
more than a year in waves. So life has to go on, so our 
preparation for a pandemic is different.
    The Chairman. I am sorry to interrupt you.
    Secretary Leavitt. No, that is fine. I would just say that 
we are overdue, and we are not as well prepared as we need to 
be. We are better prepared today than we were yesterday. We 
will be better prepared tomorrow than we are today. It is a 
continuum of preparedness.
    No one knows whether this current virus will be the spark 
of a pandemic. We do know that pandemics happen and that we 
need to be better prepared. Everything we do on a pandemic 
helps us become a safer and a healthier community. Whether it 
is for a pandemic or whether it is a bioterrorism event, the 
preparation essentially is the same.
    The Chairman. Does that conclude your testimony?
    Secretary Leavitt. That concludes my statement, yes.
    The Chairman. Do you think local communities are taking 
this seriously? I know you are and I know the Department is 
because I have seen evidence of it everywhere on news shows and 
reporting that is going on. But is this just sort of, well, 
that is what happened in the bubonic plague era, not ours?
    Secretary Leavitt. Well, I think we are clearly moving from 
the buzz phase to the business phase. There are lots of 
communities, many companies, many schools and colleges and 
communities, and so forth, that are beginning to take action. 
Regrettably, there are those who haven't yet, and that is where 
we need to focus.
    The thing about a pandemic and preparedness is that it 
requires everyone to prepare. This isn't just something we can 
delegate to our local government. Every business needs to have 
a plan. Every college needs a plan, every school needs a plan. 
Every day care center, every residential facility or long-term 
care facility for the elderly needs a plan. Every hospital 
needs a plan. Every family needs a plan. This is something on 
which there is a shared responsibility throughout society.
    The Chairman. Isn't it true that where we have had these 
recent outbreaks in Indonesia just this week, and I believe 
Romania where there have been deaths, there is literally human 
handling of birds, specifically plucking the feathers, wringing 
the necks and eviscerating them in a very hand-held fashion?
    Secretary Leavitt. You are making an important point. I 
have said if you are a bird, it is a pandemic. If you are a 
human, it isn't. This is clearly a bird disease at this point. 
The worry is that it will mutate, and there are steps of 
progress that viruses make and one of those steps is to go from 
bird to human, and then the next step is to go from human to 
human, and the next step is to go from human to human in a 
sustained and efficient way.
    We have done a very good job in this country of sensitizing 
people to the human-to-human worry. What we have not done as 
good job in is making certain that we underline the words 
``sustainable and efficient.'' We have seen human-to-human 
transmission in a very inefficient and highly unusual way.
    We saw it in Hong Kong in 1997. We have seen it in Thailand 
last year, and now we have seen it, or at least there is some 
suspicion we may be seeing it in this case in Indonesia. In 
each of those cases, it can be found in an index case. The 
first case generally started with a bird. What we are finding 
in Indonesia is that there was, in fact, the index case of a 
woman who was, in fact, handling birds and became sick in a way 
very similar to that which others have.
    The investigators have found that those who then later 
contracted it were in very close proximity to a severely ill 
woman, and they were sleeping in quarters that are described as 
essentially a closet. While it has not been demonstrated, the 
best hypothesis we have at this moment is that because of their 
intimate and close contact with the highly sick patient, they 
may have, in fact, contracted it as well. There is nothing 
inconsistent about that over what we saw in Thailand or in Hong 
Kong in 1997.
    We continue to watch that very closely. I am happy to 
report to you that we have some of the best scientists in the 
world on this subject who are literally on the scene and who 
are literally examining those people and doing the kind of 
investigation that needs to be done.
    The Chairman. Mr. Secretary, it probably needs to be said 
as an assurance to the elderly who often tune in to this 
hearing that there is a reason why we haven't had these 
sporadic outbreaks in the United States, in Europe and the more 
Westernized parts of Asia, and that is that the eviscerating 
operations in this country run to very high sanitary and 
mechanized kinds of procedures. I suspect you have seen the 
turkey plants in Utah. I have seen the chicken ones in 
Arkansas. It is amazing. It is not a business I would want to 
be in, but it is very clean and sanitary.
    Is it important to remind the American people what is being 
done to protect the fowl and the consumption of bird products 
in this country?
    Secretary Leavitt. It is. It is important not only to 
remember that, first of all, it is a bird disease, not a 
broadly based human disease. Second of all, we have not seen an 
H5N1-positive bird in the United States yet, and we have 
certainly not seen it in a human being.
    It would not be a big surprise to us to see a wild bird 
with the virus on board, simply because they are wild and they 
fly through natural flyways all over the world. When that 
occurs, it will not be a crisis. It would not be a big surprise 
at some point to see it in a domestic flock, but your point is 
an important one. We manage those flocks with great care. The 
Department of Agriculture has seen these kinds of high-
pathogenic viruses before. They know what to do.
    Perhaps the final point that must be made is that poultry 
when properly cooked is safe. Cooking kills the virus, and 
there is not a reason for people to reduce, for example, their 
consumption of poultry out of worry because of avian influenza.
    The Chairman. One of the other concerns I have, Mr. 
Secretary, really relates to where we are as a Nation in terms 
of vaccines. As you know better than anyone, we don't do many 
vaccines in this country anymore. We have literally litigated 
them abroad.
    Secretary Leavitt. Well, that may be among the most 
important problems that our preparedness has brought focus to. 
The good news is we believe there is the capacity to develop a 
vaccine that could provide an immune response to this virus. 
The bad news is we do not have the capacity domestically to 
produce a sufficient supply for every person in the United 
States to have a vaccine. That is part of what the President 
has put forward, an ambitious effort to change that.
    Some of that is because the vaccine business has become a 
lousy business in our country. Over the last 25 years, most of 
the vaccine manufacturers have gone out of business or have 
discontinued that work. The Congress was, I think, insightful 
in appropriating $3.3 billion. Two weeks ago, I spent $1 
billion of it on vaccine manufacturing technology research that 
is being done.
    We have a plan that, within 3 to 5 years, we will change 
that. Our ambition is to have the capacity to not only isolate 
a virus, but then to be able to produce a sufficient supply of 
vaccines for every person within the United States who chooses 
to have one.
    The Chairman. Within the United States?
    Secretary Leavitt. Within the United States.
    The Chairman. That is an important thing to achieve, 
frankly, because if we actually had a pandemic and all the 
manufacturers in Europe have the same problem, they are not 
likely to want to send it here; they are going to use it there.
    Secretary Leavitt. That is an important insight and one 
that we acknowledge. Consequently, part of our criteria has 
been to assure that any new manufacturing capacity that we 
partner to develop is done domestically.
    The Chairman. Senator Kohl.
    Senator Kohl. Thank you.
    Just to follow up a little bit more on that, Mr. Secretary, 
what sense of urgency is there to develop our capacity for this 
vaccine? You know, if it is coming on board 5 or 10 or 15 years 
from now, then we are just having a nice conversation today.
    Secretary Leavitt. When I first began focusing on this 
problem, it appeared that, first of all, there was no 
additional capacity coming online. Second of all, the plan to 
get to what is known as cell-based technology, which is the big 
hope in being able to manufacture it more quickly, appeared to 
be somewhere between 8 and 10 years away.
    I have met with all of the manufacturing organizations, 
with NIH, with the scientists. The President has, as well, and 
we have asked them to help us find every way possible to 
accelerate the development of this technology, and for that 
reason we are partnering and the $1 billion of contracts that I 
released on May 4 are a very good and important indication of 
that. The 3 to 5 years that I have spoken of is an ambitious, 
and I might say very aggressive approach, and will have 
substantially reduced the amount of time that it would have 
taken had we not taken that action.
    Senator Kohl. If we have a pandemic this year or next year, 
is it fair to conclude that we will not have what we need to 
have by way of vaccinations?
    Secretary Leavitt. Let me go a step further than that, 
Senator. Pandemics, as I indicated in my opening statement, 
generally last about a year to a year-and-a-half, and they come 
in waves of between 6 and 8 weeks. It takes about 6 months from 
the time we have isolated the virus that caused the pandemic to 
create a safe vaccine and to manufacture it.
    Best case: What that tells me, and I am sure you, is that 
during the first 6 months of a pandemic we will be without a 
vaccine no matter what. The business of creating vaccines is 
really about being able to have it for the second and the third 
wave.
    What you have stated is correct. We would not have 
sufficient supply of vaccines for the first wave even after we 
have been able to develop this capacity because you really 
can't stockpile in large measure vaccines because the virus you 
are ultimately going to be preparing the vaccine for may be 
substantially different than the one that you have been 
preparing for.
    Now, we are stockpiling significant stockpiles of vaccines. 
We have 8 million doses of the best of an isolate we created in 
Vietnam. That would produce some level of immune response, but 
it would be far from perfect and we are basically working as we 
go. What that means it that when you start dealing with a 
pandemic, you have got to have a comprehensive approach, and we 
are working intensively right now to develop social distancing 
and public health tools that communities can use in order to 
limit or to contain viruses as they happen in their 
communities.
    Senator Kohl. You said that local communities to a large 
extent will be on their own during a flu pandemic and shouldn't 
expect a great deal of help from the Federal Government. What 
assistance should State and local communities expect from the 
Federal Government in the event of a pandemic?
    Secretary Leavitt. Thank you, Senator. There is a very 
important role for the Federal Government and we are going to 
play it, but it is important to define it. An example of one of 
our roles is the international monitoring that we have just 
reflected with respect to Indonesia. We are building a network 
of laboratory capacity and having personnel on the ground all 
over the world so that if this begins to happen anywhere, we 
have a knowledge of it at the earliest possible moment.
    That gives us the capacity to respond and prepare. It also 
would give us a head start or a jump start in the development 
of vaccines, for example. So international monitoring and 
national monitoring are a role that only the Federal Government 
can play, and we will play it.
    Vaccine development--again, it would be unreasonable that 
any one community or a State, even, would develop a vaccine. 
Therefore, the Federal Government has taken responsibility for 
the development of vaccines, and we are making substantial 
progress and I have reported partially on that.
    The third area would be in the development of stockpiles of 
anti-virals and other matters. Now, I have been very careful 
and direct in telling the States that our stockpiles will be 
insufficient to cover every community, but at least it gives 
them a start on something that they can begin to build.
    A fourth area in my mind is State and local preparedness. 
We have begun to create checklists and to hold exercises and to 
push hard for local communities to realize that they simply 
cannot ignore this and expect that the State government or the 
Federal Government overall will resolve it.
    These checklists that I have--this is one on long-term care 
facilities, for example. You mentioned that in your statement. 
Those checklists and the exercises that we do reveal our 
weaknesses. We can never be afraid to see our weaknesses 
because that is how we get stronger, and that is one of the 
roles of the Federal Government.
    Another role that we are playing is to work on how to 
communicate on this. This is a tough subject to deal with. The 
problem is anything you say in advance of a pandemic seems 
alarmist. On the other hand, everything you would do to get 
ready for it when it starts is inadequate. So we are working to 
teach State and local governments and businesses and schools 
how to talk about this in ways that inform, but will not 
inflame, and ways that will help people to prepare, but not to 
panic. Those are all roles that the Federal Government can and 
must play, and we are doing everything possible to assure we do 
our responsibility well.
    Senator Kohl. Earlier this week, the Washington Post 
reported on a study at Baylor College of Medicine that shows 
that people older than 65 may need as much as four times the 
standard level of flu vaccine for effective protection. Are you 
taking that into consideration as you build our stockpile of 
flu vaccine?
    Secretary Leavitt. That is a very important piece of 
information and we are taking that very seriously, and it gives 
me an opportunity really to talk about one of the side benefits 
of all of this pandemic preparedness.
    We have had inadequate annual flu vaccine for many years 
now. Every year, we go through a period of are we going to have 
enough, are we not going to have enough. We have had a lot of 
producers offshore or out of the United States that have had 
problems and it is an ongoing problem that we have to solve.
    One of the benefits of creating new vaccine manufacturing 
capacity is that we can take that annual flu vaccine problem 
off the table forever because we will have to keep our pandemic 
vaccine capacity warm, if you will, and the best way to use it 
will be to make annual flu vaccine. That would give us now an 
opportunity to say, rather than use a one-size-fits-all method 
of application for the annual flu, we can begin to say, well, 
perhaps we have got to look at seniors. Maybe they don't have a 
similar immune response, and if that is the case, we will now 
have flu vaccine that will allow us to provide it.
    Senator Kohl. Thank you very much, Mr. Secretary.
    The Chairman. Thank you, Mr. Secretary, for giving us 
insight for all the contingencies and make the preparations.
    Secretary Leavitt. Thank you, Senator.
    [The prepared statement of Secretary Leavitt follows:]

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    [Recess.]
    The Chairman. Thank you for your patience, ladies and 
gentlemen.
    Let me first begin with an introduction of our panel. We 
will first hear from Dr. Steve Cline. He is the Chief of 
Epidemiology for the State of North Carolina and he is 
overseeing the State's pandemic flu preparation efforts. He 
will discuss the work which States like North Carolina are 
beginning to undertake with the new pandemic influenza 
preparedness funding that Congress recently appropriated, 
specifically highlighting plans for outreach to the elderly 
community.
    Then we will hear from Nancy Donegan. She is the director 
of Infection Control for the Washington Hospital Center. She is 
here today speaking on behalf of the American Hospital 
Association. The Washington Hospital Center was one of the 
primary facilities involved in the 2001 anthrax scare, so they 
have had firsthand experience in responding to a community-wide 
emergency event. Her facility has developed a communicable 
disease response plan and she will discuss the specific issues 
it addresses.
    We appreciate your both being with us today. Shall we go 
ladies first?

  STATEMENT OF NANCY DONEGAN, DIRECTOR OF INFECTION CONTROL, 
 WASHINGTON HOSPITAL CENTER, WASHINGTON, DC; ON BEHALF OF THE 
                 AMERICAN HOSPITAL ASSOCIATION

    Ms. Donegan. Good morning. I am Nancy Donegan, the director 
of Infection Control at the Washington Hospital Center, a 900-
bed, Level I trauma center which is part of the MedStar Health 
Corporation. On behalf of the American Hospital Association's 
4,800 members, I appreciate this opportunity to appear before 
you today.
    Pandemic influenza is one of many possible emergencies that 
hospitals face. Hospitals maintain all-hazards plans for 
responding to a range of events, from natural disasters, to 
terrorist attacks, to pandemic outbreaks. Today, my testimony 
will highlight three issues: the capacity demands of pandemic 
influenza, the pandemic plan at the Washington Hospital Center, 
and AHA's recommendations for the Federal Government's role 
related to hospital preparedness.
    To prepare for emerging infectious diseases like avian 
influenza, hospitals must be ready to care for a large 
increase, or surge, in the numbers of acutely ill patients over 
a prolonged period of time. Surge capacity involves increasing 
hospital staffing and resources needed for patient care.
    Hospitals can increase their patient care capacity for 
relatively short periods of time by surging in place; that is, 
rapidly discharging appropriate patients, canceling elective 
procedures and increasing the number of staff. While surging in 
place can temporarily increase patient capacity, most hospitals 
will be overwhelmed if an event involves large numbers of ill 
over a prolonged period of time, such as in a pandemic, as 
supplies and staff are depleted. At the same time, hospitals 
will need to continue providing routine acute care, such as 
treating traumatic injuries and attacks and delivering babies.
    Over the last 5 years, hospitals receiving funds through 
the National Bioterrorism Hospital Preparedness Program have 
improved readiness. To date, hospitals have received about $2 
billion. However, there is still a significant gap in 
readiness. In a sustained disaster such as a pandemic, 
hospitals would rapidly face a shortage of personnel and 
critical supplies such as ventilators, gloves, masks, gowns and 
drugs. The New York Times has reported that the national supply 
of ventilators, which would be critical for caring for patients 
in an influenza pandemic, falls far short of the estimated 
need.
    The Center for Biosecurity at the University of Pittsburgh 
Medical Center has estimated that the minimum cost of realistic 
readiness for a severe 1918-like pandemic are at least $1 
million for an average size hospital. We believe that to have 
adequately prepared hospitals, a portion of Federal pandemic 
funding should be directly applicable to hospitals.
    The pandemic plan at the Washington Hospital Center follows 
the three pillars of the National Implementation Plan: one, 
preparedness and communication; two, surveillance and 
detection; three, response and containment. Our plan employs 
both high- and low-tech methods to communicate important just-
in-time messages to staff and physicians. We have developed 
computerized and paper-based tools for reporting cases to the 
public health department and to hospital clinical areas.
    During a pandemic, all entry points into the hospital will 
need to screen patients based on epidemiologic definitions 
provided by the CDC. Hospitals will also need to screen all 
workers on a regular basis during a pandemic episode. In our 
plan, we have detailed methods to have workers self-monitor and 
self-report symptoms of respiratory infection.
    The best clinical response would include the use of 
effective vaccine or anti-viral therapy. Without effective 
vaccination, prophylaxis and therapy, infection control 
measures are the only strategies left to prevent transmission 
in the hospital.
    Infection control measures rely on patient isolation and 
personal protective equipment, along with engineering controls. 
The hospital has designed ER One, the Nation's first all-risks-
ready scalable emergency facility to handle mass-casualty 
events, including the ability to handle contagious patients.
    The AHA supports the Federal Government's efforts to 
increase the stockpile of anti-viral drugs, increase research 
on non-egg vaccine production, and develop a prototype vaccine 
for avian influenza. In addition, an allocation plan for anti-
viral drugs and vaccines must recognize the importance of 
hospital staff, physicians and emergency personnel.
    In conclusion, the National Pandemic Influenza 
Implementation Plan states, preparation requires infrastructure 
and capacity, a process that can take years. Hospitals do not 
have the means to create infrastructure or capacity with 
current funding. If the Nation is to be protected, hospitals 
will look to the Federal Government for greater resources to 
meet the anticipated burden.
    Mr. Chairman, thank you for the opportunity to testify. I 
look forward to answering any questions.
    [The prepared statement of Ms. Donegan follows:]

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    The Chairman. Thank you, Nancy, and we will have questions.
    Steve, take it away.

  STATEMENT OF J. STEVEN CLINE, DDS, MPH, CHIEF, EPIDEMIOLOGY 
 SECTION, DIVISION OF PUBLIC HEALTH, NORTH CAROLINA DEPARTMENT 
           OF HEALTH AND HUMAN SERVICES, RALEIGH, NC

    Dr. Cline. Thank you, Mr. Chairman and distinguished 
members of the Senate Special Committee on Aging. I am honored 
to be testifying here today before you on behalf of public 
health and the 8.7 million citizens of North Carolina, 2.4 of 
whom are over the age of 50, representing 28 percent of our 
population. In the next couple of decades, we expect that to 
increase to 35 percent of the North Carolina population over 
the age of 50.
    I am proud to be here. When I was explaining to my family 
that I was doing that, children have a way of keeping you 
humble. They said, why are you speaking to the Committee on 
Aging? Oh, Dad, it is because you are old. [Laughter.]
    Preparing for and responding to an influenza pandemic will 
be a monumental task that will affect all of us, young and old. 
The National Influenza Response Plan and the National Influenza 
Implementation Plan you heard Secretary Leavitt speak of places 
much of the responsibility to appropriately planning, 
preparing, detecting and responding on our Nation's State and 
local health departments. Our citizens have expectations that 
we will get that right.
    This sense of urgency is further heightened by the amount 
of media attention pandemic flu is getting. We see daily death 
counts of human cases of bird flu as they move from Southeast 
Asia across Europe, and certainly on its way to the U.S.
    We have TV movies dramatizing fictional pandemics in this 
country, and newspaper stories almost daily, some saying we are 
not ready, some saying there is more transmission happening 
human-to-human, as in yesterday's article. Of course, as we 
have already alluded to, we all watched the devastation of 
Katrina on the Gulf Coast and wonder is our community ready for 
such a big disaster.
    In my comments today, I would like to focus on three 
things: the progress that we have made in the area of 
preparedness; second, the challenges that we still face; and, 
third, how can Congress help keep us making progress.
    First, in the area of accomplishments, let me say thank you 
to Congress for the substantial Federal investment you have 
made in public health preparedness. States like North Carolina 
have done much to get ready, and as Secretary Leavitt said, we 
are much better prepared today than we were yesterday and we 
hope we will be better prepared tomorrow. I will mention 
briefly just some of our accomplishments in North Carolina and 
would be happy to answer questions about them following the 
testimony.
    As you heard, all emergencies start locally, so we have 
invested a substantial amount of money in our State in local 
public health preparedness in all 100 counties, in all 85 
health departments serving those counties. We have built a 
health alert network system, a secure system for notifying our 
key partners when an emergency occurs.
    We have increased our capacity in our State Laboratory of 
Public Health, which will be a critical component to 
identifying, isolating and understanding the infection. We have 
built a hospital emergency department surveillance system that 
connects all 113 hospital emergency departments in North 
Carolina and reports every 12 hours to the State Health 
Department.
    We have built public health regional strike teams and based 
them across the State so that they can respond wherever it 
emerges. We have built State medical assistance teams, which is 
a three-tiered system for scaling up medical surge capacity in 
our State. We have created public health epidemiologists in 
hospitals, borrowing from the concept of embedded journalists 
in the Iraq War, and put public health people inside hospitals, 
which has helped tremendously. We have also improved our 
interoperable communications, and training, training, training.
    In the area specifically of pandemic flu response, we have 
a very robust plan in North Carolina, the North Carolina 
Pandemic Flu Response Plan, first written in October 2004 and 
revised substantially this year. We have a broad-based pandemic 
flu planning committee which makes sure we are taking into 
account all of the citizens of North Carolina. In particular, 
we have a special populations work group that can focus on the 
unique needs of elderly, disabled, home-bound and other 
minority groups, particularly those who have English as a 
second language. We are developing a tool kit building upon the 
checklists that our Federal Government has and making those 
specific to North Carolina.
    There are challenges that are unique to being an older 
American and I would like to highlight just a couple of those. 
Older Americans, we have already acknowledged, are one of the 
fastest-growing segments of our population. They often have 
fragile health, which requires more services, not fewer. More 
services during a pandemic may create a problem.
    We are worried about reaching the non-institutionalized 
older adults. How do we find them? How do we know they are 
safe? How do we know they are healthy? We are working closely 
with community-based organizations who often are best at 
reaching those people, but will they be available and able to 
help us during an emergency? We have heard some discussion this 
morning already about the annual flu vaccine and the importance 
of providing good annual flu vaccine to all Americans, 
particularly our elderly.
    Where do we go from here? I have already mentioned the 
importance of funding. Sustained funding is the key component 
for us to continue making progress in preparedness.
    The second is to improve our adult immunizations. We heard 
Secretary Leavitt speak about hopefully improving the vaccine 
production system. That is important, but it is also important 
to improve the demand for that vaccine. Our people need to show 
up for those vaccines. Only about 48 percent of adults in our 
State get the annual flu vaccine. Also, the infrastructure to 
provide those vaccines needs to be improved. Vaccine 
production, we have already heard about.
    Communications is another important component. The 
communications are tricky in a normal day. In a crisis and in 
an emergency, they will be even trickier. We will need strong 
leadership and clear messages if we hope to reach the public 
with the important information that they are going to need.
    In closing, I would like to say responding quickly and 
effectively to a pandemic flu will require extraordinary 
measures, in an atmosphere of fear, chaos and human tragedy. A 
strong, well-supported public health system is critical to 
saving lives and managing the crisis. The investments that have 
been made must continue if we expect to serve our citizens 
well.
    Thank you. I would be happy to answer questions.
    [The prepared statement of Dr. Cline follows:]

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    The Chairman. Thank you, Steve. Forty percent of adults or 
seniors show up for flu shots in North Carolina?
    Dr. Cline. No. Forty-eight percent in North Carolina get 
the annual flu vaccine.
    The Chairman. What if the other 52 percent showed up? Would 
you have it?
    Dr. Cline. It is often an issue of timing and mal-
distribution, not that we haven't had enough vaccine. We have 
had seasons when we did not have enough vaccine, but most 
recently the vaccine arrived late. People think about getting 
their vaccine in October, November, December. January and 
February, which is still part of the annual season--often, that 
is not on their mind anymore and they don't show up for those 
vaccines.
    The Chairman. Is it for want of information, or is part of 
it some choose not to have it?
    Dr. Cline. I think some choose not to have it. I bet we 
have all heard of people who say I am worried the flu vaccine 
is going to give me the flu, which is false. Let me go on the 
record saying that.
    The Chairman. That is why I asked the question. I want to 
get that out. It is false.
    Dr. Cline. But also I think people think if it is a vaccine 
toward the end of the season, it is not going to help them that 
season. That is also false. Flu can occur all year. In fact, we 
have flu all year, and whatever immunity you develop to that 
virus that year may help you, in fact, in any other flu virus 
attack.
    The Chairman. Steve, since this is the Committee on Aging, 
what is your State, and what should other States be doing to 
have some coordination with nursing homes and assisted living 
or people living independently, but who are still needy?
    Dr. Cline. We have built something in our State called--the 
acronym is SMART, but it is the State Medical Assets Tracking 
System. What it does is allow us to know exactly how to contact 
every long-term facility, hospital, group home in our State 
that is licensed. We are able to put that in a geographic 
information system so we can map it. They are part of an 
electronic communications system so that we can easily 
communicate with them. Hopefully, working with them to develop 
their own facility plans, there will be a way for us to get 
good information to those residents.
    The Chairman. You are getting information to them to have a 
plan in case of an epidemic?
    Dr. Cline. Yes. I would say probably the most important 
thing we are doing now, and I would suggest we should all be 
about, is engaging that group, that population, the facility 
employees, directors, staff, as well as the public.
    Dr. Cline. Do you also have a relationship with area 
agencies on aging and with faith-based organizations that have 
their own networks?
    Dr. Cline. We do. We work with them at the State level and 
their State representatives, but our real work is getting our 
local public health departments to work, and know those and 
build those relationships locally.
    The Chairman. Well, that is very commendable.
    Nancy, I wonder if Washington Hospital Center and other 
MedStar facilities have staff vaccination policies; in other 
words, getting the people who are working there and taking them 
coming in--how do you keep them healthy?
    Ms. Donegan. We do have a policy and we encourage flu 
vaccine very actively. It is not adequate that some of these 
biases and feelings that people have about flu vaccine have 
continued through time, despite, I would say, increasing 
campaigns to reach our health care workers to get a better 
vaccinated staff.
    Recently, the guidelines for influenza for next year 
introduced a new issue that encourages us to have declination 
statements from health care workers who refuse the vaccine. 
Although it hasn't been implemented yet, I think it is a very 
good strategy as the bridge to probably some time when we will 
have mandatory vaccine for our workers.
    We hope that when there is a face-to-face decision with 
some face-to-face counseling rather than posters and education 
campaigns that people will make that choice. We approach the 
campaign with a little bit of information focused on protecting 
the employee, but I think we focus more and have our greater 
success when we focus on the patients they are talking of and 
their obligation to not be a conduit to expose their most 
vulnerable patients, and probably most effectively that, being 
in the public exposure, we want them to protect their babies at 
home and their elderly at home. That seems to be our greatest 
take right now, now that it is voluntary.
    The other thing that we are doing with that in preparation 
for pandemic flu is that we are trying to increase the 
dedication to vaccine that everyone in the hospital recognizes 
is their obligation, so that as we sometimes fall on a bad 
year, whether it is avian influenza or just a very bad non-
avian influenza, we already will have the infrastructure; that 
this is a hospital where our workers get vaccinated. So the 
last couple of years, we are really trying to promote that with 
a much more aggressive stance.
    The Chairman. You mentioned in your testimony the need for 
Federal dollars coming directly to hospitals for these 
preparations. That is not happening now?
    Ms. Donegan. No. It seems as though most of the funding 
goes to public health and that we appeal to public health for 
distribution to hospitals, so that hospitals are really quite 
independent in their problem-solving, although they look to 
public health for reinforcement.
    The Chairman. Are public health agencies not sympathetic to 
hospitals?
    Dr. Cline. I would like to answer that. She is correct. The 
HRSA funding for hospital preparedness comes to public health, 
and we think at least in our State that is a very good way to 
do it because we are actually able to work at a State level and 
coordinate all of the needs--hospitals, emergency medical 
services, homeland security grant dollars and public health 
dollars--and then apply it where it is appropriate.
    The Chairman. But if you see the need, you are going to be 
there. She is saying the need is there, or at least it could 
be. Are you sensitive to that, Steve?
    Dr. Cline. Well, all of that money is going out to 
hospitals, correct, yes.
    The Chairman. I know we are spending a lot of money. It 
just seems like there is never enough, but that is true in 
almost any category of the appropriations that goes on here. 
Senator Kohl is in charge of appropriations, so we will look to 
him to figure out how to get the right amounts.
    The question I have, Nancy, is as to partnerships that 
Washington Hospital may have with other medical facilities in 
the area. Are there regulatory issues that are an impediment to 
using one another's backups or anything you need us to be aware 
of that we should----
    Ms. Donegan. No. I think that the hospital community has 
worked together one institution with the other quite well 
through time. We refer to each other, we refer to each other's 
services, and many of our workers work in multiple 
institutions.
    Clearly, after September 11 and after the anthrax attacks, 
that communication linkage became much more formalized. There 
are networks that are very formalized, and even some of the 
smallest threats that--you know, in this area, sometimes we 
have worries that will come up and we quickly go into a network 
kind of methodology where we have communication and reinforce 
that communication.
    Our hospital, the Washington Hospital Center, is part of a 
corporation, so we have a linkage with the corporation that is 
very formalized, and then one that is somewhat formalized with 
other hospitals in the region so that we have sharing.
    Our biggest problem, despite our sharing--our sharing is 
really more on the communication level, but in our area, and I 
think in many areas, we really have all of our beds full 
everyday. We have patients in our hallways. So the idea that we 
could take more patients from another location--we aren't able 
to do it, nor are we able to send our patients to another 
facility. They are full, too.
    So the idea of surge capacity, I think, is limited. We have 
limited success in that, in that we can do sort of an immediate 
response. But once we have filled those beds and once we need 
to maintain an ever-increasing population of patients, we 
really max out and we run out of structure, and there isn't a 
sister institution that can pick up our burden. We really sort 
of max out through the system.
    The Chairman. Just one last question. Are there any 
protocols existing between post-9/11 and Katrina from lessons 
learned there that would help all the medical facilities in 
this area? If there were actually someone who came down with 
avian flu here, is there a facility identified as the best one 
to take that individual, someone with a contagion of that 
nature?
    Ms. Donegan. I don't know everyone's readiness. Our 
hospital does work very much to be able to stand behind the 
statement that we are all-risk-ready. Clearly, we have quite 
elaborate plans for a pandemic, and we had those plans 
beginning before 9/11. We clearly ramped them up after anthrax 
and the idea of bioterrorism, and I think our greatest educator 
so far has been SARS, especially what happened with Toronto and 
their experience. We really used that as our model for 
readiness.
    So we would say we are very ready, but I suspect from 
talking to people in other hospitals that each hospital has 
amplified their readiness significantly. I don't know if it is 
to the same degree as we have. Partly because of our location 
and partly because of our sort of unique make-up, I think we 
are really dedicated to this issue. But I think most hospitals 
have changed their point of view on this and have much more 
accelerated degrees of readiness than they had.
    The Chairman. Well, I am not even suggesting that the 
policy implicit in my question is a good one. I don't know.
    Steve, should there be a facility designated or not, or 
should each one be prepared to deal with it on their own?
    Dr. Cline. I think each one has to be prepared to deal with 
it on their own, and I think if we look at the smallpox 
experience when we were planning how we would deal with 
smallpox, no hospital wanted to stand up and say, OK, I will be 
the smallpox hospital. It really didn't make sense until you 
knew more about where it was emerging and how it was happening.
    I think the best readiness is going to be to make sure each 
hospital has a plan and that all hospitals are talking to each 
other and public health, and we will make a good decision when 
that happens.
    The Chairman. Senator Kohl.
    Senator Kohl. It seems as though it would be a reasonable 
conclusion that, depending upon individuals such as yourselves 
all across this country, some communities are far more advanced 
in making preparations. Would it be reasonable to assume that 
other communities of equal size would be far less advanced? 
Because it is apparently being handled as a situation that 
needs to be dealt with on a State-to-State and local-to-local 
basis, would you estimate that to be the case?
    Ms. Donegan. I would suspect there is some variability. For 
the most part, the efforts that you take in preparing for 
these, there are not special teams; no one gets hired to be the 
pandemic coordinator. The efforts come from taking busy people 
in busy jobs and sort of peeling off a new layer of 
responsibility. So I would imagine there is significant 
variability in the amount that different institutions have been 
able to do and that it is quite a task, but I don't know the 
measurement of that variability.
    Dr. Cline. I would agree there is not really a good 
measurement of it. North Carolina is an urban and rural State, 
so we have small communities that we know are not as well 
prepared as some other parts of the State. What we are doing to 
compensate for that is to build some regional capacity that we 
hope can move into that area if it happens and while we are 
still working trying to get every community ready.
    Senator Kohl. In the event of a flu pandemic, isn't it 
essential that we have sufficient quantities of vaccination, 
without which most other preparations are going to be totally 
inadequate? Is that a fair conclusion?
    Dr. Cline. Well, I think we are preparing for the reality 
that for the first wave of the flu there will not be a vaccine 
that is highly effective. But after that, we are hoping that 
there will be a vaccine and there will be some control measures 
that our citizens have gotten used to. Vaccination is one of 
the marvels of modern medicine in terms of preventing disease. 
We certainly want to get there as fast as we can, but with the 
flu virus, which changes regularly, we are going to have to 
wait until it emerges and then develop the vaccine.
    Senator Kohl. How long does that take? In your judgment, 
how long will that take?
    Dr. Cline. Well, I think Secretary Leavitt said 6 months. I 
think the annual cycle is closer to 9 months for when they 
develop and can manufacture enough to get it out to all the 
providers. As you heard, they are making efforts to reduce that 
cycle to where it is a shorter time, and if we can move to the 
newer cellular technology--right now, they use eggs for 
developing that vaccine--we hope that will shorten that time.
    Senator Kohl. Well, does this mean that if a flu pandemic 
breaks out, we are defenseless for several months?
    Dr. Cline. I will let you answer, but it does mean that 
infection control is going to be the important factor.
    Senator Kohl. Is that right, Ms. Donegan?
    Ms. Donegan. That is exactly right. The SARS experience 
really is our best model for teaching us not only that 
hospitals can put in good practices without therapy and without 
vaccine, but that infection control can work. However, 
infection control efforts are very difficult to maintain 
because they are behavior-based and they are barrier-based. In 
a complicated hospital setting where the technology and the 
acuity of the patients demands sort of a focus on patient care, 
some of the burden of using masks and goggles and gowns--it is 
very hard to have personnel do that with the reliability that 
they need to do to make this a fail-safe plan.
    So with a vaccine, you can really protect the employee 
while they are doing their typical activities. Otherwise, you 
are left with this infection control behavior that is difficult 
and has an element to fatigue to it. The workers in Toronto 
needed quite a bit of reinforcement because of the fatigue 
factor from really doing infection control strategies 
completely. Clearly, as they do more work on a respiratory 
track--when they sort of do a more high-risk procedure, then we 
need to provide even more barrier for them to protect them 
during those procedures.
    So those elements work, but they need reinforcement, they 
need a lot of equipment. They really need us to protect our 
employees for issues like the fatigue factor and that we have a 
good stream of material for them.
    Dr. Cline. I do think SARS was a success story for 
containment without treatments and vaccines in this country, 
but it was much smaller scale. North Carolina had one of only 
eight laboratory-confirmed cases of SARS in the United States. 
It involved three of our hospitals. At the time, we thought it 
was only being transmitted in the health care setting. So it 
was not in the community. Pandemic flu will be very different 
because it will be in the community and our public will be 
asking how do I protect myself and my family. Some of the 
extreme measures of mask and gown and barrier protection are 
not going to be available, or maybe not even effective in the 
community.
    Senator Kohl. What do you imagine will happen if the flu 
pandemic breaks out and communities all across our country know 
that it is here and about, but we don't have a vaccine? What is 
going to be the individual reactions of families and entire 
communities? You have probably thought about that. What do you 
think?
    Dr. Cline. We have thought about that and we have also 
asked our public what is their likely response. What we get is 
they will self-isolate. They will figure out how to take care 
of themselves and their family in their homes as much as 
possible for as long as possible to try to avoid being in a 
place that they are worried could transmit the flu.
    Senator Kohl. Does that mean they won't go to work and 
won't send their kids to school, just go out maybe to buy 
essentials at the store and go back home?
    Dr. Cline. Exactly, exactly.
    Senator Kohl. Is that what is likely to happen across our 
country?
    Ms. Donegan. I think that is the view that we share, yes.
    Senator Kohl. You can imagine a situation where the entire 
country virtually shuts down if it is a truly national 
pandemic, a flu pandemic, because there is no vaccination 
available and the hope is isolation so that you are not 
contaminated. The only way you can do that is by staying 
isolated, meaning you don't go to work and the kids don't go to 
school. All the meetings that are scheduled are called off. Is 
that right?
    Ms. Donegan. I think so. I think the dim view is how much 
economic and social impact this will have by behaviors like you 
are talking about. Then the more rosy view I think we also 
learned from SARS is that we saw this adaptability of a 
population where they met many of their responsibilities in 
life. They put on masks and they kept their social distancing. 
Humans in large degree are adaptive, and so I don't know to 
what extent--clearly, I would think there would be the extent 
that we are talking about with this enormous impact and 
dysfunction. Then I would imagine that we would also see 
examples of resiliency and some return with adaptation that 
comes on a personal level, is my view on that.
    Dr. Cline. Yes, I agree with her. Obviously, though, if we 
all self-isolated, there are some things about our way of life 
that would stop and that we not really prepared to do. There is 
some critical infrastructure and critical business that gets 
done in this country that we really can't afford for all of 
them to stay home.
    So we are beginning that dialog in North Carolina to say 
where do you draw that line. Has every business taken a look at 
what they need to do to maintain just the bare minimum of their 
work going and develop a plan for that? We are trying to help 
them with that and coordinate that so that those critical needs 
of food and power and shelter can continue.
    Senator Kohl. Thank you. Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Kohl.
    Nancy and Steve, we are grateful for your presence here 
today and your patience with the interruption of the roll call 
vote. You have contributed greatly to our understanding and we 
salute your preparations.
    With that, we are adjourned.
    [Whereupon, at 11:33 a.m., the Committee was adjourned.]


                            A P P E N D I X

                              ----------                              


          Prepared Statement of Senator Hillary Rodham Clinton

    Thank you, Chairman Smith and Senator Kohl, for calling 
this hearing today, and bringing attention to the issues of the 
elderly population in pandemic situations.
    In many of our discussions around pandemic influenza, we 
have been looking back at the events of 1918, when young, 
healthy individuals bore the brunt of illness and death.
    But when you consider the other pandemics of the 20th 
century--those that occurred in 1957 and 1969--the elderly were 
among those that were hardest hit by the virus.
    The pattern in the 1957 and 1969 pandemics mirrored those 
that we see every year during our seasonal flu epidemic, when 
we have over 36,000 deaths and more than 200,000 
hospitalizations that are concentrated among elderly 
individuals, who are at greater risk of complications from the 
flu.
    As such, I think that we need to increase our preparedness 
for the special needs of senior citizens to ensure that they 
will be able to continue to access necessary medical and 
support services without interruption.
    But what is particularly worrisome to me, when thinking 
about our nation's ability to help seniors get the vaccines and 
antivirals that will help them survive a pandemic, is the fact 
that we aren't even prepared to deal with the seasonal 
influenza epidemic that we face--that we know with certainty 
that we will face every single year.
    Since 2000, we have had multiple shortages of seasonal flu 
vaccine. We all recall senior citizens lining up for hours to 
obtain flu vaccine, unscrupulous distributors attempting to 
sell scarce vaccine to the highest bidder, and millions of 
Americans delaying or deferring necessary flu shots.
    Because we don't have a system through which to track 
vaccine, we can't ensure the supplies that we do have reach the 
highest priority populations--including seniors and the 
chronically ill--who should get vaccinated as early as possible 
in any given flu season.
    I've introduced legislation with Senator Pat Roberts, the 
Influenza Vaccine Security Act, that would help us make some 
positive changes in our nation's system for distributing, 
tracking and delivering seasonal flu vaccine.
    Our legislation would establish a tracking system through 
which we could better trace the distribution of vaccine from 
the factory to the provider and identify counties with high 
numbers of priority populations, including senior citizens.
    With such a system in place, we could easily determine in 
times of shortage where vaccine was most needed and facilitate 
distribution to those areas to help our elderly get the shots 
that they need. All of this could take place in a matter of 
hours, rather than days or weeks.
    It simply makes sense to establish an operational tracking 
system for vaccine distribution that can be used in both 
seasonal and pandemic events, rather than rely on untried 
mechanisms in an emergency situation where we will already be 
facing multiple obstacles to delivery of health care--in 
particular, life saving care for elderly populations.
    I look forward to working my colleagues on this committee 
to continue to raise awareness of the needs of senior citizens 
in pandemic and other emergency situations. Thank you.

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