[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]


 
  EMERGING BIOLOGICAL THREATS AND PUBLIC HEALTH PREPAREDNESS: GETTING 
                          BEYOND GETTING READY

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

                             FIELD HEARING

                               before the

                        SUBCOMMITTEE ON EMERGING
                        THREATS, CYBERSECURITY,
                       AND SCIENCE AND TECHNOLOGY

                                 of the

                     COMMITTEE ON HOMELAND SECURITY
                        HOUSE OF REPRESENTATIVES

                       ONE HUNDRED TENTH CONGRESS

                             SECOND SESSION

                               __________

                             JULY 22, 2008

                               __________

                           Serial No. 110-131

                               __________

       Printed for the use of the Committee on Homeland Security
                                     

[GRAPHIC] [TIFF OMITTED] TONGRESS.#13


                                     

  Available via the World Wide Web: http://www.gpoaccess.gov/congress/
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                     COMMITTEE ON HOMELAND SECURITY

               Bennie G. Thompson, Mississippi, Chairman

Loretta Sanchez, California          Peter T. King, New York
Edward J. Markey, Massachusetts      Lamar Smith, Texas
Norman D. Dicks, Washington          Christopher Shays, Connecticut
Jane Harman, California              Mark E. Souder, Indiana
Peter A. DeFazio, Oregon             Tom Davis, Virginia
Nita M. Lowey, New York              Daniel E. Lungren, California
Eleanor Holmes Norton, District of   Mike Rogers, Alabama
Columbia                             David G. Reichert, Washington
Zoe Lofgren, California              Michael T. McCaul, Texas
Sheila Jackson Lee, Texas            Charles W. Dent, Pennsylvania
Donna M. Christensen, U.S. Virgin    Ginny Brown-Waite, Florida
Islands                              Gus M. Bilirakis, Florida
Bob Etheridge, North Carolina        David Davis, Tennessee
James R. Langevin, Rhode Island      Paul C. Broun, Georgia
Henry Cuellar, Texas                 Candice S. Miller, Michigan
Christopher P. Carney, Pennsylvania
Yvette D. Clarke, New York
Al Green, Texas
Ed Perlmutter, Colorado
Bill Pascrell, Jr., New Jersey

                    I. Lanier Lavant, Staff Director

                     Rosaline Cohen, Chief Counsel

                     Michael Twinchek, Chief Clerk

                Robert O'Connor, Minority Staff Director

                                 ______

   SUBCOMMITTEE ON EMERGING THREATS, CYBERSECURITY, AND SCIENCE AND 
                               TECHNOLOGY

               James R. Langevin, Rhode Island, Chairman

Zoe Lofgren, California              Michael T. McCaul, Texas
Donna M. Christensen, U.S. Virgin    Daniel E. Lungren, California
Islands                              Ginny Brown-Waite, Florida
Bob Etheridge, North Carolina        Paul C. Broun, Georgia
Al Green, Texas                      Peter T. King, New York (Ex 
Bill Pascrell, Jr., New Jersey       Officio)
Bennie G. Thompson, Mississippi (Ex 
Officio)

                   Jacob Olcott, Director and Counsel

       Dr. Chris Beck, Senior Advisor for Science and Technology

                       Carla Zamudio-Dolan, Clerk

           Kevin Gronberg, Minority Professional Staff Member

                                  (II)


                            C O N T E N T S

                              ----------                              
                                                                   Page

                               Statements

The Honorable James R. Langevin, a Representative in Congress 
  From the State of Rhode Island, and Chairman, Subcommittee on 
  Emerging Threats, Cybersecurity, and Science and Technology....     1

                               Witnesses

Dr. Jeffrey W. Runge, Assistant Secretary for Health Affairs and 
  Chief Medical Officer, Department of Homeland Security:
  Oral Statement.................................................     4
  Prepared Statement.............................................     7
Rear Admiral W. Craig Vanderwagen, M.D., Assistant Secretary for 
  Preparedness and Response, Department of Health and Human 
  Services; Accompanied by Dr. Michael G. Kurilla, Director, 
  Office of Biodefense Research Affairs, and Associate Director 
  for Biodefense Product Development, National Institute of 
  Allergy and Infectious Diseases, National Institutes of Health; 
  and Dr. Daniel M. Sosin, Director, Biosurveillance Coordination 
  Unit, and Associate Director for Science, Coordinating Office 
  for Terrorism Preparedness and Emergency Response, Centers for 
  Disease Control and Prevention:
  Oral Statement.................................................    12
  Prepared Statement.............................................    13
Captain Peter Boynton, Deputy Regional PFO for Pandemic Influenza 
  and Federal Security Director, Bradley International Airport 
  (Connecticut), Transportation Safety Administration, Department 
  of Homeland Security:
  Oral Statement.................................................    21
  Prepared Statement.............................................    23

                                Panel II

Dr. David R. Gifford, Director of Health, Rhode Island Department 
  of Health:
  Oral Statement.................................................    44
  Prepared Statement.............................................    46
Major General Robert T. Bray, Adjutant General, Rhode Island; 
  Commanding General, Rhode Island National Guard; Director, 
  Rhode Island Emergency Management Agency; and Homeland Security 
  Advisor, State of Rhode Island:
  Oral Statement.................................................    58
  Prepared Statement.............................................    59
Mr. Thomas J. Kilday, Jr., Homeland Security Program Manager, 
  Rhode Island Emergency Management Agency:
  Oral Statement.................................................    63
  Prepared Statement.............................................    65
Mr. Peter T. Ginaitt, Director, Emergency Preparedness, Lifespan 
  Hospital Network:
  Oral Statement.................................................    69
  Prepared Statement.............................................    72

                                Appendix

Questions From Chairman James R. Langevin........................    85


  EMERGING BIOLOGICAL THREATS AND PUBLIC HEALTH PREPAREDNESS: GETTING 
                          BEYOND GETTING READY

                              ----------                              


                             July 22, 2008

             U.S. House of Representatives,
                    Committee on Homeland Security,
      Subcommittee on Emerging Threats, Cybersecurity, and 
                                    Science and Technology,
                                                    Providence, RI.
    The subcommittee met, pursuant to notice, at 10:30 a.m., at 
Rhode Island State House, Smith Street, Room 313, Providence 
Rhode Island, Hon. James Langevin [Chairman of the 
subcommittee] presiding.
    Present: Representatives Langevin and Pascrell.
    Also present: Representative Christensen.
    Mr. Langevin. The Committee on Homeland Security will come 
to order. The committee is meeting today to receive testimony 
on ``Emerging Biological Threats and Public Health 
Preparedness: Getting Beyond Getting Ready.''
    Well, good morning. I'd like to thank my colleagues, 
Congressman Bill Pascrell from New Jersey and Congresswoman 
Donna Christensen from the Virgin Islands joining us here 
today. Welcome to Rhode Island. You've traveled all this way to 
be with us.
    I'd also like to thank our witnesses on the Federal panel 
for traveling here today, as well as welcoming and thanking our 
Rhode Island witnesses and guests. It's certainly an honor for 
me to be able to tackle such an important issue here in my own 
State and also to highlight the practical efforts and best 
practices of the State of Rhode Island and to have your 
expertise and your guidance in these efforts.
    Today, we will discuss the challenges States and localities 
face in preparing for and responding to emerging biological 
threats such as pandemic influenza or weaponized anthrax, among 
other things, that could affect every sector of society and 
every person potentially on a global scale.
    Efforts to address biological threats are among the most 
difficult. In fact, they are so challenging that for decades 
planning for situations involving biological terrorism using 
diseases such as smallpox, emerging infectious diseases such as 
ebola, or re-emerging infectious diseases such as pandemic 
influenza took a back seat to planning for other situations 
where response would be more straight forward, such as 
terrorism or accidents involving chemicals.
    Now this, obviously, has changed. Our Government no longer 
considers planning and preparedness for biological threats to 
be too hard, nor do we think that they are unlikely events. 
We've effectively determined what we need to do save lives, but 
clearly, more needs to be done.
    Now we all remember the anthrax events of 2001. Before and 
since then, there have been other biological incidents that 
have made equally vivid impressions. The outbreak of SARS, West 
Nile fever, extensively drug-resistant and multi-drug resistant 
tuberculosis; outbreaks of meningitis and mumps on college 
campuses; super bugs such as MRSA and VRSA; and the recent 
cases of salmonella and E. coli that have tainted our Nation's 
food supply are only a few that have occurred here in the 
United States.
    Time and again, public and private sectors have responded 
to these threats, but not without difficulty. Our Nation prides 
itself on confronting the tough issues and not shying away from 
a fight.
    The citizens of Rhode Island exemplify this and it's 
because of them and others like them throughout our great 
Nation that we're here today.
    It comes down to saving lives. In the case of pandemic 
influenza and diseases caused by some agents of bioterrorism, 
in the best case scenario we expect hundreds of thousands of 
people to become sick across the Nation. In the worst case 
scenario, hundreds of thousands could be sick just in one State 
or territory with death resulting.
    Now in the case of a biological weapons attack, I'm mindful 
of the findings of the Hart-Rudman Commission on U.S. National 
Security in the 21st Century which stated and I quote: 
``Terrorists and other disaffected groups will acquire weapons 
of mass destruction and mass disruption and some will use them. 
Americans will likely die on American soil, possibly in large 
numbers.''
    It's a sobering finding. The price we have to pay in terms 
of lives, the economy, and society is too great to make 
preparedness for these events a low priority. Now we've 
increased our readiness for any number of biological threats 
and it is clear to me, and my colleagues on the subcommittee 
that our resources and efforts have gone into ensuring that 
we're more prepared. I know that those we have invited to 
provide testimony today would agree that clearly still more 
needs to be done and we have to also work to get beyond getting 
ready and we have to actually be ready.
    Now we've established and added to Federal and State 
stockpiles of drugs and equipment, but we're not ready yet. 
We've engaged in planning efforts, but we're not ready yet. 
We've done a great deal of research on developing methods to 
get us new drugs and better treatments faster, but we're not 
ready yet. We've increased communications between public and 
private sectors, but we're not ready yet.
    Although we recognize that difficult decisions will need to 
be made regarding the delivery of medical care, when resources 
are short, and patients number in the millions, we're not ready 
yet to make those decisions.
    There are many issues that need to be addressed, but among 
them the most important are encouraging different sectors to 
partner with each other to counter these threats; integrating 
efforts to increasing efficiencies in public health and 
emergency response to biological events and helping our health 
care professionals save as many lives as possible when 
resources are strained by biological disaster.
    Now when it comes to large-scale issues like diseases for 
which we have few or no treatments and which could sweep across 
the country and the world, it's clear that no one sector or 
entity is solely responsible for prevention, deterrence, 
preparedness, detection, response, recovery, or mitigation. 
Different sectors must partner with each other and the kinds of 
partnerships that we need to see between the Department of 
Homeland Security and the Department of Health and Human 
Services or the State Emergency Management Agency and the State 
Department of Health are critical.
    There are hundreds, if not thousands of efforts going on 
right now to address Federal requirements for getting ready for 
a variety of different situations that would affect the health 
of the public. Now we've talked about coordinating those 
efforts before, but we need to go from coordinating to 
integration.
    Public health and public health care resources are limited, 
so the efforts of these sectors need to be as efficient as 
possible. This efficiency must be inherent in what the Federal 
Government is asking the non-Federal, public, and private 
sectors to do, the way shelf life is extended for various 
medications and the way grants and planning guidance go out to 
the States and the territories--in a way that truly means to 
hold the States and territories accountable to the Executive 
branch, and the Executive branch accountable to the Congress 
and ultimately to the American people.
    Decisionmaking when lives are at stake is difficult at best 
especially when large number numbers of people could be 
affected. I realize that there are certain decisions that no 
leader wants to make. But emergencies, disasters, and 
catastrophes demand this of us. To the greatest extent 
possible, we need to decide now what we're going to do when the 
number of people ill with a disease far exceeds the number of 
resources available to treat them.
    The Federal Government has issued some guidance in these 
and other areas, but we have not made enough headway. Everyone 
needs to roll up their sleeves, work their way through these 
challenges and develop decisionmaking criteria for those that 
will have to make the tough calls in the midst of a crisis. We 
must not back down from the fight against biological threats of 
any type whether naturally occurring or intentionally produced 
by a terrorist. We cannot let artificial situations like 
boundaries between States and countries or change of 
administrations keep us from continuing that fight.
    I certainly appreciate the efforts of the public and the 
private sector witnesses here today. Together, we will address 
a number of issues including partnering across sectors and 
creating greater efficiency in public health and other 
preparedness efforts and making the most difficult decisions of 
all, those that affect the lives of our families, our friends 
and our citizenry.
    Again, I want to thank everyone for being here this morning 
and also I want to point out something. It has certainly taken 
a tremendous amount of work to put this hearing together and I 
appreciate the interest that is shown by the number of people 
who have turned out for the hearing today. We also have an 
overflow room down in the House Finances Committee room down in 
the basement. However, if the room gets too crowded and people 
get uncomfortable and want to go down there--I thank everyone 
for attending.
    Because this is an official congressional hearing, it was 
also mentioned that we have to abide by certain rules of the 
committee and of the U.S. House of Representatives, so I would 
kindly ask that there be no applause of any kind or any kind of 
demonstration with regards to testimony. I would also ask that 
cell phones be turned off and put on vibrate mode. It's 
important to respect the decorum of the rules of the committee 
and again, I want to thank everyone for being here.
    With that, I would just ask if any Members have opening 
statements they would like to make?
    I'm reminded of the committee rules that opening statements 
may also be submitted for the record.
    Well, let me begin by welcoming our Federal panel here 
today. I want to begin by welcoming our first panel of 
witnesses. Our first witness is Dr. Jeff Runge. He is the 
Assistant Secretary for Health Affairs and the Chief Medical 
Office of the Department of Homeland Security. This will be his 
last appearance before this or I believe any committee of the 
Congress as he's set to depart from his current post and we 
thank you for your service, Dr. Runge. We thank you for being 
here.
    Dr. Runge. Mr. Chairman, thank you.
    Mr. Langevin. Our second witness is Rear Admiral Craig 
Vanderwagen, Assistant Secretary for Preparedness and Response 
at the Department of Health and Human Services. Dr. Vanderwagen 
was the senior Federal health official in response to Hurricane 
Katrina and Rita. Welcome to you, Dr. Vanderwagen.
    Our third witness is Dr. Michael Kurilla, Director of the 
Office of Biodefense Research Affairs for the Institute of 
Allergy and Infectious Diseases at the National Institutes of 
Health; and also Dr. Daniel M. Sosin, Director of the 
Biosurveillance Coordination Unit at the Centers for Disease 
Control and Prevention for being here to answer questions in 
regard to the Agency's efforts specifically and also Captain 
Peter Boynton is here to answer questions as the Deputy 
Regional PFO.
    With that, without objection the witnesses' full statements 
will be submitted for the record and I now ask each witness to 
summarize their testimony for 5 minutes, beginning with Dr. 
Runge, who as a courtesy will actually be given a couple extra 
minutes since he's departing.
    Welcome, Dr. Runge.

  STATEMENT OF JEFFREY W. RUNGE, MD, ASSISTANT SECRETARY FOR 
    HEALTH AFFAIRS AND CHIEF MEDICAL OFFICER, DEPARTMENT OF 
                       HOMELAND SECURITY

    Dr. Runge. Mr. Chairman, thank you for the going-away 
present. I want to thank you for the chance to be here with the 
subcommittee, and I also want to thank Congressman Pascrell and 
Dr. Christensen for making the trip. I'm a veteran of these 
field hearings. I know it's not the easiest thing to be here 
and you all have consistently demonstrated your interest and 
passion on this issue and I want to thank you for being here.
    Mr. Chairman, I also wanted to thank you publicly for all 
that you have done to ensure the success of our new Office of 
Health Affairs. You have sat through the classified briefings. 
You have been a great partner with you and your staff and I 
really appreciate your helping us accomplish what we have been 
able to do.
    As you and I have discussed, our efforts toward readying 
our Nation for widespread disease outbreaks are not centered 
solely around pandemic influenza, but on the broader threat. 
Fortunately today on the panel are the Nation's preeminent 
experts on pandemic management, so I'm not going to dwell on 
that topic. We'll take a slightly different tack on emerging 
infectious diseases by discussing the intentional use of 
biological agents against our Nation.
    The multi-use biological preparedness planning that we've 
been doing in preparation for a pandemic will pay off 
regardless of whether an attack is naturally occurring or a 
terrorist attack. But it's the intentional use of biological 
agents by a terrorist or terrorist group that keeps me up at 
night. I'd ask the subcommittee to consider first the current 
biological threat environment and the effect that a biological 
attack might have in a mid-size city like Providence, Rhode 
Island; second, the need for effective biosurveillance and 
environmental detection; and third, the roles and 
responsibilities of Federal, State, and local governments and 
the private sector and the public down to the family level in 
responding to and recovering from a biological attack.
    Now this discussion is not to cause fear and we're not 
fear-mongering here. Rather, making the public aware of and 
prepared for such an event creates, in our view, a more 
resilient community. By reducing the elements of surprise and 
creating a culture of readiness, we can eliminate the terror 
associated with such a horrific event and make the public's 
reaction a key part of the solution to a successful response, 
rather than part of the problem.
    So what is the risk? We believe that a large-scale, 
biological attack on the Nation is significant. We know that 
terrorists have sought to use biological agents as instruments 
of warfare and we are searching for better assessments of their 
capability. Our intelligence sources have determined that in 
the late 1990's, al Qaeda began developing a biological weapons 
program for anthrax production. Fortunately, this facility was 
disrupted by our military during Operating Enduring Freedom, 
but the intent to use biological agents as a weapon of mass 
destruction has not gone away.
    You may recall that in 2002 al Qaeda stated that they had 
the right to kill 4 million Americans, 2 million of them 
children. An advisor to bin Laden later increased that number 
to 10 million. There are not many weapons that can kill 
millions of people, but it can come close if one considers a 
coordinated attack on multiple cities. This should not be 
confused with the type of anthrax attack that occurred through 
the mail in 2001 which killed five people and injured three 
times that many. Even though it cost disruption to the Postal 
Service's building in Washington and elsewhere, it had an 
economic impact in the billions.
    The magnitude in both lives and economic effects is very, 
very small when compared to the scenario of an aerosolized 
anthrax attack envisioned by our enemies. It is that threat 
which we vigorously plan on, invest in, and intend to defeat. 
We cannot depend strictly on receiving action or specific 
warning of an imminent biological attack which is why it is 
imperative that we continue to enhance our Nation's efforts to 
provide the earliest possible detection and warning immediately 
after an attack, to strengthen our preparedness and response 
efforts and to increase our capacity to recovery, physically, 
psychologically, and environmentally.
    While it may be easy to assume that terrorists are only 
interested in striking major cities like Washington, DC or New 
York City, we cannot ignore the attractiveness of softer 
targets to our enemies. No one can forget that Oklahoma City 
experienced the horrors of terrorism when a truck bomb was 
detonated in the Murrah Federal Building killing 168 people 
including 19 children, and injuring hundreds more. Who would 
have thought that Oklahoma City would have been a target for 
terrorism? Is it therefore imperative that every State and 
every local jurisdiction be adequately prepared to handle 
catastrophic events across the threat spectrum.
    The city of Providence, Mr. Chairman, like many mid-sized 
cities has a number of characteristics that make it and many 
cities like it a potentially attractive target, proximity to 
military assets, concentrated population, and a vital 
transportation route along the East Coast. Without an 
environmental detection system in place, an aerosolized anthrax 
would not necessarily be detected in time for HHS and local 
health providers to provide prophylactic antibiotics. Clinical 
symptoms of inhalational anthrax would appear after 2 to 6 days 
following the release. But the earliest clinical cases would be 
harbingers of tens of thousands or more, nearly all requiring 
intensive care in medical facilities including ventilatory 
support and whatever anthrax countermeasures we have in the 
national stockpile. But by then the die is cast. We predict 
that if an attack of a plausible magnitude were directed at 
Providence, the number around 180,000 people would be exposed 
to a sufficient dose of anthrax spores to make them ill and we 
would expect about 90 percent of those to die without 
aggressive treatment which in those numbers may simply not be 
available.
    We can reduce the numbers of people who would die only by 
ensuring that affected people receive treatment before they 
show symptoms. This requires an environmental warning system. 
Moreover, without detection devices to characterize the area of 
exposure, I'm very concerned about managing the immediate 
aftermath with respect to giving valid information to the 
public about the extent of the release and the maintenance of 
public confidence.
    Mr. Chairman, the response to such an attack would be a 
monumental effort requiring seamless cooperation and 
coordination at all levels of government. That's why Congress 
created DHS. We do not provide the health care or the medical 
countermeasures. HHS does that. We do not catch the bad guys. 
FBI and local law enforcement does that. We don't clean the 
environment. EPA does that. We do not manage the international 
ramifications of such an attack. The Department of State does 
that.
    We do, however, Mr. Chairman, have the responsibility for 
coordination of all of those efforts and for several programs 
that are multi-agency and are under your oversight 
jurisdiction. They are crucial and in need of the support of 
the subcommittee.
    While we're continuing to make significant strikes in our 
BioWatch Program which provides that early and necessary 
detection of biological attack, we are quickly moving toward 
the next generation of detectors that will significantly reduce 
that time to allow our health providers to get countermeasures 
into the hands of the affected populations within the time 
window to save lives. However, we need the funding to continue 
this vital progress.
    We are also developing the National Biosurveillance 
Integration Center known as NBIC, authorized in the 9/11 Act, 
which brings together data from other Federal departments, the 
public domain and eventually the private sector in State and 
local governments to understand and characterize biological 
events and incidents across the areas of human health, animal 
health, food, water, and the environment.
    Mr. Chairman, I have a number of recommendations for the 
subcommittee to consider which I put into my written testimony 
and I will enumerate here.
    Again, I sincerely appreciate your personal dedication 
toward the security of the Nation. It has been a real pleasure 
working with you, with Dr. George, with Chris Beck and others 
on the committee staff during my time at DHS. I think I have 
created an office that is completely ready for the transition. 
I'm the only political in the office in the programmatic area 
and I think we're ready. I would ask for the subcommittee's 
continued support of my career staff in the office.
    Thank you, Mr. Chairman.
    [The statement of Dr. Runge follows:]

                 Prepared Statement of Jeffrey W. Runge
                             July 22, 2008

                              INTRODUCTION

    Good morning Mr. Chairman. Thank you for the opportunity to testify 
before the subcommittee on this important and timely issue. My 
colleagues and I have testified before your subcommittee on several 
occasions on this topic, and I appreciate your continued interest in 
ensuring that an outbreak of a disease, intentional or natural in 
origin, does not threaten our homeland security, economic stability, 
and our Nation's critical infrastructures and key resources. I am thus 
pleased to have the opportunity to share our views with you and your 
constituents through this hearing in Providence, RI.
    As you know, Mr. Chairman, this is one of the last events where I 
will appear as the Assistant Secretary for Health Affairs and Chief 
Medical Officer of the Department of Homeland Security (DHS), as I will 
be leaving Federal service at the beginning of August. I delayed the 
timing of my departure in order to testify once again to the urgency 
and importance of giving sufficient attention to biological threats to 
our Nation. At this, my last hearing, I would like to take this 
opportunity to thank you personally for all that you have done to 
ensure the success of the Office of Health Affairs and our mission to 
make the Nation safer and more secure.
    Today I will discuss a number of important issues surrounding 
emerging biological threats and our Nation's preparedness, including: 
the current biological threat environment as illustrated by the effect 
a biological attack might have in a city like Providence, our approach 
to biosurveillance and environmental detection, and the roles and 
responsibilities of Federal, State, local and the private sector in 
response to and recovery from a biological attack. Providing this 
information to the public creates a more resilient public. By reducing 
the elements of surprise, fear and panic, we can reduce the terror 
associated with such an event, making the public reaction a key part of 
the solution rather than the problem.

                       CURRENT BIOLOGICAL THREAT

    The risk of a large-scale biological attack on the Nation is 
significant. We know that our terrorist enemies have sought to use 
biological agents as instruments of their warfare, and we believe that 
capability is within their reach.
    I know many here today recall the anthrax attacks of 2001. As you 
know, Mr. Chairman, certain buildings occupied by Members of the 
Legislative branch were temporarily closed while they were 
decontaminated. The magnitude of that terrorist attack is miniscule 
compared to the larger, anthrax release envisioned by our enemies. It 
is nonetheless exemplary of the potential health and economic damage to 
which we are vulnerable. Unfortunately, the threat has not diminished 
since then--in fact, it has been building since well before the attacks 
of 9/11.
    We know that, in the late 1990's, al Qaeda began developing a 
biological weapons program and constructed a low-tech facility in 
Qandahar, Afghanistan for anthrax production. Fortunately, U.S. 
military forces disrupted this activity and additional American and 
coalition operations in the region have damaged al Qaeda leadership and 
operational capabilities--but not their intent to use biological 
weapons. You will recall that in 2002, al Qaeda stated that they had 
the right to kill 4 million Americans--2 million of them children--and 
cripple thousands. An advisor to bin Laden later issued a fatwa on the 
permissibility of using weapons of mass destruction and increased the 4 
million casualty figure to 10 million.
    We have determined that al Qaeda seeks to develop and use a 
biological weapon to cause mass casualties in an attack on the 
homeland. Our analysis indicates that anthrax is a likely choice; and a 
successful single-city attack on an unprepared population could kill 
hundreds of thousands of citizens. A coordinated attack on multiple 
targets would come much closer in magnitude to our enemy's goal. 
Because of this, we see the threat of an aerosolized anthrax attack as 
our No. 1 bioterrorism concern, and it is that threat which we 
vigorously plan, invest and intend to defeat. Our efforts are not 
optional or discretionary. The ramifications of such an attack include 
tremendous loss of life, economic costs, damage to critical 
infrastructure, and unprecedented environmental contamination.
    A biological attack would impact every sector of our society--not 
just the medical and public health communities. A biological attack 
respects no geographic or geopolitical boundary and will have an impact 
well beyond our Nation's emergency departments and public health 
infrastructure. Absenteeism across multiple sectors due to illness, 
fear of contagion, or public health measures could threaten the 
function of critical infrastructure, the movement of goods and 
services, and the operation of our institutions. No Federal department 
or agency will be exempt from the consequences of such an attack. 
Further, critical life-saving activities will depend on actions taken 
in the first few moments of the event. State and local governments will 
be called on to take several critical actions--alerting the public of 
the crisis without inciting panic; maintaining public confidence while 
making critical decisions; and bolstering local communities to rebound 
quickly.
    As we work together to counter this threat, we must keep in mind 
that acts of biological terrorism don't go ``bang.'' It could be hours 
or even days before we realize the full extent of an incident. Because 
of the lack of an explosion or immediate visual damage, many do not 
perceive the threat of bioterrorism to be as significant as that of a 
nuclear or conventional strike, even though such an attack could kill 
as many people as a nuclear detonation and have its own long-term 
environmental effects. This has caused a lack of public urgency in 
devoting significant resources to countering this threat--a luxury we 
simply cannot afford.
    Mr. Chairman, many people ask me ``what keeps you up at night?'' It 
is the possibility of a large-scale biological attack on our homeland.

                            THREAT AWARENESS

    Given the challenges we face in assessing current terrorist 
capabilities and identifying plots, it is unlikely that we will receive 
actionable or specific warning of an imminent biological attack. 
Furthermore, many of these deadly biological agents, including anthrax, 
are readily available in nature, relatively easy to procure, culture, 
and weaponize. There are numerous domestic and international biological 
research programs using these agents for legitimate purposes, making it 
more difficult to separate the ill-intentioned research initiatives. As 
a result, it is unlikely that we will have credible knowledge of an 
imminent biological threat before it occurs.
    This is why it is imperative that we continue to enhance our 
Nation's efforts to disrupt biological plots, provide the earliest 
possible detection and warning of an attack, strengthen our 
preparedness and response efforts, and increase our capacity to quickly 
recover.
    Secretary Chertoff and I have been promoting the inclusion of 
health and medical expertise in our State and local fusion centers as 
they develop and expand. OHA is working with the DHS Office of 
Intelligence and Analysis to provide information on biological threats 
to communities in harm's way and to encourage fusion centers to tap 
into local expertise in public health and health care to be a part of 
their information fusion. We have begun discussions with the HHS 
Assistant Secretary for Health regarding the incorporation of officers 
from the corps of the U.S. Public Health Service to help communities 
achieve this capability. DHS will be holding meetings in the late 
summer and early fall with States and local representatives with the 
goal of providing information on the biological threat and discussing 
the value of public health in fusion centers.

                             PROVIDENCE, RI

    While it is easy for us to assume that terrorists are only 
interested in striking major cities such as Washington, DC or New York 
City, we cannot ignore the attractiveness of softer targets to our 
enemies. On April 19, 1995 Oklahoma City experienced the horrors of 
terrorism when a truck bomb was detonated in front of the Alfred P. 
Murrah Federal Building, killing 168 people, including 19 children, and 
injuring hundreds more. Who would have thought that Oklahoma City would 
have been a target for terrorism? It is therefore imperative that all 
States and local jurisdictions are adequately prepared to handle events 
across the chemical, biological, radiological and nuclear spectrum, as 
well as more conventional attacks or naturally occurring outbreaks.
    The city of Providence, like many mid-size cities, has a number of 
characteristics that make it potentially attractive as a target, such 
as its proximity to military assets, major metropolitan areas, and an 
important transportation routes. An aerosolized sprayer releasing air-
borne anthrax particles into the air throughout a city like Providence 
would not necessarily be detected in the immediate aftermath of the 
release. Clinical symptoms of inhalational anthrax would not be 
discovered for at least 2 or 3 days after the attack occurred, yet the 
health effects and environmental consequences could be catastrophic.

                       SURVEILLANCE AND DETECTION

    It is critical to receive warning of a biological attack as soon as 
it occurs and to identify the causative agent immediately. Such a 
warning would enable the prevention of most cases of inhalational 
anthrax, through the combined response of the CDC and its State and 
local partners in distributing sufficient prophylactic antibiotics to 
the public before the onset of disease. A delay of just 1 day in 
detection of an anthrax release--and therefore treatment of affected 
populations--would result in thousands of unnecessary deaths.
    Sufficient early warning through environmental detection is one of 
the Department's top priorities, one for which the Office of Health 
Affairs, working with the Science and Technology Directorate (S&T), is 
responsible. We are investing significant amounts of taxpayer resources 
to our BioWatch program, which provides detection and warning of a 
biological attack in our Nation's highest-risk urban areas through a 
series of pathogen detectors. With S&T, we are developing the next 
generation of detectors, known as Generation 3, which will be automated 
and significantly reduce detection time to allow our health providers 
to get countermeasures into the hands of affected populations within 
the critical window of time to save lives.
    Complementing our BioWatch capabilities is our establishment of a 
robust biosurveillance integration center, where other departments and 
agencies come together to monitor their biological data and analyze 
potential biological threats. The National Biosurveillance Integration 
Center (NBIC), authorized in the 9/11 Act (Pub. L. 110-53), will bring 
together data from other Federal departments, the public domain and 
eventually the private sector and States and local government to 
understand and characterize biological events and incidents across the 
areas of human health, animal health, food, water and the environment. 
Through robust data analysis and integration across these sectors, we 
aim to provide the earliest possible warning of outbreaks and threats 
to human and veterinary health and the food and water supply. Over the 
past several months, we have made great progress in our governance 
structure. We now have all the relevant departments coming to an 
``ownership meeting,'' which recognizes that DHS is the host for NBIC, 
but the system belongs to every department across the Federal 
Government that needs access to a bio-surveillance common operation 
picture (BCOP). We are working very closely with the CDC as they 
develop improved human health surveillance systems, which will be a 
vital element of the Government's BCOP. It is in all of our interest to 
ensure the success of our partner agencies' improvements in their data 
systems.

             FEDERAL, STATE AND LOCAL RESPONSE AND RECOVERY

    If a large-scale biological attack occurred here in downtown 
Providence using aerosolized anthrax, it would likely go undetected for 
days, until large numbers of people begin showing up in emergency 
departments and doctors' offices 2 to 5 days after the attack. 
Unfortunately, most cases would progress quickly to a form of pneumonia 
that is very resistant to treatment once it has started. The sentinel 
cases would be those receiving the highest doses of anthrax spores, and 
would be the harbinger of tens of thousands more, nearly all requiring 
intensive medical care, including ventilatory support and the anthrax 
countermeasures we have in the Strategic National Stockpile (SNS). 
Federal, State and local law enforcement would seek to identify the 
perpetrators to prevent subsequent attacks. Since we do not know the 
extent of the exposure, Federal and local health officials would likely 
mobilize the SNS for antibiotics to be given to the population as 
environmental sensors and samples identify the affected areas. In such 
a scenario, State and local resources, including medical assets, would 
be taxed if not overwhelmed. Rather than a smoking building defining 
the extent of the victims, every man, woman, and child in the area--and 
every building and every farm in the plume--could be affected. This is 
not a pretty picture, so preparedness is required to minimize the 
impact.
    In such a case, the Secretary of Homeland Security would stand up 
all of the power and assets of Federal Government to manage the 
incident. The Federal Emergency Management Agency (FEMA) would stand up 
its National Resource Coordination Center to bring Federal assets to 
bear. The responsibility for the public health and medical response 
lies within the Department of Health and Human Services under the 
Public Health Services Act and as the lead for Emergency Response 
Function (ESF) 8: Public Health and Medical Response, with the 
Assistant Secretary for Preparedness and Response (ASPR) as the HHS 
Secretary's principal advisor and as the official responsible for 
certain functions. In order to have the tools to execute its mission 
successfully, HHS has invested thousands of hours and billions of 
dollars to make sure we have the appropriate medical countermeasures to 
deal with the threats to human health. This includes research and 
development of new medicines, vaccines and anti-toxins, as well as 
their stockpiling and distribution. DHS has been their advocate and 
partner every step of the way.
    Additionally, law enforcement and security measures are directed by 
the Department of Justice as the lead for ESF-13: Public Safety and 
Security; decontamination activities and environmental cleanup are 
directed by the Environmental Protection Agency as the lead for ESF-10: 
Oil and Hazardous Materials Response; and the terrorism crime scene 
investigation, as well as attribution and characterization to prevent 
second attacks are led by the Federal Bureau of Investigation. Our 
success is dependent on their success, Mr. Chairman. I encourage you to 
lend them your support in this effort, and encourage the support of 
your congressional colleagues. While homeland security may not be the 
primary mission of these agencies, their homeland security 
responsibilities are crucial to our mission.
    The Department of Homeland Security is charged with leading the 
overall domestic incident management, including coordinating the 
Federal response and integrating it with the State and local response 
efforts. OHA leads the DHS biodefense activities, which includes 
oversight and management responsibility for implementation for Homeland 
Security Presidential Directive 10, Biodefense for the 21st Century, 
although many other components and offices have major related 
responsibilities. The DHS National Biodefense Analysis and 
Countermeasures Center, a component of S&T, is responsible for the 
bioforensics analysis, and working with I&A and law enforcement, to 
determine the likely source of the germ. Our National Operations Center 
(NOC) coordinates all of the Federal operations and monitors the 
responses and requirements of local entities. DHS would quickly stand 
up a Joint Information Center (JIC) with all the relevant departments 
and agencies to ensure accuracy and timeliness of information to the 
public. Under a Stafford Act declaration, FEMA coordinates Federal 
assistance to requesting States. In accordance to the National Response 
Framework and because a biological incident would likely be an 
unusually complex incident requiring extraordinary coordination 
Secretary Chertoff has named a pre-designated a Principal Federal 
Official (PFO) to lead the response to a biological event. The PFO 
would assist States, local and tribal governments by overseeing a 
coordinated Federal response. A PFO is a senior Federal official with 
proven management experience and strong leadership capabilities. Vice 
Admiral Vivien Crea of the U.S. Coast Guard is our predesignated PFO 
for biological events and provides excellent leadership and knowledge.

                            RECOMMENDATIONS

    Mr. Chairman, I have a number of recommendations for the 
subcommittee to consider to enhance the state of preparedness in the 
event of a biological attack or natural outbreak.
    1. Continue to support our development of next generation automated 
        detection technologies to reduce the time-to-detect to allow 
        the necessary time to deliver life-saving medical 
        countermeasures to the population. Because a biological attack 
        is so challenging to accurately predict, we must continue to 
        refine our early detection and warning capabilities. If our 
        partners at HHS are to deliver life-saving prophylactic 
        antibiotics, we must be able to detect a biological release 
        sooner. Our current detection equipment has a built-in delay of 
        up to 36 hours, which is not consistent with the requirements 
        of disease prophylaxis. Over time, we must seek to cover more 
        of our Nation's population with earlier environmental warning. 
        Such an expansion must be risk-based which takes into account 
        population density and critical infrastructures.
    2. Continue to support the development of the National 
        Biosurveillance Integration Center (NBIC). It is the one place 
        where agencies can come together to share data across the 
        sectors of human health, animal health, food, water and the 
        environment. The center illustrates the very nature of DHS--to 
        integrate the assets and resources of sister Government 
        agencies in a protected, open environment for the purposes of 
        subject matter expertise and information sharing. The service 
        we must provide is a common operating picture for 
        decisionmakers before and during events to afford them the best 
        possible information upon which to make good decisions. The 
        oversight of NBIC belongs to the Committee on Homeland Security 
        in full view and participation of other congressional 
        committees and sister agencies.
    3. Support the full integration of health expertise into 
        information fusion centers. While intended initially for law 
        enforcement, with the threats including biological and chemical 
        events, the expertise of the health community is needed in the 
        information fusion process. The assistance of HHS may be 
        available to assist local agencies where needed. DHS will work 
        with local health directors to ensure necessary security 
        clearances and information analysis training to ensure the 
        success of such participation.
    4. Consolidate the committee's jurisdiction over issues of homeland 
        security. While DHS is by its authorization (Pub. L. 109-295) a 
        collaborative agency, so must Congress work collaboratively to 
        ensure a more secure homeland, empowering an effective yet 
        supportive oversight environment. As Secretary Chertoff has 
        mentioned on numerous occasions, the current threat environment 
        does not lend itself to jurisdictional disputes in Congress 
        over the Department's authorities and responsibilities. 
        Homeland Security is a team sport and we all should have the 
        common goal of a more secure Nation as our first priority.

                               CONCLUSION

    The threat of bioterrorism against the United States remains a 
significant concern. We continue to face an enemy determined to acquire 
and develop biological agents into weapons of mass destruction against 
the homeland. The Office of Health Affairs and the Department of 
Homeland Security takes this threat very seriously and are doing 
significant work to prevent, enhance early detection and surveillance 
and integrate Federal, State and local preparedness and response 
capabilities to reduce the catastrophic consequences of a biological 
attack on the homeland.
    Mr. Chairman, I sincerely appreciate your dedication and efforts to 
enhance the security of the Nation. Thank you again for the opportunity 
to testify. It has been a real pleasure working with you during my time 
at the Department of Homeland Security. I have created an office that 
is completely ready for the transition. I leave the office in the 
experienced and capable hands of Dr. Jon R. Krohmer, the Principal 
Deputy Assistant Secretary and Deputy Chief Medical Officer. I ask for 
your support of Dr. Krohmer over the coming months, as he is eager to 
work with you to better secure the homeland.

    Mr. Langevin. Thank you, Dr. Runge. I appreciate your 
testimony and for your service to our Nation. The Chair now 
recognizes Admiral Vanderwagen to summarize your statement for 
5 minutes.
    Welcome, Dr. Vanderwagen.

STATEMENT OF REAR ADMIRAL W. CRAIG VANDERWAGEN, M.D., ASSISTANT 
 SECRETARY FOR PREPAREDNESS AND RESPONSE, DEPARTMENT OF HEALTH 
    AND HUMAN SERVICES; ACCOMPANIED BY MICHAEL G. KURILLA, 
DIRECTOR, OFFICE OF BIODEFENSE RESEARCH AFFAIRS, AND ASSOCIATE 
DIRECTOR FOR BIODEFENSE PRODUCT DEVELOPMENT, NATIONAL INSTITUTE 
  OF ALLERGY AND INFECTIOUS DISEASES, NATIONAL INSTITUTES OF 
    HEALTH; AND DANIEL M. SOSIN, DIRECTOR, BIOSURVEILLANCE 
    COORDINATION UNIT, AND ASSOCIATE DIRECTOR FOR SCIENCE, 
 COORDINATING OFFICE FOR TERRORISM PREPAREDNESS AND EMERGENCY 
      RESPONSE, CENTERS FOR DISEASE CONTROL AND PREVENTION

    Dr. Vanderwagen. Thank you, sir. It's always nice to be in 
Providence. I think the history and beauty of this place is 
pretty remarkable. I've appreciated every opportunity I've had 
to come and visit here.
    I want to add then my piece to Jeff's overview because 
really DHS has the overview on these issues. They provide us 
with threat assessments that we analyze the public health 
impacts of so that for anthrax, for instance, what is the real 
public health impact that we would expect to have and what are 
the tools that we have to address it?
    These are the medical countermeasures that Jeff was 
speaking to. This begins with the research pipeline and Mike 
Kurilla here today I think can talk a little bit about the 
research pipeline activities. What are we studying? What do we 
know from the science that offers us an opportunity to develop 
countermeasures?
    Then we move to develop those ideas into a productive 
product that can be utilized in a meaningful way to the 
delivery platforms owned, operated, and managed in the local 
environment.
    Dan Sosin is going to be able to speak today to questions 
you may about biosurveillance that are supportive to the 
systems that Jeff described earlier. But our responsibility 
runs from the development of those countermeasures to delivery 
platforms at the community level to assure that those medical 
countermeasures get to the people who need them.
    As you suggested in your opening statement, Mr. Chairman, 
we are much better prepared, however, we are not fully ready 
and part of that is because we still exist in our operational 
silos more than we reasonably should. That's not to say that 
tremendous effort has not gone into the process of developing a 
national response plan as opposed to a Federal, State, local 
response plan, but there is more work to be done to synergize 
and harmonize the planning from the Federal level through the 
local level to assure that we have a national response plan as 
opposed to a series of localized plans for action.
    I think second there is much more work to do in the area of 
bringing about public and private partnerships that is shared 
responsibility that extends beyond the public sector, whether 
that's State, local, or Federal and embraces the opportunity 
for local, private sector entities to have an active role. This 
is important as Jeff suggested because of the resiliency that 
is built when you provide people with the opportunity to build 
tools and activities that will lead to control in the face of 
chaos in these kinds of events.
    As Jeff has said and as you have alluded to in your opening 
statement, Mr. Chairman, there's much focus on kinetic events, 
IEDs, improvised nuclear devices, and there is no question that 
these are threats that are significant and important. But it's 
our belief that the biothreats have a much broader impact in 
our society, both from a public health perspective and from the 
wider intersectoral perspective in economics, in transportation 
and energy, et cetera.
    Therein lies another challenge that we have not fully 
addressed and that is the broad multisectoral involvement. DHS 
has done a great job in establishing the national response 
framework and promoting and working forward with that, but 
there continues to be challenges at the local and State level 
in assuring that all the sectors are talking to each other.
    I've traveled around the country significantly over the 
last year and a half, much like Jeff, and one of the things 
that I've observed is some places there is great intersectoral 
cooperation, planning, action, exercise, et cetera, and that 
has brought about meaningful best practices. But there are 
other places where the guns and hoses don't talk to the health 
people, don't talk to the banking people, et cetera. No blame 
placing here. It's just a matter of the fact that people aren't 
necessarily working in an intersectoral way to maximize their 
local capability to respond.
    Indeed, as Jeff has suggested, therein lies the resiliency 
that will be needed when we face a significant event of the 
kind of proportions that we're talking about here. The other 
thing that's uniquely problematic with bio events is unlike an 
IED or even an IND or a natural event like a hurricane, it is 
not geographically and temporally limited. This is very 
difficult because you're not sure exactly when it started, as 
Jeff pointed out. The technical challenge there is a large one 
and you're not exactly sure when it's going to end. Quite 
commonly it will extend over a wide geographic area.
    Again, this argues for the fact that we need to have broad, 
intersectoral dialog, communication, planning, and activity. We 
need greater investment in tool development, the advanced 
development of some of these good research ideas is not 
progressing as fast as it reasonably could. So we think there 
are things ahead that will allow us to be beyond prepared and 
begin to become ready in effect, as you suggested.
    Thank you, Mr. Chairman, for the opportunity.
    [The statement of Dr. Vanderwagen follows:]

               Prepared Statement of W. Craig Vanderwagen
                             July 22, 2008

    Good Morning Chairman Langevin, Mr. McCaul, and Members of the 
committee. I am RADM W. Craig Vanderwagen, M.D., the Assistant 
Secretary for Preparedness and Response (ASPR) at the U.S. Department 
of Health and Human Services (HHS). I appreciate this opportunity to 
discuss the HHS plans and initiatives in public health and emergency 
preparedness to respond to emerging biological threats, including 
pandemic influenza. HHS's Office of the ASPR has adopted an ``all-
hazards'' approach to our preparedness and response activities, moving 
us from stand-alone plans to a process that addresses all of the 
hazards that potentially threaten the public's health. We have 
collaborated and coordinated closely with our Federal interagency 
partners and have provided States and municipalities with funding to 
enhance their public health and medical preparedness.

                         EMERGENCY PREPAREDNESS

    Our ``all-hazards'' preparedness involves a shared responsibility 
among our entire Department, our partners in the international 
community, the Federal, State, local, tribal and territorial 
governments, the private sector, and, ultimately, individuals and 
families. Additionally, before an event, government agencies at all 
levels work with the private sector to plan and exercise so they can be 
ready when a disaster occurs. During an emergency, local and State 
response agencies, including public health departments, are the first 
to respond. For regional or severe emergencies, the Federal Government 
may be asked to provide additional resources and coordinate response 
efforts across multiple jurisdictions.
    In that context, some of the emergency preparedness efforts 
currently being led by HHS involve working with our Federal, State, and 
local partners. For instance, we support State and local authorities 
through the Hospital Preparedness Program and the Public Health 
Emergency Preparedness Program for a broad range of medical and public 
health preparedness activities, including the development of medical 
and public health plans for response, increasing the number of 
exercises to evaluate these plans, increasing the training 
opportunities in key preparedness areas, increasing epidemiological and 
laboratory detection capabilities, establishment of local stockpiles of 
critical medical equipment and supplies, improving surveillance and 
investigation capabilities, maintenance and distribution of 
countermeasures, and sharing of resources.

  EMERGENCY SUPPORT FUNCTION NO. 8--PUBLIC HEALTH AND MEDICAL SERVICES

    The National Response Framework (NRF) Emergency Support Function 
(ESF) No. 8--Public Health and Medical Services--provides the mechanism 
for coordinated Federal assistance to supplement State, local, tribal, 
and territorial resources in response to a public health and medical 
disaster, potential or actual incidents requiring a coordinated Federal 
response, and/or during a developing health and medical emergency. The 
Secretary of HHS; here forth the Secretary, leads all Federal public 
health and medical response to public health emergencies and incidents 
covered by the NRF. The response addresses medical needs and other 
functional needs of those requiring medical care and other assistance 
during an emergency.
    Except for the personnel and assets under the command of the 
Department of Defense, the Secretary assumes operational control of 
Federal emergency public health and medical response assets, as 
necessary, in the event of a public health emergency. The Secretary, 
through ASPR, coordinates National ESF No. 8 preparedness, response, 
and recovery actions.
    HHS has implemented an incident command system that is National 
Incident Management System compliant. Additionally, all States have 
established emergency operation centers and have also implemented an 
incident command system. We have trained and equipped response 
personnel who include not only the National Disaster Medical System 
(NDMS) teams, but also Public Health Service Commissioned Corps 
Officers.
    The operational command of personnel deployed under our auspices is 
fully consistent with and supportive of the Department of Homeland 
Security's (DHS's) role as overall incident manager, including liaisons 
in the National Operations Center, National Response Coordination 
Center, and the Joint Field Office. The HHS recognizes and supports the 
overall lead of DHS in coordinating the Federal response and we take 
seriously our role as the lead Federal agency for Public Health and 
Medical Services through ESF No. 8, of the NRF.

           PANDEMIC AND ALL-HAZARDS PREPAREDNESS ACT (PAHPA)

    Consistent with requirements contained in the Public Health Service 
Act, as amended by the Pandemic and All-Hazards Preparedness Act 
(PAHPA), HHS has updated the performance measures for both the Hospital 
Preparedness Program and the Public Health Emergency Preparedness 
Program. Specific improvements include greater clarity in language, the 
use of definitions, and the addition of targets. For example, in fiscal 
year 2006, HHS asked grantees to report participating hospitals' 
ability to track bed status electronically, and report it to the 
grantee's Emergency Operations Center within 60 minutes of a request. 
In 2007, the numerator and denominator were defined to improve clarity. 
For fiscal year 2008, the target percentage of hospitals able to report 
was increased to 100 percent by the end of the end of the year.
    HHS strongly supported the new accountability provisions included 
in PAHPA and is implementing these provisions. First, fiscal year 2009 
award funds will be based on the successful achievement of targets 
during the previous budget cycle. In addition, the matching provision 
will be applied to the Public Health Emergency Preparedness Program 
(PHEP) in fiscal year 2009. We also intend, through notice and comment, 
to apply the matching provision to the Hospital Preparedness Program 
(HPP) in fiscal year 2009. The audit and carryover provisions apply to 
both the PHEP and HPP programs currently; the withholding provision 
will be applied to these programs in fiscal year 2009. The HPP and PHEP 
programs implemented the maintenance of funding provision in fiscal 
year 2007.

          PUBLIC HEALTH EMERGENCY PREPAREDNESS (PHEP) PROGRAM

    From fiscal year 2002-fiscal year 2008, the Public Health Emergency 
Preparedness (PHEP) program has provided $6.3 billion to State, local, 
tribal, and territorial public health departments. This amount includes 
targeted supplements to prepare for smallpox (in fiscal year 2003) and 
for an influenza pandemic (fiscal year 2005-fiscal year 2007). This 
program has greatly increased the preparedness capabilities of public 
health departments:
   All States can receive and evaluate urgent disease reports 
        24/7, while in 1999 only 12 could do so.
   All States now conduct year-round influenza surveillance.
   The number of State and local public health laboratories 
        that can detect biological agents as members of CDC's 
        Laboratory Response Network (LRN) has increased to 110 in 2007, 
        from 83 in 2002. For chemical agents, the number increased to 
        47, from 0 in 2001. Rather than having to rely on confirmation 
        from laboratories at CDC, LRN laboratories can produce 
        conclusive results. This allows local authorities to respond 
        quickly to emergencies.
   All States have trained public health staff roles and 
        responsibilities during an emergency as outlined in the 
        Incident Command System, while in 1999 only 14 did so.
   All States routinely conduct exercises to test public health 
        departments' ability to respond to emergencies. Such exercises 
        were uncommon before PHEP funding.

                  HOSPITAL PREPAREDNESS PROGRAM (HPP)

    We have made considerable investments in building the health care 
preparedness and response capabilities required during an incident 
resulting in mass casualties, and are committed to performance 
measurement. Over the past 5 years, the Hospital Preparedness Program 
(HPP) has provided more than $2.6 billion to fund the development of 
medical surge capacity and capability at the State and local level. As 
a result of HPP funds awarded to States and territories, hospitals and 
other health care entities:
   Increased their ability to provide needed beds during an 
        emergency;
   Can now track bed and resource availability using electronic 
        systems;
   Engaged with other responders through interoperable 
        communication systems;
   Appropriately train their health care workers for all-
        hazards approach to emergencies;
   Protect their health care workers with proper equipment;
   Have installed equipment necessary to decontaminate 
        patients;
   Have developed fatality management and hospital evacuation 
        plans, and
   Coordinate regional exercises.

                    REGIONAL EMERGENCY COORDINATION

    HHS has worked diligently to partner with State, tribal, 
territorial, and local officials to enhance their level of preparedness 
and to ensure they can see how HHS will respond to disasters. Our 
Regional Emergency Coordination/Coordinator (REC) program has been 
enhanced. In the past year, we have increased the number of RECs from 
10 to over 30. The REC's role is to work with the States and local 
jurisdictions to coordinate and enhance preparedness within the region. 
I have personally been to each of the 10 HHS regions to participate in 
local exercises and meet with State and local health leadership to 
discuss the level of preparedness and how HHS can support them.

            U.S. PUBLIC HEALTH SERVICE, VOLUNTEER PERSONNEL

    HHS has a number of resources that are rapidly available to deploy 
in response to a biological event. The full-time U.S. Public Health 
Service (USPHS) responders include the Rapid Deployment Force (RDF) 
Teams, Applied Public Health Teams (APHT), Mental Health Teams (MHT) 
and additional USPHS Officers. Volunteer health care professionals are 
available through the Medical Reserve Corps, which has over 160,000 
members in approximately 700 teams. The Emergency System for Advance 
Registration of Volunteer Health Professionals (ESAR-VHP) ensures the 
availability of volunteers for quick exchange between jurisdictions.

                    NATIONAL DISASTER MEDICAL SYSTEM

    We are also continuously improving HHS's operational capabilities 
to respond to emergencies. The NDMS, transferred from the Department of 
Homeland Security to HHS, remains the ``tip of the spear'' as the 
Federal disaster health care response capability, maintaining 6,200 
medical and public health professionals and over 1,800 participating 
hospitals that offer definitive care services, with approximately 
34,000 available beds (at most recent count). NDMS field teams include 
the Disaster Medical Assistance Teams (DMAT), Disaster Mortuary 
Operational Response Teams (DMORT), National Medical Response Teams 
(NMRT), and International Medical and Surgical Response Teams (IMSRT).
    Since the transfer of NDMS last year, we have achieved a number of 
accomplishments aimed at improving the system including the integration 
of NDMS into the larger ESF No. 8 response framework and 
regionalization of NDMS response operations and caches to provide 
increased accountability and standardization for supplies as well as 
fiscal savings. Future goals for NDMS include enhancing readiness and 
accountability through regionalization of NDMS response operations and 
enhancing equipment caches.

                        FEDERAL MEDICAL STATIONS

    The HHS Federal Medical Station (FMS) is a deployable health care 
platform that can provide non-acute hospital bed surge capacity and 
special medical needs sheltering. A standard FMS can house 
approximately 250 patients and is staffed by the Rapid Deployment Force 
teams. The FMS are useful in care of patients with suspected or 
confirmed exposure to biological threats, and who may require for 
example, observation, limited definitive care, or primary care.

                               PLAYBOOKS

    HHS prepares playbooks for the different scenarios of man-made and 
natural disasters. For biological emergencies response there are 
separate playbooks including anthrax, Clostridium botulinum, small pox, 
and pandemic influenza. These playbooks are used by HHS during an event 
and include sections for the:
   Scenario;
   Concept of operations, or CONOPs, for the response;
   Action steps;
   Briefing and decision papers; and
   Essential elements of information.
    The action steps are time-oriented, and include pre-event steps 
should there be credible intelligence that the risk of an event is 
high. The action steps are arranged into natural stages for a response 
and include a trigger for each stage, a recommended strategy to follow, 
and specific actions to take.
    ASPR has written and exercised playbooks based on 11 of the 15 
national exercise scenarios. The process of developing these playbooks 
provides opportunities for input from our ESF No. 8 Federal partners. 
Additionally, HHS playbooks, starting with the hurricane playbook, will 
be placed on the HHS web site to facilitate their examination and use 
by State, local, tribal, and territorial, officials. We will make 
additional playbooks available as they become ready for release.

      THE MEDICAL RESPONSE SYSTEM FOR TRIAGE, TRANSPORT, TREATMENT

    HHS has developed a response system called the TR system for 
Treatment, Triage and Transport in an event, that takes into account 
the factors and character of the agent or threat, in determining 
medical response. The triage of individuals will be based on medical 
evaluation including where they were during and shortly after the event 
with particular attention to special needs that they may have. The 
initial triage will attempt to separate people into three broad 
categories:
   those needing immediate medical attention, which would 
        include those with clinical effects of known exposure to a 
        biological agent or highly suspect exposure risk;
   those without clinical effects to the biological agent but 
        at risk from potential exposure (due to location, etc.);
   those with minimal or no likelihood of exposure and no 
        clinical effects from the biological agent, who do not require 
        immediate medical care.

                                 MEDMAP

    HHS is developing an interactive geographic information system 
(GIS)-based mapping system, called MedMap, which will include data for 
resources in a response to any type of hazard such as potential medical 
care sites and assembly centers in the United States, evacuation 
routes, hazards, etc. so that up-to-date information will be 
immediately available by which to organize the response. Determining 
which local medical care and assembly center facilities are functional 
or not in the exposure area is essential, as is having information on 
what regional and Nation-wide resources are available.

                          RESPONSE OPERATIONS

    HHS maintains an operations center 24/7/365. The Secretary's 
Operations Center (SOC) is directly connected to the DHS National 
Operations Center and the FEMA National Response Operations Center. It 
serves as the focal point for situational awareness, information 
management and response coordination for HHS. We have established 
relationships with subject matter experts from within HHS Operating and 
Staff Divisions such as NIH, CDC, FDA, and ASPR.

            HOMELAND SECURITY PRESIDENTIAL DIRECTIVE NO. 18

    In January, 2007 the President issued Homeland Security 
Presidential Directive (HSPD) No. 18, which directed the Secretary and 
the Federal Government in development and acquisition of medical 
countermeasures for weapons of mass destruction. The HSPD-18 builds on 
the National Strategy to Combat Weapons of Mass Destruction and 
Biodefense for the 21st Century by focusing on medical countermeasure 
research, development, and acquisition efforts. The HSPD-18 objectives 
for countermeasure include: (1) Identification of target threats with 
potential for catastrophic impact on public health and able to be 
mitigated; (2) yielding rapidly deployable and flexible capabilities to 
address threats; (3) integration with WMD consequence management 
through risk assessments of threats, vulnerabilities, and capabilities; 
and (4) development of realistic, effective concepts of response for an 
attack. With this in mind, the research, development, acquisition of 
medical countermeasures is driven by principles that focus on: (1) 
Current and anticipated threat agents with greatest potential for use, 
and catastrophic consequences; (2) greatest potential to prevent, 
treat, and mitigate WMD threats; and (3) integration with effective 
deployment strategies supportable by realistic current or future 
operational and logistical capabilities.
    The biological threats focus of HSPD-18 addresses four distinct 
categories which present unique challenges and significant 
opportunities for development of medical countermeasures.
    (1) Traditional agents are naturally occurring microorganisms or 
        toxins with the potential to be disseminated to cause mass 
        casualties. Such agents include Yersinia pestis, plague; and 
        Bacillus anthracis, anthrax.
    (2) Enhanced Agents are modified or selected traditional agents 
        that enhance their ability to cause mass casualties. Such 
        agents would include antibiotic resistant organisms that as 
        such, circumvent medical countermeasures.
    (3) Emerging Agents are pathogens that previously did not pose a 
        recognizable risk to human populations, but are now identified 
        to pose this risk, such as Severe Acute Respiratory Syndrome 
        (SARS).
    (4) Advanced Agents are novel pathogens or biomolecules that have 
        been artificially engineered, and can circumvent current 
        medical countermeasures to produce a more severe or enhanced 
        spectrum of disease. In a way, genetically engineered smallpox 
        strains could fit under this guise, as would engineered Ebola 
        strains.
    The HSPD-18 authorizes the Secretary to lead Federal Government 
efforts to research, develop, and acquire medical countermeasures via 
establishment of an interagency committee to provide advice in setting 
medical countermeasure requirements, research, development, and 
procurement activities; and establishment of a strategic planning 
initiative to integrate requirements, development and acquisition of 
countermeasures across the full range of research and life cycle 
development. The Public Health Emergency Medical Countermeasures 
Enterprise (PHEMCE) and the PHEMCE Strategy and Implementation Plan for 
CBRN Threats address these directives respectively.

                        MEDICAL COUNTERMEASURES

Biomedical Advanced Research and Development Authority--Development and 
        Acquisition
    Our progress in securing medical countermeasures begins with and 
depends on effective planning. The central framework for medical 
countermeasures planning and implementation in the Federal Government 
is the HHS PHEMCE, established in July 2006. This coordinated 
interagency group is led by the ASPR, and includes the Centers for 
Disease Control and Prevention (CDC), the Food and Drug Administration 
(FDA), and the National Institutes of Health (NIH) as well as our 
partners from the Department of Defense (DOD), DHS, and Department of 
Veterans Affairs (VA). Through this Enterprise-wide effort, we are able 
to ensure that Federal activities with respect to needed medical 
countermeasures are effectively coordinated from research and 
development to acquisition and ultimately deployment. This supports a 
range of programs that I will briefly summarize for developing and 
acquiring medical countermeasures for man-made and naturally occurring 
public health threats while building domestic manufacturing 
infrastructure.
    HHS established the Biomedical Advanced Research and Development 
Authority (BARDA) to direct and coordinate the Department's 
countermeasure and product advanced research and development 
activities. In support of the mission and priorities of PHEMCE, BARDA 
establishes systems that encourage and facilitate the development and 
acquisition of medical countermeasures such as vaccines, therapeutics, 
and diagnostics, as well as innovative approaches to meet the threat of 
chemical, biological, radiological and nuclear (CBRN) agents and 
emerging infectious diseases, including pandemic influenza. The BARDA 
provides an integrated, systematic approach to the development and 
purchase of the necessary vaccines, drugs, therapies and diagnostic 
tools for public health emergencies. It directs and coordinates the 
Department's countermeasure and product advanced development activities 
and medical countermeasure domestic manufacturing infrastructure 
building, including strategic planning for medical countermeasure 
research, development, and procurement. This coordinated approach is 
critical to achieving success in the area of bioterrorism preparedness.
    Anthrax.--Anthrax remains a top priority for ongoing public health 
emergency preparedness efforts at HHS. The Department is committed to 
developing and acquiring a robust, comprehensive portfolio of medical 
countermeasures against this threat. Antibiotics represent the first 
line of defense to protect the Nation following an anthrax attack. 
Today, we have over 60 million courses of antibiotics on hand and on 
order for the Strategic National Stockpile (SNS). Anthrax vaccines are 
also an essential element of our national preparedness. It is possible 
that vaccines given as post-exposure prophylaxis in combination with 
antibiotics could provide longer-term protection, or allow for a 
reduction in the duration of the antibiotic regimen. HHS has awarded 
contracts for the acquisition of nearly 30 million doses of anthrax 
vaccine since 2005, including the recent contract award of 18.75 
million doses of Anthrax Vaccine Adsorbed (AVA, BioThraxTM) 
in partnership with the DoD. In addition, antitoxins are necessary to 
treat individuals with advanced stages of infection, and may contribute 
to a more successful therapeutic outcome. Beginning in 2007, HHS has 
awarded contracts to two manufacturers to deliver antitoxins sufficient 
for treating 30,000 people. These vaccine and antitoxin contracts were 
awarded under the authorities of the Project BioShield Act of 2004. In 
addition, three BARDA contracts for the advanced development of other 
anthrax therapeutic candidates were recently awarded through a 
partnership with the NIH/National Institute of Allergy and Infectious 
Diseases (NIAID).
    HHS remains committed to the development and acquisition of a 
second generation anthrax vaccine. While procuring and continuing to 
improve the currently available anthrax vaccine, HHS is investing over 
$40 million in the continued development of a recombinant anthrax 
vaccine. This investment builds on the recombinant vaccine program that 
has been ongoing at the NIAID since 2002. BARDA also released a Request 
for Proposals (RFP) in March 2008 for a recombinant anthrax vaccine 
contract award. In addition, BARDA and NIAID released a Broad Agency 
Announcement in September 2007 for vaccine enhancement that will 
support important improvements in storage conditions and administration 
for vaccines against a wide array of biological threats; these 
proposals are currently under USG review.
    Smallpox virus.--In June 2007, BARDA awarded a contract for a next 
generation modified vaccinia Ankara (MVA) smallpox vaccine for use in 
immune-compromised Americans. This was the first BARDA contract to 
utilize performance-based milestone payments allowable under the 
Pandemic and All Hazards Preparedness Act (PAHPA). HHS/CDC has also 
procured ACAM-2000, a live, single-dose smallpox vaccine developed by 
Acambis, which is the first new bio-defense vaccine to be approved by 
the FDA.
    Botulinum toxin.--In June 2006, HHS awarded a contract under 
Project BioShield to the Cangene Corporation for 200,000 doses of a 
botulinum antitoxin that targets all 7 serotypes of Clostridium 
botulinum. The $363 million contract will expand greatly our existing 
stockpiles in the SNS. Deliveries of this product to the SNS initiated 
in 2007.
    Pandemic influenza.--The pandemic influenza program is focused on 
vaccines, antivirals, diagnostics, and non-pharmaceutical 
countermeasures. In December 2005, and June 2006, Congress appropriated 
$5.6 billion for HHS pandemic influenza preparedness efforts. With 
these funds, scientists and public health experts at HHS have built an 
aggressive and broad-based medical countermeasures program for pandemic 
influenza. These funds support the acquisition of existing products, 
advanced development projects to produce modernized and next-generation 
countermeasures, and the retrofitting and construction of the 
facilities necessary to produce pandemic influenza vaccines.
    With respect to vaccines, HHS has a number of efforts underway. 
These efforts supported the first U.S. licensure of an H5N1 vaccine in 
April 2007, which was highlighted as the No. 1 medical breakthrough of 
2007. By the end of 2007, HHS in coordination with DoD had stockpiled 
12 million courses of pre-pandemic H5N1. However, maintaining a 
domestic production capability for these priority countermeasures is 
also an essential component of the pandemic influenza preparedness 
strategy. In May 2006, HHS awarded five contracts for over $1 billion 
to GlaxoSmithKline, MedImmune, Novartis (formerly Chiron), Solvay, and 
Dynport (with Baxter) for support of advanced development of cell-based 
influenza vaccines toward U.S. licensure and expanded domestic vaccine 
manufacturing surge capacity. In June 2007, we awarded two contracts 
for the retrofitting of existing domestic biological manufacturing 
facilities to produce egg-based influenza vaccines and included warm 
base operations for up to 5 years. Additionally, contract awards are 
expected in 2008 for the construction of new domestic facilities for 
manufacturing cell-based influenza vaccines that is expected to 
quadruple the domestic pandemic vaccine manufacturing surge capacity by 
2012.
    A robust and groundbreaking advanced development program has led to 
the rapid maturation of modernized cell-based influenza vaccine 
production and antigen-sparing technologies. New combinations of 
adjuvants and products provided by multiple manufacturers are currently 
supported by performance-driven milestone contracts. More rapid vaccine 
production may be afforded by the development of next generation 
recombinant influenza vaccines, which HHS will support.
    Antiviral drugs have become an increasingly important medical 
countermeasure for influenza. Today, in coordination with DoD and VA, 
the SNS contains 50 million treatment courses of antiviral drugs, 
completing the Federal stockpile 1 year ahead of schedule. HHS has also 
supported antiviral stockpiling at the State level. Through a federally 
subsidized program, States have purchased 22 million treatment courses 
of influenza antiviral drugs to date and are expected to reach our goal 
of 31 million courses by the end of 2008.
    The nature of severe influenza infections has also required us to 
focus on preparedness through non-pharmaceutical countermeasures, such 
as ventilators which play an essential role in the health care of 
critically ill patients. The fiscal year 2009 President's budget 
includes $25 million to develop ventilators that are more amenable to 
public health emergency use. This presents a prime example of the 
integrative, all-hazards approach that the PHEMC Enterprise seeks. A 
more portable and easier to use ventilator could be an essential tool 
for responding to many different public health threats, when having a 
sufficient supply of ventilators could have an impact on the morbidity 
and mortality of exposure.

                        MEDICAL COUNTERMEASURES

Strategic National Stockpile--Distribution and Dispensing
    The Division of Strategic National Stockpile (DSNS) at CDC can 
deploy medical countermeasures rapidly after notification to do so. In 
addition to medical countermeasures that can be tailored to meet the 
event's specific needs, the DSNS inventory contains supplies and 
materiel required in the medical management of burns, trauma, injuries 
that may be seen in conjunction with explosive threats.
    The collaborative arrangements DSNS has with a variety of agencies, 
corporations, companies, and organizations are essential to not only 
increase the ability of State and local public health agencies to 
dispense medical countermeasures in a timely manner but also are 
critical to identifying and overcoming many of the inherent challenges. 
The broadness of the partnership is vital in that each of the 
participants brings not only a different perspective to the challenges 
but also expands the possibilities for finding answers to breach 
obstacles and barriers. Developing partnerships with private and public 
sector agencies to sponsor closed points of dispensing (PODs) is 
necessary to alleviate the burden on PODs for the general public. 
Lightening the load on these general public PODs reduces many of the 
challenges faced by local health agencies, i.e., staffing, security. 
These partnerships also reflect the directives within HSPD-21 and PAHPA 
to cultivate, enhance, and maintain interagency collaboration.
    An example of this collaborative partnership is demonstrated as 
CDC/COTPER work with the Business Executives for National Security 
(BENS) to promote the involvement of private corporations in 
preparedness planning and response. BENS is working with the State of 
Georgia and Los Angeles County to establish a model system, to 
hopefully be duplicated nationally, of corporate points of dispensing. 
This pilot initiative is funded through the CDC PHEP Cooperative 
Agreement. BENS officials presented and networked with State and local 
planners at all four regional Cities Readiness Initiative workshops.

            HOMELAND SECURITY PRESIDENTIAL DIRECTIVE NO. 21

    On October 18, 2007 President Bush signed HSPD No. 21, ``Public 
Health and Medical Preparedness,'' establishing a new National Strategy 
for Public Health and Medical Preparedness (the Strategy).
    As directed by HSPD-21, HHS has been successful in establishing two 
advisory committees. The National Biosurveillance Advisory Committee 
has been established as a subcommittee to the CDC Advisory Committee to 
the Director (ACD) and a Disaster Mental Health Advisory Committee is 
being established as a subcommittee under the National Biodefense 
Science Board (NBSB) which advises the Secretary. Additionally, HHS 
leads the development of a national strategy on biosurveillance through 
CDC's efforts and creation of the Biosurveillance Coordination Unit 
charged with coordinating the necessary activities to address the 
mandates of HSPD-21 in the development of a strategy and implementation 
plan for the Nation's next-generation biosurveillance capability.
    Under the leadership of CDC, the HSPD-21 requirement to ensure the 
adequate flow of information before, during, and after an event, 
including critical biosurveillance data and risk analysis has quickly 
drafted a strategic plan of national scope. Planning is being 
undertaken using a broad collaborative approach that will increase 
stakeholder buy-in, assure effective implementation, and guide the 
strategic allocation of resources.
    Also delegated to CDC leadership, HSPD-21 requirements pertaining 
to 48-hour post attack countermeasure distribution are being addressed 
through the strategic development of new models of distribution and 
dispensing of medical countermeasures that would enhance and improve 
the existing capabilities of the DSNS and its State and city partners. 
New models can incorporate other partners into a national network, 
including the CDC Laboratory Network, Department of Veterans Affairs, 
businesses, and hospital and pharmaceutical distribution systems.
    Tasked to DHS leadership, HSPD-21 requirements for health risk and 
threat briefings to non-health political leaders at the State and city 
level are being met with active involvement of HHS health experts.
    Finally, HHS is implementing HSPD-21 through the establishment of 
the Emergency Care Coordination Center (ECCC). This new center, an 
intradepartmental and interdepartmental collaborative effort involving 
the DOD, DHS, Department of Transportation and VA, will serve as the 
coordinating focal point for an Emergency Care Enterprise, coordinating 
with the Federal Interagency Committee on Emergency Medical Services. 
Its vision is exceptional daily emergency care for all persons of the 
United States and its mission is to promote Federal, State, local, 
tribal and private sector collaboration to support and enhance the 
Nation's emergency medical care.
    The ECCC will assist the U.S. Government with policy implementation 
and guidance on daily emergency care issues and promote both clinical 
and systems-based research. Through these efforts, ASPR and its Federal 
partners will improve the effectiveness of pre-hospital and hospital-
based emergency care by leveraging research outcomes, private sector 
findings and best practices. The ECCC will promote improved daily 
emergency care capabilities to improve resiliency of our local 
community health care systems. This will provide a stronger foundation 
on which to advance disaster preparedness efforts and strengthen our 
Nation's ability to respond to mass casualty events. Currently, the 
ECCC Charter is being finalized and we anticipate having the center up 
and running by the end of the year.

                       GLOBAL HEALTH COORDINATION

    In addition to these domestic efforts, other approaches to 
improving our national capabilities include partnering with allied 
nations. At the recent Global Health Security Action Group ministerial 
meeting, there was some consideration paid to the possibility of 
establishing international laboratory networks among the member 
nations. Links with Canada would be particularly useful given the 
geographic proximity. Informal discussions among the scientists and 
subject matter experts have been ongoing for a few years but no formal 
arrangements have been made. We continue to explore possibilities that 
serve the national interest.

                               CONCLUSION

    HHS staff work diligently to progress and expand the initiatives in 
public health and emergency preparedness for emerging biological 
threats. We continue to assess potential biological threats in the 
context of an all hazards approach, and compare the plans and programs 
available to us for mitigating these threats to ensure we are focused 
on the right initiatives. Through cooperation with our Federal 
partners, and State, local, tribal, and territorial governments, we 
have implemented a number of preparedness programs and assets that have 
strengthened our ability to respond to a biological event.
    Thank you for your time and interest. I am happy to answer any 
questions.

    Mr. Langevin. Thank you, Dr. Vanderwagen, thank you for 
your testimony.
    I now recognize Captain Peter Boynton, the Deputy PFO for 
Pandemic Influenza and Federal Security Director for Bradley 
Airport in Connecticut. He's standing in today for the Regional 
PFO, Admiral George Naccara.
    Captain Boynton, welcome and thank you for being here.

  STATEMENT OF CAPTAIN PETER BOYNTON, DEPUTY REGIONAL PFO FOR 
   PANDEMIC INFLUENZA AND FEDERAL SECURITY DIRECTOR, BRADLEY 
  INTERNATIONAL AIRPORT (CONNECTICUT), TRANSPORTATION SAFETY 
        ADMINISTRATION, DEPARTMENT OF HOMELAND SECURITY

    Capt. Boynton. Thank you, and good morning, Mr. Chairman, 
and Members of the subcommittee. Thanks for the opportunity to 
testify before the committee to discuss the Department of 
Homeland Security's role in pandemic influenza outbreak.
    I am Peter Boynton. I currently serve as the Federal 
Security Director for the Transportation Security 
Administration in Connecticut. I am also the Deputy Regional 
Principal Federal Official for the Northeast Region in the 
event of a pandemic or biological event.
    I am here today on behalf of the Regional Principal Federal 
Official, George Naccara, who was predesignated by Secretary 
Chertoff in December 2006 to serve as the Regional PFO for 
these issues. Region A encompasses both FEMA Regions 1 and 2 
which is all of New England, the States of New York, New 
Jersey, Puerto Rico and the U.S. Virgin Islands.
    Based on projections from prior pandemics, an influenza 
pandemic could result in 200,000 to 2 million deaths in the 
United States, depending on its severity. Further, an influenza 
pandemic could have major impacts on society and the economy, 
including our Nation's critical infrastructure and key 
resources as many of our Nation's work force could be absent 
for an extended period of time either sick themselves or caring 
for loved ones at home.
    Under the Homeland Security Presidential Directive 5, in 
order to prevent, prepare for, respond to and recover from 
terrorist attacks, major disasters, and other emergencies, the 
U.S. Government has established a single comprehensive approach 
to domestic incident management with the Secretary of Homeland 
Security designated as the Principal Federal Official for 
domestic incident management.
    Understanding the complex effects resulting from a 
pandemic, in December 2006, the Secretary predesignated Vice 
Admiral Vivien Crea, Vice Commandant of the U.S. Coast Guard, 
as the National Principal Federal Official, and five Regional 
Principal Federal Officials to assist States, local and tribal 
governments by overseeing a coordinated Federal response. Five 
``pandemic'' regions were established by the Secretary in order 
to create a manageable span of control. Each region consists of 
two FEMA regions combined into one ``pandemic'' region. In 
March 2008, the Secretary issued an updated pre-designation of 
PFOs letter to the States and to each Federal department and 
agency. This letter expanded the role of the Principal Federal 
Official for pandemic influenza to include other similar 
Nation-wide biological events. Also, with the anticipation that 
Joint Field Offices in each of the standard Federal regions 
would be established in a pandemic or other similar Nation-wide 
biological event, the Secretary also predesignated two Deputy 
Regional Principal Federal Officials to assist of the five 
Regional Principal Federal Officials.
    The Principal Federal Officials serve as the Secretary's 
representatives to ensure consistency of Federal support as 
well as the overall effectiveness of the Federal incident 
management. It is important to note that PFOs may be utilized 
in situations covering the full spectrum of homeland security 
operations, preventing, protecting, responding, and recovering 
from major disasters or terrorist attacks. The Secretary 
activates PFOs for the most complex and catastrophic terrorist 
or natural disasters, pandemic influenza, and national special 
security events.
    In the spring of 2008, the national response framework was 
released and the rules and responsibilities of the PFO and 
other unified coordination group members as described in the 
framework reflect the feedback given by our Federal, State, and 
local partners.
    In the case of a pandemic influenza outbreak, the PFOs 
would identify and present to the Homeland Security Secretary 
in coordination with the DHS Office of Policy and the Office of 
Health Affairs any policy issues that require resolution. The 
PFOs promote collaboration and as much as possible resolve any 
Federal interagency conflicts that may arise at the operational 
level. The PFOs serve as part of a unified coordination group 
at the Joint Field Office.
    Since the initial predesignation in December 2006 we have 
received great cooperation from the Department of Health and 
Human Services, the Department of Defense and components within 
the Department of Homeland Security by the predesignation of 
senior officials, defense coordinating officers, FEMA, Federal 
coordinating officers, and DHS infrastructure protection 
liaisons for pandemic influenza and other similar national 
biological events. By working together before a pandemic or 
biological threat occurs, these Federal partners have forged 
professional relationships and an understanding of each of 
their key roles and responsibilities.
    Our PFO cell led by Admiral Naccara and the FEMA Regional 
Administrator met with the Governor of Rhode Island and his 
senior staff last fall, coincidentally in our parallel world of 
PFO for hurricanes we exercised with the Governor and his staff 
and held a mock press conference with the Governor and with 
yourself, Mr. Chairman, during the hurricane exercise in April 
2007.
    In closing, DHS through this PFO framework will continue to 
serve as State and local issues to policy officials at 
headquarters for resolution and to foster and improve upon the 
partnership with the Federal interagencies, State, local, 
tribal, territorial, and private sector stakeholders to 
complete the work of pandemic and biological threat 
preparedness.
    Thank you again for the opportunity to testify on behalf of 
the Department of Homeland Security, and I'd be happy to answer 
any questions you may have.
    [The statement of Capt. Boynton follows:]

                  Prepared Statement of Peter Boynton
                             July 22, 2008

    Good morning, Chairman Langevin, Ranking Member McCaul, and Members 
of the subcommittee. Thank you for the opportunity to testify before 
the committee to discuss the Department of Homeland Security's role in 
a Pandemic Influenza outbreak. I am Peter Boynton, and I currently 
serve as a Federal Security Director for the Transportation Security 
Administration. I am also the Deputy Regional Principal Federal 
Official for the northeast region (termed ``Region A'') of the United 
States in the event of a pandemic or biological event.
    I am here today on behalf of Regional Principal Federal Official 
Rear Admiral (Retired) George Naccara, who was pre-designated by 
Secretary Chertoff in December 2006 to serve as the Regional PFO for 
these issues. Region A encompasses FEMA Regions I and II, which is all 
of New England, New York, New Jersey, Puerto Rico and the U.S. Virgin 
Islands.
    To begin, I would like to take a few moments to review some basic 
facts about pandemics and their potential impacts on our Nation. 
Pandemic influenza occurs when a novel strain of influenza virus 
emerges that has the ability to infect humans and to cause severe 
disease, and when efficient and sustained transmission between humans 
occurs. This scenario creates unique challenges. Unlike other 
incidents, a pandemic is not a singular event, but is likely to come in 
waves, each lasting weeks or months, passing through communities of all 
sizes across the Nation and the world simultaneously making mutual aid 
difficult if not impossible. The complete event may last as long as 18 
months. Based on projections from prior pandemics, an influenza 
pandemic could result in 200,000 to 2 million deaths in the United 
States, depending on its severity. Further, an influenza pandemic could 
have major impacts on society and the economy, including our Nation's 
critical infrastructure and key resources, as many of our Nation's work 
force could be absent for extended periods of time, either sick 
themselves or caring for loved ones at home.
    Under the Homeland Security Presidential Directive 5, in order to 
prevent, prepare for, respond to, and recover from terrorist attacks, 
major disasters, and other emergencies, the U.S. Government has 
established a single, comprehensive approach to domestic incident 
management, with the Secretary of Homeland Security designated as the 
Principal Federal Official for domestic incident management.
    Understanding the complex effects resulting from a pandemic, in 
December 2006, the Secretary pre-designated Vice Admiral Vivien Crea, 
of the U.S. Coast Guard, as the National Principal Federal Official, 
and five Regional Principal Federal Officials to assist States, local 
and tribal governments by overseeing a coordinated Federal response. 
Five ``pandemic'' regions were established by the Secretary in order to 
create a manageable span of control. Each region consists of two FEMA 
regions combined into one ``pandemic'' region. In March 2008, the 
Secretary issued an updated pre-designation of PFOs letter to the 
States and to each Federal department/agency. This letter expanded the 
role of the Principal Federal Officials for pandemic influenza to 
include other similar Nation-wide biological events. Also, with the 
anticipation that Joint Field Offices in each of the standard Federal 
regions would be established in a pandemic or other similar Nation-wide 
biological event, the Secretary pre-designated two Deputy Regional 
Principal Federal Officials to assist each of the five Regional 
Principal Federal Officials.
    The Principal Federal Officials serve as the Secretary's 
representatives to ensure consistency of Federal support as well as the 
overall effectiveness of the Federal incident management. The PFOs 
would identify and present to the Homeland Security Secretary, in 
coordination with the DHS Office of Policy and the Office of Health 
Affairs, any policy issues that require resolution. The PFOs promote 
collaboration and as much as possible resolve any Federal interagency 
conflicts that may arise at the operational level. The PFOs serve as 
part of a Unified Coordination Group at a Joint Field Office.
    Since the initial pre-designation in December 2006, we have 
received great cooperation from the Department of Health and Human 
Services, the Department of Defense, and components within the 
Department of Homeland Security by the pre-designation of Senior 
Officials, Defense Coordinating Officers, FEMA Federal Coordinating 
Officers, and DHS/Infrastructure Protection Liaisons for Pandemic 
Influenza and other similar Nation-wide biological events. Pandemic/
Biological Threat PFO Teams have been created, so these participating 
Federal agencies/departments may work together now before the 
catastrophic event may occur as well as to conduct outreach to States, 
local and tribal governments and the private sector. Each of the five 
Regional PFO teams would be comprised of the same members in a Unified 
Coordination Group described in the National Response Framework. 
However, by working together before a pandemic or biological threat 
occurs, these PFO teams have forged professional relationships, and an 
understanding of each of their key roles and responsibilities. In fact, 
our PFO cell and the FEMA Regional Administrator met with the Governor 
of Rhode Island and his senior staff last fall; coincidentally in our 
parallel role of PFO for hurricanes, we exercised with the Governor and 
staff and held a mock press event with the Governor and with Chairman 
Langevin during the hurricane exercise in April 2007. Also, the States, 
private sector, local and tribal governments will have familiarity of 
these key Federal Government officials prior to a catastrophic event.
    Since the initial December 2006 pre-designation, the PFO teams have 
performed a myriad of training, exercise, and outreach activities. 
Activities have included the following: Pandemic PFO training in 
February 2007; PFO Orientation in January 2007; meetings with State 
Governors, and State officials in both public health and emergency 
management operations; exercise with the Centers for Disease Control 
and Prevention in their pandemic influenza activities; participation in 
the National Governors Association Pandemic Influenza Workshops; 
participation in the Association of State and Territorial Health 
Officers (ASTHO) Pandemic Influenza Table Top Exercises; participation 
in an internal PFO Team Exercise Workshop in November 2007; and 
participation in the Assistant Secretary Principal Level Exercise at 
the White House in February 2008. In December 2007, Region A with great 
support from FEMA Regions I and II held a regional pandemic influenza 
exercise whereby a Regional Joint Field Office was established in 
Maynard, Massachusetts and the Region A States stood up their Emergency 
Operations Centers. In April 2008 and May 2008, Region C under Mr. 
Edward Buikema, the Regional PFO, hosted two pandemic influenza summits 
in Chicago, Illinois and Denver, Colorado, respectively, with 
invitations to the States in Region C to participate. Both events 
included a tabletop exercise sponsored by the U.S. Naval Postgraduate 
School in Monterey, California.
    Both the national and five regional PFO teams will continue to 
conduct training, outreach, and exercise activities. In September 2008, 
Region B PFO and Vice Admiral Crea will participate in a CDC Pandemic 
Influenza Tabletop Exercise. In late October 2008, the Department of 
Homeland Security will conduct an intra-departmental exercise with 
participation from the pre-designated PFOs, the Office of Health 
Affairs, FEMA Federal Coordinating Officers, and DHS/Infrastructure 
Protection Liaisons. Finally, the Homeland Security Secretary recently 
requested the Attorney General pre-designate a national and five 
regional Senior Federal Law Enforcement Officers to join our respective 
teams.
    In closing, many of these accomplishments can be incorporated into 
an all-hazards framework to promote the national culture of 
preparedness, effective outreach and partnering. DHS, through this PFO 
framework will continue to surface State and local issues to policy 
officials at headquarters for resolution, to foster and improve upon 
the partnership with the Federal interagency, State, local, tribal, 
territorial, and private sector stakeholders to complete the work of 
pandemic and biological threat preparedness, to promote the culture of 
preparedness in general and to further the Nation's ability to prepare 
for, respond to, and recover from all hazards.
    Thank you again for the opportunity to testify on behalf of the 
Department of Homeland Security on these issues of critical importance 
to our Nation's security and well-being. I would be happy to answer any 
questions you might have.

    Mr. Langevin. Thank you, Captain Boynton, for your 
testimony. I should have mentioned earlier that Dr. Vanderwagen 
has submitted joint testimony along with Dr. Kurilla and Dr. 
Sosin and has given the verbal testimony for both of those 
gentlemen, so I know you'll be available for questions. I want 
to thank the panel for their witness testimony today. I remind 
each Member that he or she will have 5 minutes to question the 
panel. It's my intention, time permitting, that we will do two 
rounds of questions for Members for each panel.
    Dr. Kurilla, tell me what is the current status of Project 
BioShield that was created in 2002 to try to speed new vaccines 
or drugs to the market to protect the public in the event of a 
potential attack or response to such things as Avian Flu? What 
meaningful treatments, antidotes, or vaccines have we produced 
or are we close to producing right now?
    Go ahead and answer that and I'll go with the second one.
    Dr. Vanderwagen. We have just submitted a written report 
for the progress through 2007 to the Congress and I would want 
to make sure you have a copy of that for more detailed 
reference.
    We have used Project BioShield which is an acquisition 
program, not a development program, to acquire a wide variety 
of materials, most of which existed in the marketplace before 
BioShield came into place, but the authority to acquire these 
things was strongly enhanced by BioShield as an approach.
    Congress augmented this by providing us with an advanced 
development authority that is significant in its impact as 
well. But let me speak to BioShield. The acquisitions there 
have been focused on readily available market products, in 
general. We have acquired significant products for chemical 
events, for radical nuke events and that would include 
chelating agents, KI, Prussian Blue and other radiation 
medications which exist in the marketplace. We've acquired 
antibiotics that exist under the program as well to assure that 
we have existing broad-spectrum antibiotics available for 
things like Bubonic Plague, for anthrax, et cetera.
    We have through the Advanced Development Program, supported 
the development of the development of a number of things 
including anti-toxins for botulism, for anthrax, et cetera, and 
the acquisition to that products now are reading to delivery in 
the national stockpile and the other positive thing to be said 
is some of our international partners now are purchasing from 
the companies that we've supported in development so that they 
have a wider market base of support so that infrastructure will 
persist.
    But I'll turn to Mike, and Mike, do you want to say some 
more about the research developments in this area?
    Dr. Kurilla. So with the publications----
    Mr. Langevin. Pull the mic very close to you, if you could.
    Dr. Kurilla. So with the publication by the Department of 
the Public Health and Emergency Medical Countermeasures 
Strategy and Implementation Plan, we have used that as a basis 
for our more advanced research and development programs in 
order to provide candidates that would be eligible for 
BioShield.
    In addition, as Dr. Vanderwagen has mentioned, although 
there's been an acquisition for botulism antitoxin, we are 
continuing to assist in that development through our animal 
model and assay work that would be supportive of the FDA 
licensure. We have supported through fairly well advanced both 
a second generation anthrax vaccine, as well as a second 
generation smallpox vaccine, the MVA, modified vaccinia Ankara, 
for smallpox which has, in fact, been acquired by Project 
BioShield.
    We have a number of other activities going on.
    Mr. Langevin. Let me question you there on that because as 
we know with the cancellation of the VaxGen contract, the next 
is developing the next generation vaccine for anthrax. That 
seemed to go nowhere. Give me the current status, more 
specifics of the next generation anthrax----
    Dr. Kurilla. So given the high probability of failure for 
products at the point when we entered into our contract with 
VaxGen, we actually were supporting two separate companies, 
VaxGen being one. Avecia Biologics being the second one, that 
contract has continued successfully. That company has 
subsequently been purchased by Pharmathene so the names keep 
changing, but in fact, we have a second generation anthrax 
vaccine that is currently undergoing validation of its 
commercial scale process manufacturing and----
    Mr. Langevin. When do you expect that to be completed?
    Dr. Kurilla. The validation, we anticipate would be done 
some time in early 2009 and then it would move on to generation 
of their fill finish, that is the final product production will 
be later in the year. There is currently a BioShield 
acquisition contract for recombinant protective antigen that is 
under review, but that's something for the Department to 
address. That's not my acquisition contract, but that has been 
moving forward reasonably successfully. It has completely two 
Phase 2 clinical trials and so far it's looking very good as a 
product.
    Mr. Langevin. Dr. Vanderwagen, Dr. Kurilla, as you know, 
BioShield, obviously is important, to contribute to public 
health security. It's too important to fail, but there have 
been numerous problems with the program as I mentioned earlier. 
To remedy these problems, Congress enacted legislation to 
create BARDA and how do you think BARDA has helped, if at all, 
to improve the coordination between HHS, NIH, CDC, et cetera 
and DHS and do you think that we're getting enough threat-
related information from DHS to inform these efforts to develop 
countermeasures to make the link between threat and actual 
resource development for the next generation antidotes?
    Dr. Vanderwagen. Thank you, Mr. Chair. I think that the 
threat determinations are proceeding along fairly well. There 
are emerging infectious disease that go outside the threat 
environment that we still have concerns about, but DHS is 
setting the threats very effectively and our public health 
modeling is working along fine.
    The BARDA package goes to what I just alluded to earlier. 
That is, there's a limited amount of advanced development that 
NIH can do. They're in the research business. They can take 
development to a certain point that have to sort to give it up 
at that point. Neither the industry and venture capital pick it 
up or not. What the Congress has done in providing us the BARDA 
authority is allowing us to pick up more of those good research 
ideas, help those companies develop those through the clinical 
trials so we don't have a failure like we have with the VaxGen, 
and then we can talk about an acquisition of those products.
    We think that BARDA has come along very nicely in the kinds 
of things that Mike just talked about, that is, products that 
they have brought to a point that we will move forward with, 
for instance, in the acute radiation area, not bio, but in the 
acute radiation area, we had 20 products almost, come to the 
fore that needed advanced development. We will fund half of 
those in all probability through to the clinical trial base 
that will allow us to make acquisition decisions about them as 
mature products.
    We think BARDA is a very effective tool and I'll let Mike 
comment about the transition piece between the research world 
and the advanced development world.
    Dr. Kurilla. BARDA has been a welcome addition. At NIH we 
are not, and do not intend to be, a commercial manufacturer, 
distributor of products. So the products that we develop to a 
certain point in the pathway toward licensure I have to hand 
off to a customer. My customer is not the person on the sharp 
end of the needle. It's the person holding the needle. BARDA is 
that customer who can then carry forward with the commercial 
scale development because those technical issues involved in 
that phase of product development are uniquely dependent on the 
specifics of procurement and since HHS is doing the 
procurement, they really need to be involved in that major 
advanced development commercial scale manufacturing. It allows 
you to set the conditions that will make the product successful 
and bring it in on time. It has been a welcome addition and we 
work very, very closely such that we overlap our programs so 
that by having a little bit of overlap we ensure that there 
really are no gaps in the development which allows these 
products to fall through the cracks. So it has been a welcome 
relief.
    Mr. Langevin. On that point let me ask what were the 
lessons learned from VaxGen, that contract, and have you 
changed your development and clinical trials process in 
response to that failure?
    Dr. Kurilla. The major lesson we learned that I think it is 
very difficult to cast your bets on products in terms of 
acquisition too early in the development cycle, simply because 
and this is not anything unique to Government, this is industry 
standards and industry benchmarks is that the failure rate 
early in clinical development is exceedingly high, getting into 
a Phase 1 first time in man, you are no better than a 10 to 20 
percent success rate.
    So what we have done in our development is that we have 
tried to stage them a little more so that we work with options 
so that if a company moves to a certain point and looks 
successful, we can engage the option and carry them a little 
further. It doesn't--it avoids us having to cast our bets on a 
few possibilities and allows us to expand our repertoire of 
candidate products that makes more available downstream for 
BARDA and HHS in terms of Project BioShield to select from.
    Dr. Vanderwagen. Yes, the relevant examples occurred in 
pandemic influenza where we supported a number of manufacturers 
through the early trial process and weeded out those that could 
be successful and that ultimately led to an H5N1 vaccine that's 
licensed and safe. That's the kind of process that Mike's 
describing.
    Early on, there may be four or five companies that have a 
good idea, but they may not have the skill, capability to bring 
it to a safe and effective product. We can support them through 
that test phase and those that can't make it drop out and those 
that can do the job then become candidates for a broad-scale 
acquisition and with VaxGen there was no early indication about 
whether they were going to be able to do it or not. It was a 
high-risk venture.
    Mr. Langevin. Thank you for those answers. Last question I 
have in this round is for Dr. Runge, and then I'll go to Dr. 
Christensen.
    Dr. Runge, you said in your testimony that you were very 
concerned about the threat of weaponized anthrax. Clearly, I 
share that concern, of course. However, we receive many 
biological threats for which we must be prepared, not just 
anthrax.
    How ready are we for terrorist use of anthrax and how do 
you suggest preparing for this threat, while preparing for 
other biological threats at the same time?
    Dr. Runge. Mr. Chairman, thank you for that question.
    First of all, with respect to other agents, as Dr. 
Vanderwagen mentioned earlier, we--what keeps me up at night is 
the intentional use of a biological agent and certainly anthrax 
is not the only one.
    The Science and Technology Directorate recently released a 
draft of its integrated threat assessment that--risk 
assessment, excuse me, that stratifies the agents by degree of 
risk and once again our No. 1 is still our No. 1. But there are 
others that are considerable.
    We also have included zoonotic disease for the first time 
in that analysis simply because of the tremendous economic 
impact that something like foot-and-mouth disease might have on 
our agriculture economy, on our ability to export food products 
and so forth.
    With respect to how ready are we, we are as ready as we can 
be at this point in time, but again as Craig mentioned we are 
better prepared, but we are not ready.
    Every piece of our--the four pillars of biodefense have to 
work seamlessly or we will not be able to answer this 
challenge. We need improved intelligence. We need better threat 
defense. We need enhanced biosurveillance.
    Dr. Sosin is a key part of the governance now of our new 
NBIC enterprise governance. The CDC is responsible for human 
health. USDA is responsible for animal health. We are moving 
forward very quickly with the more successful biosurveillance 
integration system.
    With respect to biodetection, we are not where we need to 
be right now. We have a built-in delay of up to 30 to 34 hours 
in our ability to detect a pathogen in the air. We must press 
forward with the bridging technology that New York has 
successfully deployed, as well as the successful completion of 
Generation 3. Our target date for S&T is in spring of 2009 for 
operational testing evaluation.
    We have to improve our response and recovery. The CDC can 
get medications out to local communities within 12 hours. 
That's great, but we still do not have a uniform capability 
across the country of countermeasure delivery within that very 
narrow time window for both plague and for anthrax.
    With respect to environmental recovery, EPA, HHS, and DHS 
have been working very, very closely on protocols as to how we 
would even begin to sample a building. How clean is clean? We 
are codependent then on the development of vaccine, on third 
generation antibiotics, for anthrax strains that may be 
resistant to doxycycline or suprafloxicine, our current weapons 
for medical prophylaxis. So every piece of this has to work. We 
don't have a double-fail-safe mechanism for this. So this 
integration, the working together and the concepts of 
operations all the way down to the local level where if an 
attack like this occurred our PFO cadre has to be trained along 
with their Federal coordination officers and State and local 
emergency management officials in order to do this work.
    So I wish I could say that we were done, but we're not 
done.
    Mr. Langevin. Obviously, we need to continue to make these 
things a priority, especially as you know, we just had the 
hearing last week on Project BioWatch and the NBIC and I'm 
anxious to get those next generation detectors deployed as soon 
as possible as I know you are.
    With that, I'm going to turn now to Congresswoman Dr. 
Christensen for her questions.
    Mrs. Christensen. Thank you, Mr. Chairman, and thank you 
for holding this hearing which happens to include the Virgin 
Islands since we're in the same region and I want to thank the 
testifiers, I want to thank all of you for your service, but as 
Dr. Runge is getting ready to leave us I want to particularly 
thank him for the work he's done in really creating the Office 
of Health Affairs. When you came there, we were not quite sure 
what it was going to be. Now it's a little clearer.
    I wanted to follow up on the biosurveillance question 
because you spoke in your testimony about soft targets and the 
importance of those and the impact it could have, a 
bioterrorism event could have because of the slowness of 
picking up the agent.
    So I wonder if--well, to the best of my knowledge, BioWatch 
detectors are in major cities and I wonder if there's a plan 
for expanding to a second round of bio detectors in softer 
areas and to what extent would the delay, the 1-year delay in 
the Gen 3 biodetectors impact any expansion of BioWatch?
    Dr. Runge. Thank you, Dr. Christensen. It's almost 
rhetorical to say that if we had our way we would have 
completely automated detection systems covering the entire U.S. 
population. That is neither practical nor affordable. We have 
modeled a number that we believe would cover the part of the 
population that we believe is at risk. For instance, with an 
intentional anthrax attack, one can probably draw the line 
where it would simply not be worth the while of the terrorists 
to use that weapon on a very sparse part of the population.
    So we have a number in mind for what it would take to cover 
the entire country in the areas that we consider the highest 
threat. When BioWatch stood up, it stood up, I'd like to remind 
the committee in 32 days. It was a phenomenal piece of work 
that we did with the CDC, with the State and local governments 
and the model that was created was to franchise the detection 
and decisionmaking to local laboratories.
    With the advent of automated detection systems, we can 
actually move beyond that and will have to work out a better 
partnership arrangement with local governments and with a 
central biosurveillance system, along with the CDC so that we 
can actually see things in real time.
    I'm a little distressed about--there are naysayers out 
there with respect to whether we actually need to do this sort 
of environmental detection. Even to the point that the House 
Appropriations Committee in their House report cut the budget 
for BioWatch by $22.8 million to buy that bridging technology 
which we've successfully deployed in New York City. It's 
inexplicable to me. The Center, of course, included it. So I 
would ask your attention to that as well when it comes to be 
conference time.
    But we will continue to enhance this program and we'll to 
do this and we'll have to cover more of the population over 
time until we have a universal vaccine and the policy becomes 
that we can take this germ off the table with a recombinant 
antigen that is safe and effective. So it's a long answer, I'm 
sorry, but I hope I answered your question.
    Dr. Christensen. We recognize that the Appropriations 
Committee had had those kind of questions and I think they were 
answered. We asked questions when we had that hearing back a 
couple of weeks ago to the people who run the program in your 
office. I think it was answered to my satisfaction.
    Dr. Sosin, would you like to comment on that?
    Dr. Sosin. Thank you, Dr. Christensen. Thank you for the 
honor and privilege of being here representing biosurveillance 
as an area broadly, nationally, and CDC.
    It strikes me that your job is particularly challenging in 
that it's not really a matter of weeding out unuseful or 
wasteful solutions to biosurveillance or preparedness, but 
weighing the relative values of them.
    From where I sit and the public health community that I 
reside in and in this exchange that we've having over the last 
6 months around a national biosurveillance strategy, it's 
striking that top all hazard, all jurisdiction capability for 
biosurveillance falls in the context of our clinical public 
health relationship. You're spending a lot of time talking 
about partnerships and those relationships. Those have improved 
dramatically. In the years that we've been funding preparedness 
and building the capabilities of health departments to interact 
with their clinical environments, to share information 
effectively, and that keeping that strong and strengthening 
that which is strained is a critical resource that we need to 
consider.
    As we look at the mass release aerosolized release of 
agents such as anthrax, we anticipate that large exposures to 
aerosolized anthrax can cause disease within 12 hours, so that 
our clinical presentation and not just of single cases as has 
been our experience with anthrax to date, but large number of 
cases mixes virtually impossible not to be recognized in 
clinical environments, not initially as anthrax, per se, but to 
set up alarms and to initiate the types of investigation on 
public health and clinical providers undertake for unknown 
diseases.
    So to think in terms of the capability that we need to 
strengthen that's all hazards and all jurisdiction, it's really 
important to keep the infrastructure of the health system in 
mind.
    Mrs. Christensen. You're singing my song. I'm glad to hear 
the emphasis on the public health response side.
    Dr. Vanderwagen, in your testimony, you talk about $2.6 
billion having been spent over 5 years on surge, increase in 
surge. How much surge have we bought with that $2.6 billion? 
Can you quantify the increase in surge capability across the 
country and can you tell us, for example, in terms of the 
States, territories, and tribes, a ballpark percentage of who 
is prepared, who has built capacity--sufficient capacity to 
meet the standards you've set?
    Dr. Vanderwagen. Right. Doctor, it's a great question. What 
is surge?--and surge, to me, is a challenge.
    It's wholly different if you're expecting to meet the 
challenge of a train bomb as we saw in Madrid or if we're 
expecting to deal with a pandemic flu. So surge capability I 
think incrementally has improved significantly from the 
perspective of can we meet the challenge of things like IEDs, 
kinetic events, geographically, temporally limited, yes, we've 
made significant improvement.
    Here in Rhode Island, there are 15 hospitals, 14 of them 
participate in hospital preparedness program. They've made 
significant strides forward in training their staff, developing 
things like IED capability, management of beds, management of 
traffic, patient flow, et cetera.
    I think these are the hallmarks of what's happened over the 
last 5 years with funding in the surge, medical surge world. In 
2006, there were over 9,500 exercises conducted by hospitals 
and facilities involving their staff and action. That's pretty 
dramatic stuff. What has happened is that JHACO and the other 
accrediting organizations have begun to internalize these 
higher standards of expectation into their performance 
requirements for hospitals to get accredited and so the 
profession, if you will, and the industry itself has begun to 
internalize many of these kind of changes, what is effective 
sheltering in place? What does it take to shelter in place? 
Your generator shouldn't be two floors below ground level, 
things like this, that become normative in the industry.
    Where we have difficulty and the GAO report highlighted 
this, is in a large-scale event where the demand far exceeds 
the asset base that's available. What kind of decisions will we 
be making about triage, about changing standards of care, 
alternate care sites, et cetera.
    Some communities are addressing this very aggressively. 
Miami, the Board of Education and the schools and the public 
health system have partnered to develop alternate care sites 
using mothballed schools which they've warm based, they can use 
them.
    Other communities really have not done the heavy lifting. 
In August, we met with Costco executives, Starbucks executives, 
public health and hospital people in Seattle and they admitted 
up front they hadn't done the heavy lifting to deal with some 
of these issues yet.
    Last week, we met in Indianapolis, 31 States, District of 
Columbia and four territories, including the Virgin Islands and 
Puerto Rico, to map out an approach to national consensus 
generation in dealing with the ethics of high-demand, short 
availability of assets. It will require community, State, 
regional and national activity and the GAO report I think was 
on target that now is the time people are ready and while we 
will not dictate from a Federal perspective, we can facilitate 
and provide guidelines for dealing with those tough issues.
    So we've moved a long way in the last 5 years. 
Notwithstanding that, we have not dealt with the worst event 
which is high-demand, low-asset and that's the next challenge 
in front of us.
    Mrs. Christensen. We'll come back to that somewhat in the 
second round.
    I wanted to ask Captain Boynton, we've spent a fair amount 
of funding and lot of time and exercises on pandemic flu which 
everyone is pretty sure at some point it's going to come, we 
don't know when. Can you tell me how this preparation may have 
prepared us better for a more all-hazard kind of biologic 
event?
    Another part of my question is: How does the national PFO 
relate to Admiral Vanderwagen?
    Capt. Boynton. Thank you. From my perspective, and I'm 
coming at this from a perspective of the regional perspective 
as the Deputy PFO, we think that there are a lot of synergies 
to be gained from our work in preparing for pandemic influenza 
and other biological hazards. It doesn't mean that all aspects 
of the incident response that the PFOs will be focusing on, the 
incident response part of the operation. It doesn't mean that 
they're all the same, but we do believe that there are a lot of 
synergies that can be gained.
    The five regional PFO cells have been, the cells have been 
built. They all include PFOs, Deputy PFOs, senior health 
officials, senior defense coordinating officials, and we have 
exercised both regionally and nationally with the national PFO 
team led by Admiral Crea, so we think there are synergies there 
between them even though not every aspect of an incident 
response would be the same.
    Dr. Vanderwagen. The quick answer Vice Admiral Crea and I 
are very close. She's a good person and right up front when 
Secretary Chertoff named her, she got support from Dr. Runge, 
but she reached right over to us and said: ``How do we play?''
    She has my Deputy Assistant Secretary, Kevin Yeskie, 
assigned to her to answer and work with her on any questions 
related to the House sector, but as was alluded to here, this 
will not be an ops response much like we would have in a 
hurricane and so on. This is going to extend over time. So she 
has used our health players in conjunction with the PFOs to 
begin to reach out to the wider community to bring all the 
sectors into play.
    Mrs. Christensen. One more question in this round that sort 
of comes out of that.
    Dr. Runge, Mr. Kilday will testify later about a newly 
imposed ban on using Federal resources for local emergencies 
and are you aware of that?
    Dr. Runge. I'm at a loss, Congresswoman. No. Recently 
imposed ban?
    Mrs. Christensen. I probably can't locate the exact place 
in his testimony, but they used to be able to use the Federal 
resources that were here. ``Until recently nearly all of the 
team's equipment was Federal property and, as such, would not 
be available for use within the State of Rhode Island.'' If I 
understand that correctly, at one point they were able to use 
it and now they have to purchase their own equipment. This is 
in DMAT.
    Dr. Vanderwagen. What you're referring to is the Disaster 
Medical Assistance Team. There's one located here in Rhode 
Island and it's had a long and illustrious history.
    When NDMS, the National Disaster Medical System was 
initiated back in 1982, 1983, 1984, it was designed to meet a 
Cold War challenge, that is, the transport of a large number of 
wounded warriors from Europe to the United States, how do we 
get them to definitive care? How do we receive them at the 
airheads, et cetera?
    Emergency response teams were developed. Mobile emergency 
rooms. Increasingly, that concept was extended into use in the 
domestic response environment. These Disaster Medical 
Assistance Teams of which there are about 56 active Medical 
Assistance Teams at the moment, were predicated on they managed 
their own assets, et cetera. They were required under the 
Federal domain and they managed their assets.
    What we have determined is that given the challenge we have 
with wide domestic response capability that we believe that 
regional caching and delivery of those caches on a regional 
basis with the teams coming to play is a much more effective 
way to assure that we have people and equipment in place and 
it's allowed us to expand up to an additional 15 teams who are 
available to play.
    There are challenges to the existing teams because the 
question of what will they train on and so on are still issues 
that have not been fully resolved to their satisfaction, but I 
would tell you that the regional caching of that equipment has 
subserved our response capability significantly. My chief 
logistician came to us from the Army Medical Command where she 
was the director of logistics for a number of years and she 
knows this business. FedEx is delivering for us on a Q6 hour 
turnaround time. So we think there's been improvements in our 
response capability overall. There are questions of how we 
support the training requirements of the teams and that's still 
an open question that will need further resolution.
    Mr. Langevin. We're going to come back to this DMAT issue 
in a lightning round, in the second round of questions. With 
that, the Chair now recognizes the gentleman from New Jersey, 
for his questions.
    Mr. Pascrell. Thank you, Mr. Chairman, good morning. Thank 
you for your service to your country.
    I would like to ask an open question with a brief, 
hopefully, a brief answer. Then we'll get into some other 
questions.
    It appears that you all agree that the risk of the 
possibility of slowly detected outbreak of a specific situation 
is more acceptable than the risk of vaccination. I would like 
your responses to that.
    Dr. Runge, why don't we start with you?
    Dr. Runge. I'm not sure--my answer will be very brief, sir, 
because I'm not sure I really understand the question. We have 
to make choices.
    Mr. Pascrell. Yes. We're not going to have a seamless 
defense concerns. We passed that hurdle, is that correct? Is 
that correct, gentlemen?
    Do one of you believe we can create a seamless way to 
protect the populations against the very diseases we're talking 
about today?
    Let's be straight about this.
    Dr. Runge. Yes, I think we can approach it, sir. I'm not 
sure that we can ever reach that perfection.
    Mr. Pascrell. Then let me go back to my original question. 
Is it better that we move toward the direction of vaccinating 
everyone against a particular problem or is it best that we 
develop the quickest means of responding after we realize 
that--and after we detect something?
    Is it an either/or?
    Dr. Runge. I get it now. I don't think it's an either/or. I 
do believe that until--and first of all, if we project into the 
future that there actually will be a vaccine to take certain of 
these threats off the table, it then becomes an issue of policy 
that this Nation is going to have to face together, all 
branches of government. Do we vaccinate against a highly--
excuse me, maybe not highly, but against a relatively 
improbable event than measles, mumps, rubella, or chickenpox, 
which are going to happen every season and we want our children 
protected against that?
    So then we really do have to rely on our health policy 
folks as to the relative merits of a vaccine because there are 
side effects to vaccines and if we universally vaccine everyone 
against a disease, yes, that is probably the best deterrent we 
could ever have for terrorists using that against us. But the 
cost of that is some degree of untoward effects of those 
vaccines and I think we have to have that dialog.
    Mr. Pascrell. Admiral.
    Dr. Vanderwagen. I agree with Jeff, I mean ideally I'd like 
to have the vaccines, take this off the table. For instance----
    Mr. Pascrell. Are we developing those vaccines?
    Dr. Vanderwagen. We're moving ahead pretty aggressively. 
The challenge here is--for instance, we have an H5N1 vaccine 
that we know is safe and effective, but we don't know that 
that's the bug that we could be hit with. So the events we are 
moving to go after those threats that we know to try and 
develop the appropriate vaccines. The emerging infectious 
diseases present us a challenge with is it going to be the 
right one.
    I think the next horizon and I'll let Dr. Kurilla speak to 
this because he's the expert, but the next horizon we're 
looking for is can we develop a carrier that would allow you to 
vaccinate with a single vaccine for a wide variety of diseases 
as opposed to have to give unique vaccines for each and every 
disease, but I'll let Mike comment on that dream.
    Mr. Pascrell. Captain or Dr. Kurilla.
    Dr. Kurilla. Well, I would agree with you and I agree with 
Jeff and Craig that the prophylaxis is always desirable. 
However, it's very clear even in the instance of vaccines we 
have today that we require children to receive before they go 
to school, there is still a considerable fraction of the 
population that does not get vaccinated, and so as a result we 
still need to focus on and develop countermeasures that would 
address those situations.
    In terms of universal vaccines, such as example for flu, we 
are still back at the conceptual stage, but that is a direction 
we are moving to to get us out of the requirement for an annual 
flu vaccine every year that needs to be updated. We think it 
will come down the way, but we are still some years away from 
even having something that we can move into development at this 
point in time, but it is a strategy and a concept that we are 
pushing on and moving forward on. We think we will get there.
    Mr. Pascrell. Thank you. Doctor or Captain, either one of 
you want to respond?
    Capt. Boynton. I'll defer to the medical experts.
    Dr. Sosin. Because this is not really a medical question, 
but more of a societal policy question, I think everything 
you've heard, sir, does reflect the state of balanced 
decisionmaking that has to be made.
    Mr. Pascrell. Dr. Runge, thank you for your service. You've 
brought some sanity to a real insane situation down there and I 
think Chertoff has tried to clean up the act. I don't know how 
far he's gone. You made a recommendation in your presentation 
which I find very fascinating. It goes to the very heart of a 
lot of problems in homeland security. I was just on the phone 
concerning another problem, the question of evacuation.
    We've had total bifurcation here of who is responsible, who 
pushed JCAHO? You say that while DHS is by its authorization, 
Pub. L. 109-295, a collaborative agency so must Congress work 
collaboratively to ensure a more secure homeland empowering an 
effective, yet supportive, oversight environment. Is the fact 
that we have a bifurcated situation between DHS and HHS, do you 
see that as essential to understand, that is essential to 
getting over the humps that exist between those two big 
departments?
    Dr. Runge. I think it is very, very important that the 
oversight committees on the Hill are in lockstep. We have gone 
from a kind of creative dissonance to a much more collaborative 
and synchronous relationship.
    It's no surprise to you, Mr. Pascrell, that Secretary 
Chertoff has said on numerous occasions we're sort of in an 
environment where we have incoming coming from 360 degrees and 
that happens you tend to get deeper into your foxhole. That's 
not productive for collaboration.
    We really need to be able to focus on our oversight 
committees, transportation, energy, commerce and T&I and the 
Senate commerce. It was very easy to form a relationship with 
the Members, very easy to form a relationship with the staff 
and there were very few extraneous issues that would parachute 
in from other sides.
    Since I've been at Homeland Security for the last 3 years 
we have not enjoyed that sort of relationship. So I'm not sure 
how leadership is going to get it done, sir, but I do think 
it's essential, just as we have created a much more harmonious 
and synchronous relationship with the CDC on bi-surveillance, 
with ASPR on threats and countermeasures that that--if you can 
get that to happen, that would be terrific.
    Mr. Pascrell. We had some warnings about this through the 
Chair in 2002 when we were putting this dinosaur together. The 
Government's health care experts, it seemed anyway at the time, 
would be split between health and human services and the 
proposed homeland security deployment. In some cases the new 
department would become a customer of HHS, contracting for 
services. This is a splintered process rather than a 
centralized one. That problem within those folks who get paid 
for doing, protecting America, as compared to the committees, 
83 of which--that's mind boggling.
    Dr. Runge. Yes, sir.
    Mr. Pascrell. How do we get to the central point here? How 
do we get to see who is in charge?--and it would seem in many 
areas including this one, we can't answer the question. So we 
didn't bring them together. In fact, it was proposed in 2002 
that there would be an undersecretary that would have that 
responsibility. There's no such animal.
    Would you like to take a swipe at that?
    Dr. Runge. I'm not exactly sure what the administration 
policy would be on that, sir, so I will defer right now.
    Mr. Pascrell. The administration's policy is to protect 
America.
    Dr. Runge. Yes, sir.
    Mr. Pascrell. It doesn't matter, it doesn't have to do with 
politics, it has to do with protecting Americans and Americans 
aren't going to accept the half-answers that we've been 
getting.
    Dr. Runge. DHS has been in the precarious position of 
having responsibility without the authority.
    Mr. Pascrell. I think you put it better than I could have 
put it.
    Dr. Runge. The thankless job of coordination among 
departments and agencies that don't necessarily want to be 
coordinated has been pounding one's head against the wall.
    Mr. Pascrell. Mr. Chairman, I salute you and Dr. 
Christensen for the work that you've done from the very 
beginning on this. Not only that--it's not only important that 
we talk to each other. We need results. The Chairman has been 
there and the result has been changing the culture. It is a 
culture. If we don't do that, then we're not doing our jobs on 
this side of the table. You should be badgering us to make the 
changes that are necessary.
    Eighty-three committees examine homeland security. How in 
God's name does anything get done? Then when they come to us 
they don't give us the truth half the time anyway, so if you're 
watching this and wondering who did push JCAHO?
    I'm telling you, Mr. Chairman, thank goodness for this 
committee and what your work is and I'm blowing smoke, I'm 
telling you. You know I like to say it like it is.
    Mr. Langevin. I've noticed that.
    [Laughter.]
    Mr. Pascrell. This is a very critical issue and we need to 
bring some changes that have to get done so that the people on 
the front lines know that they're getting support in our 
rhetoric. Thank you.
    Mr. Langevin. I thank the gentleman. We're going to go to 
round two and I'm going to adhere us to the strict 5-minute 
rule. We gave latitude on the first round and we appreciate our 
guests here and the Members for traveling, but we have a lot of 
questions we want to get in, so I'm going to go to a very 
strict 5-minute rule in this last round of questions.
    I want to begin with going back to Dr. Christensen's 
question for Dr. Vanderwagen on DMAT issues.
    Dr. Vanderwagen, it is my understanding that the original 
vision for the national disaster medical system included having 
at least one DMAT per State and territory. However, as you were 
talking about recently, just a minute ago, the decision was 
made by HHS to regionalize DMAT assets.
    Can you explain that decision? How do you foresee 
regionalized DMATs deploying, for example, and what I'm 
concerned about primarily when an entire region or the entire 
country is affected by widespread biological disease, per se, 
for example, if there were to be a widespread outbreak of a 
highly infectious disease in New England, how would DMAT assets 
currently centralized near Boston be deployed to respond to the 
needs of Rhode Islanders, for example, or those in nearby 
States?
    Would you answer that?
    Dr. Vanderwagen. Yes. I think in the circumstance you just 
described it's unlikely that we would be deploying any assets 
for much more than the first 2 or 3 weeks of that event because 
all this will become local inherently as the disease spreads 
across the country.
    Our current concept of operations, whether it's for Federal 
assets or MRCs or any asset is that we're unlikely to be 
deploying people from Point A to Point Z in a pandemic event 
for response operations because once you get beyond the first 
four or five cities that are involved everybody is going to 
need to be in place in their location taking care of their own 
community as opposed to looking to the feds to move people from 
here to there.
    Mr. Langevin. But doesn't that kind of speak though to why 
it's so important to have one in each State as it was 
originally planned?
    Dr. Vanderwagen. Indeed, and in fact, the States themselves 
now have gone to much more extensive investment in team 
processes. When the group was over in FEMA it was determined 
that these could not be used for State assets, that they were 
only Federal assets available for Federal deployment.
    We have encouraged States and are now supporting State 
efforts to develop State-based DMATs and have them at the call 
of States first and foremost. You've got 26 teams in North 
Carolina. You've got six teams in California, et cetera, that 
have been developed.
    We will provide the original cash support to those folks if 
called upon. If they need additional Federal assets, we would 
bring people from Point A to Point Z, but we believe that our 
job is to really try and build local capacity to the maximum 
possible degree and where we have Federal assets, place them 
regionally so they're more accessible to the local 
requirements.
    Texas is preparing for the storm to hit on shore. We have 
pre-deployed two Federal medical stations, 500 beds' worth. We 
have deployed the caches for DMAT teams to San Antonio well 
ahead of the process. Those FMSs reside in Texas full-time.
    Mr. Langevin. Well, we're going to keep following up on 
this, on the DMAT issue, and I know our second panel, the State 
folks, probably may have a slightly different perspective and 
we're interested in hearing their input.
    Dr. Runge and Dr. Vanderwagen, when we conduct exercises, 
obviously, it's important to be as realistic as possible to the 
extent that we can and use current requirements to show us how 
well we might do in a future situation.
    During a pandemic, DHS and HHS obviously will be the lead, 
with Federal agencies managing the response. At a hearing I 
held last September I stated that we should test our systems 
now using seasonal influenza as a proxy for pandemic influenza.
    Dr. Vanderwagen, starting with you, I also asked you to 
take last year's influenza season and make a concerted effort 
to see how many people we could vaccinate in the shortest 
period of time, basically, intending that seasonal influenza is 
actually pandemic influenza. The way I see it, we should be 
testing our distribution systems now, stressing our 
organizations in these sorts of real-time, real-world contexts 
while improving the health of our citizens throughout the 
Nation.
    You agreed, and you also--I also told you that I'd be 
asking about this again. So here we are at this hearing. Did 
HHS do this? If so, how? What was the outcome? If not, why not?
    Then for Dr. Runge, you were not at that hearing, but I did 
ask Dr. Jolly a similar question, asking the Office of Health 
Affairs to get the national biosurveillance integration system 
in this to start tracking seasonal influenza during influenza 
season and treating it as if it were pandemic influenza. I also 
asked that the Department get our CBP offices on the board to 
identify people who are obviously ill with something that looks 
like the flu and divert them to secondary screening. Did these 
and other activities occur and if so, how and if not, why not?
    Let's start with Dr. Vanderwagen.
    Dr. Vanderwagen. Yes, the primary event that can be tested 
in seasonal flu that would approximate pandemic is immunization 
practices and immunization access. In the first instance, 
that's going to be the primary event response. In fact, many 
States and localities have done extensive testing and 
evaluation of various modalities from drive throughs to on-work 
site to the standard go to the County Health Department 
approaches.
    We believe that there are best practices out there, but 
increasingly we're engaging with local business to participate 
in these processes as well, that they can become dispensing 
sites and capture a significant number of people in those 
events.
    That's not only useful for pandemic flu, but it's also 
useful for management of distribution of prophylactic 
antibiotics and in other biological event, the use of 
antivirals if we can expand to prophylactic, post-exposure 
prophylaxis use. So a wide variety of those were tested last 
year. Again, folks have been driving this train pretty hard, 
depending upon where they are.
    We've put it into the requirements for hospital 
preparedness program and it's built into the FEP as well, that 
they test and exercise these distribution schemes. What is 
problematic is what about alternate care sites? That's the next 
frontier, if you will, of exercising what are those alternate 
care sites? What will the standards of care be that are applied 
in those kind of environments? That's a little different than 
the logistical challenge of how we get drugs into people's 
arms.
    Mr. Langevin. Thank you. Dr. Runge.
    Dr. Runge. Mr. Chairman, with respect to the 
biosurveillance piece, I can tell you--first of all, I cannot 
tell you that there was an additional exercise that went on 
within the NBIC. However, the domain of human health 
surveillance is the CDC's contribution to NBIC. CDC has been 
consistent in having a detailee in the Center who has access to 
the human surveillance data, and thresholds are decided upon 
over which they will enter into the situation report every day.
    I do not believe that seasonal influenza met that criterion 
and I don't recall seeing it in the daily situation report or 
in the weekly summary. They do produce weekly summary on H5N1 
which is based again on CDC's human surveillance efforts. I 
will defer to Dr. Sosin for more detail on that.
    With respect to CBP, I don't know that any special effort 
went into looking for people with the flu. I can tell you 
though that these law enforcement officers who are not trained 
medically do a pretty darn good job of weeding people out and 
sending them to secondary for additional screening when they do 
appear ill. It is not an unusual occurrence for them to send 
someone to secondary who appears ill and to summon health 
authorities or in the case of the stations where we have 
quarantine stations to summon a CDC officer for a second look 
at the individual. I will inquire though as to whether 
additional efforts were undertaken.
    Mr. Langevin. That would be important. With that, I now 
recognize Congresswoman Christensen for 5 minutes.
    Mrs. Christensen. Thank you, Mr. Chairman. I think it might 
be easier, I'm going to ask my three questions and then just 
leave it to them and I think I may be able to make it in 5 
minutes that way.
    Dr. Vanderwagen, in your testimony you talk about the 2009 
funding based on how well previous targets were achieved. So if 
a State or a jurisdiction didn't meet its target, would funding 
be denied or reduced? Might they not be the jurisdictions that 
need the most funding and help? So how would you address that?
    When you talk about matching requirements coming in, I 
assume that meant that States would have to match at some 
formula. Many States have already paid a lot of--spent a lot on 
communications, training and how would that be accounted for?
    I just came back from Louisiana. The second question, just 
came back from New Orleans and I'm wondering why is there not a 
mobile hospital or two in New Orleans? More than wondering why 
they're not needed and I'd like to see at least one placed 
there.
    Last question is on this altered standard of care. I share 
health with the Congressional Black Caucus. We see altered 
standards of care every day, including disparities in people of 
color and I'm very leery about these alternate standards of 
care and I wonder ways do you see to ensure that--I understand 
when you're overwhelmed and the resources aren't there, the 
staff isn't there. It's not going to be tip-top medicine and 
the best of facilities, but I want to know how do you see 
ensuring that we won't be facing some of that systemic and 
institutional discrimination that people face because of 
language or color or gender in that situation?
    Dr. Vanderwagen. What was the first one, ma'am?
    Mrs. Christensen. The first one was about the funding.
    Dr. Vanderwagen. Oh, matching.
    Mrs. Christensen. Being tied to meeting targets.
    Dr. Vanderwagen. All right, all very good questions. I'll 
try not to be too windy.
    As you know, I spend most of my--I was raised on a 
reservation. I spent most of my career in Indian Health 
Service. Indian Health Service, Congress has funded at about 
$2,600 per capita per year and that's a 2005 figure, compared 
to the general U.S. population of about $7,000.
    Mrs. Christensen. And prison population, which is higher.
    Dr. Vanderwagen. The running joke is if you want to get 
better health care in Indian County, commit a Federal crime so 
you can get better health care.
    I have lived with that horrific, in my view, reality of 
those kind of rationing decisions throughout most of my life 
and career. This is a problem.
    What we're talking about, however, is where you have too 
few assets how will you reasonably and equitably consider your 
triage decisions in that reality? No physician wants to be in 
that position, but in fact, and indeed, this is a reality that 
could occur.
    It's our view that communities really need to think that 
through ahead of time about how they will deal with those kind 
of challenges. The answer of what constitutes equitability is 
an ethical challenge that people at the community level really 
need to work through and answer. I have my notions about that, 
but I don't feel it's the Federal role to tell communities what 
that standard should be, at least from the Executive branch 
perspective and as a health professional.
    So I understand your concern and the constraints and the 
ground rules for that discussion have to be monitored closely 
if we're going to assure that there's equity in that thought 
process. It's a difficult challenge.
    Mrs. Christensen. Should we reduce the funding to places 
that haven't met their targets when they may be the most needy?
    Dr. Vanderwagen. Congress in the passage of the Pandemic 
and All Hazards Preparedness Act required that we institute a 
matching program with appropriate penalties to be assessed in 
the event that people did not meet the standards in the 
requirements. We are acting against that authorization 
requirement. Now it's our belief that we should have no one 
fail, that it's our affirmative responsibility to work with 
those communities, with those programs with our partners, both 
Federal and State, to assure that we don't have that failure.
    Notwithstanding that, I think it's a useful exercise in 
assessing what is the investment that's needed across the 
spectrum in this country to assure that we have sustainable 
preparedness and response capability because I don't think we 
understand fully what those costs look like. We know what some 
Federal investments are. We know what some State investments 
are. But part of my conversation with our State and industry 
colleagues is this has been official tragedy and that it may 
allow us to quantify more effectively what it takes to sustain 
these kind of programs. We don't want to penalize. We're acting 
under the law. We believe we should work to assure there is no 
failure in this environment.
    Lastly, in NOLA--I lived in that school for the blind for 
months and this is my family now. My concern about NOLA is it's 
not about the hospital biz, it's about what are doing at the 
community level to provide effective chronic disease care, 
effective primary care access, because if that exists, you 
don't live in the emergency room.
    In Indian Country where we could not afford hospitals, it's 
our investment in that kind of chronic disease management and 
primary care that led to health improvements in our population 
that would be otherwise unexpected without those investments in 
that part of public health and medical services. So I don't 
know that the answer to NOLA is more hospital beds. They had 
the highest per capita Medicare rate in the country and the 
forty-eighth worst health status and yet they had 11 hospitals 
sitting there in Orleans Parish. I don't know that hospitals 
are the answer. I think there has to be a better solution to 
meeting the health needs of their people than that.
    Mrs. Christensen. I'd like to follow up back in Washington 
on that.
    Mr. Langevin. The Chairman now recognizes the gentleman 
from New Jersey for 5 minutes.
    Mr. Pascrell. Thank you, Mr. Chairman. Admiral Vanderwagen, 
you make a lot of sense in what you say. As you know, and as 
the Chairman is aware, we've been closely tracking progress on 
the national preparedness efforts for pandemic influenza 
outbreak, particularly the implementation of the national 
strategy on pandemic influenza which was released back in 
November 2005.
    One of the key parts of the plan is that in addition to 
Federal stockpiles of key medicines and supplies, we also need 
States to act to establish their own stockpiles. It's very 
clear in that charge to us. But the stockpile of antivirals, in 
particular, the national plan calls for enough to treat 25 
percent of the population and to reach that goal States have to 
act. Am I doing all right so far?
    To date, the Federal Government has purchased 50 million 
courses of treatment as recommended under the NSPI. I 
understand that States, on the other hand, have still only 
stockpiled approximately 22.2 million of the 31 million courses 
of antivirals which were called for in that strategy on 
pandemic influenza, leaving us obviously short of the 
requirement.
    In New Jersey, we purchased about 880,000 courses of 
treatment as of June, 2008, which is about 97 percent of the 
State's allocation. It was done with some difficulty despite 
the Federal match.
    Obviously, with the economy as it is, many States are 
struggling to meet this goal. So let me ask you this, for those 
States that have not yet purchased or those that want to 
purchase more, are you considering renewing a reduced national 
price under which antivirals can be purchased either to 
complete orders or to replace orders?
    Dr. Vanderwagen. Yes.
    Mr. Pascrell. You are considering that?
    Dr. Vanderwagen. Through December.
    Mr. Pascrell. If States can't purchase at the reduced price 
and with a Federal subsidy, what are the chances we ever 
complete the States' share of the national stockpiling goal?
    Dr. Vanderwagen. I believe that we will achieve the 81 
million doses that were called for which would cover 25 percent 
of the population. I do not believe that every State will have 
a State stockpile because of the decisionmaking in that State 
and local environment and this is a Federal republic, after 
all, and there are decisions.
    In New Mexico, for instance, which is where I'm from really 
elected to not participate because they wanted to acquire these 
antivirals both for use in the seasonal influenza as well as 
and they didn't want to be constrained by the Federal program, 
so they're making their own acquisition. There are only a 
couple of States that have totally said we're really not going 
to buy any at this point. There is a question of equity there, 
but----
    Mr. Pascrell. That's my next question.
    Dr. Vanderwagen. But again, this is a Federal republic and 
we can't force States to make those determination where money 
and their local considerations prevail. Again, they would get 
their pro rata share of the Federal asset, but they are at risk 
for the piece they didn't buy to cover their own.
    Mr. Pascrell. Let me ask this question, if you have funds 
left over that haven't been used to subsidize State purchases, 
I certainly hope you would use those for additional Federal 
antiviral purchases since this would directly affect any 
national stockpiling shortfall.
    Does that make any sense?
    Dr. Vanderwagen. Yes, after December, we would reexamine 
what remained in the balance for that subsidized acquisition 
and we'd be likely to purchase antivirals for Federal use 
beyond. It looks like that could be as much as $60 million 
which would be about 3 million treatment courses. We'll just 
have to see how this plays down as we go to the end of the 
calendar year.
    Mr. Pascrell. My final question to you, Admiral, is this. 
You heard me discuss with Dr. Runge about the bifurcations 
which exist throughout homeland security at the detriment, at 
all of our detriment. Do you have any specific recommendation 
that you would make to overcome these bifurcations that exist 
all over the place in terms of your own specific experience?
    What can we be doing to make your job easier and we haven't 
done it?
    Dr. Vanderwagen. Well, see, I believe that as Jeff alluded 
to, I think we've worked through these issues between HHS and 
DHS pretty well. In short, certainly DHS is the disaster 
government, but within the organic assets of our department we 
have tools that need to play in disaster response. What we've 
come to understand is that it's our responsibility to build up 
those assets so that they are available to play under the 
direction of DHS and its elements in an event under the 
national response framework.
    I'm responsible for the ESF8, the public health and 
medical. My DOD colleagues, my VA colleagues, HHS colleagues, 
all need to be there to play when DHS needs us for the disaster 
events.
    I feel very comfortable that we've come to terms with that. 
Now that's tough. You talked about a culture. Our culture is 
subject matter expertise. We've got scientists and so on. They 
live in that world. We have bureaucrats, law, regulation, 
policy, procedure. They manage in that world to giving out 
contracts and grants. For those of us in the preparedness and 
response world, it's strategy, operations and tactics. It's how 
do we talk across those three cultures that is the challenge 
and that's an educative and mission-focused issue that I'm not 
sure, sir, that the committees can influence as directly as we 
in the leadership role have to be clear about the mission and 
we have to be clear about those cross-cultural communications.
    Mr. Pascrell. We need to put egos aside because otherwise 
we cannot accomplish the goal.
    Dr. Vanderwagen. Exactly.
    Mr. Pascrell. We have problems in the Congress with that. 
We have more chairmen and ranking members who serve on homeland 
security than another committee I know of and everyone is 
protecting their turf. So thank you for being a leader here.
    Dr. Vanderwagen. It's about mission, not turf. It's 
mission, not turf. The people expect us to be there. Thank you.
    Dr. Runge. May I make one observation, Mr. Pascrell, if 
you'll permit me? One of the reasons that there was this 
dissonance between HHS and DHS is that the Congress actually 
created an entity within HHS to do this work. Now they're not 
unique as a department. We have requirements of many 
departments to do their job of emergency support functions. I 
would maintain that if all of the other relevant departments 
had an entity, and by the way, these guys are sort of--they're 
kind of weird within the HHS framework. They do operations and 
they do preparedness and response. As you said, the rest of the 
culture of the department, they pay for medical care. They do 
science. USDA, DOD, State, EPA, all of those departments need 
an ASPR-like function so that we can create more of that 
dissonance with our departments so that we can get those issues 
resolved. I would maintain that that's really something that 
the Congress should look at and the reason that there appears 
to be a bifurcation is that there was and frankly it took a 
while to reach a more consonance.
    Mr. Langevin. I will ask one parting question to Captain 
Boynton. We appreciate you being here. I'd like to know what 
activities have you personally undertaken as Deputy Regional 
PFO for this region and for Rhode Island specifically, and do 
you expect to be named Deputy Regional PFO for any other 
biological events? I think that would be important to get on 
the record.
    Capt. Boynton. Thank you, Mr. Chairman. For Rhode Island, 
it's principally been the Deputy PFO that's also the FEMA 
Regional Administrator, Art Kleves. Admiral Lakai has two 
deputies. One of those deputies is that FEMA Regional 
Administrator, Art Kleves. He participates in most of the PFO 
cell-related activities in FEMA Region 1 and as the second 
Deputy PFO, I participate in most of the PFO's cell activities 
in Region 2 which would be New Jersey and New York. So that's 
been where most of my activity has been and I have also been 
named as a Deputy PFO for hurricane in Region 2.
    Mr. Langevin. Thank you very much. I thought that would be 
important to get on the record. With that, the first panel will 
be dismissed. I want to thank you all for your testimony today. 
I want thank you very much for your service to your country. We 
obviously have great challenges before us again with emerging 
biological threats and public health preparedness. We stand 
ready to work with you as partners in this effort to better 
protect the country. Again, I want to thank you all for your 
service, particularly, Dr. Runge, as you will be departing now 
and leaving your current post. You've given great service to 
the people of the United States and I thank you for your 
service and your testimony.
    Thank you. With that, this first panel is dismissed. Thank 
you. I call up the second panel.
    The hearing will come to order. I want to welcome our 
second panel of witnesses here today, beginning with Dr. 
Gifford, who is the Director of Health for the State of Rhode 
Island Department of Health. Our second witness is Major 
General Robert Bray. General Bray is the Adjutant General of 
Rhode Island, the Commanding General of the Rhode Island 
National Guard, the Director of the Rhode Island Emergency 
Management Agency, and the Homeland Security Advisory for Rhode 
Island. Welcome to you, General.
    Our third witness is Mr. Thomas Kilday, Homeland Security 
Program Manager at the Rhode Island Emergency Management 
Agency. Welcome, Tom.
    Our fourth witness is Peter Ginaitt, Emergency Preparedness 
Director for Lifespan Hospital Network here in Rhode Island. As 
many of us here know, Mr. Ginaitt is, of course, no stranger to 
public service--he was eight-term Rhode Island State 
Representative and a Veteran of the Warwick Fire Department. So 
I want to welcome you, Peter, and again all of our witnesses 
here, thank you for your service to our State and to the Nation 
and for being here.
    Without objection the witnesses' full statements will be 
inserted into the record and I now ask each witness to 
summarize his statement for 5 minutes, beginning with Dr. 
Gifford. Because time is tight I should mention we'll have to 
stick strictly to the 5-minute rule, both for statements and 
for Member questions. So Dr. Gifford, welcome.

STATEMENT OF DAVID R. GIFFORD, DIRECTOR OF HEALTH, RHODE ISLAND 
                      DEPARTMENT OF HEALTH

    Dr. Gifford. Thank you, Chairman Langevin and 
Representative Christensen and Representative Pascrell, welcome 
to Rhode Island.
    As the Director of the Department of Health, the Agency 
that is responsible for promoting and protecting the public's 
health, I'd like to thank you all for your continued focus on 
the health and safety of Rhode Islanders and U.S. citizens.
    As you know, all 50 States, the District of Columbia and 
the territories receive public health emergency preparedness 
and hospital preparedness through cooperative agreements with 
the CDC and the Assistant Secretary for Preparedness and 
Response. State health agencies use these Federal investments 
to not only prepare for biological threats such as influenza 
pandemic or bioterrorism, but also to enhance our capacities 
and capabilities to address more frequently encountered 
incidents.
    Public health agencies are often at the forefront of 
natural and unnatural events that impact all of our citizens. 
During the 2007 calendar year, nearly all State health agencies 
were involved in a response that required activation of their 
incident command system, a system adopted Nation-wide as a 
result of the Federal preparedness funding. More than a quarter 
did this six times or more a month.
    In my written testimony, I provided brief descriptions of 
responses by health departments from around the country to such 
incidents as weather-related disasters, tornados, blizzards, 
floods, infectious disease outbreaks, food-borne illnesses, 
drinking water contaminations, technology disasters, and acts 
of violence. Each of the States were able to address these 
because of their capabilities and capacities from the emergency 
preparedness funding that you all have authorized.
    Over the course of the past few years, the Department of 
Health in Rhode Island has utilized the incident command system 
on an average of every 3 to 4 months. We maintain a low, but 
appropriate threshold when determining whether to utilize the 
ICS to respond to health care issues and incidents, therefore, 
we utilize the ICS structure for both major regional incidents 
as well as for minor, less widespread events such as the TB 
skin testing at a local high school in Central Falls, Hepatitis 
A vaccine distribution to restaurant workers and to restaurants 
are two recent examples.
    These events also allowed us to test our medication 
distribution plans developed for pandemic and bioterrorism 
events. This approach has made us more efficient and effective 
in our response to these situations and our response to these 
situations has, in turn, made us better prepared to respond to 
other potential emergencies such as a pandemic or bioterrorism.
    Emergency preparedness funds and requirements have also 
helped us purchase equipment and supplies that will help us not 
only respond to unlikely events, but to more common health 
issues. For example, we made significant upgrades in 
modernizations of State laboratory equipment that can rapidly 
detect biological agents and a whole array of chemical poisons. 
This equipment and training in turn has helped us to better 
test for pertussis, whooping cough, and mercury in cord blood. 
By using this equipment for those nonemergency purposes has 
helped our staff remain proficient and ready to use the 
equipment for emergencies. For example, recently, we were able 
to respond to a credible, white powder incident and provide an 
answer to the FBI and law enforcement agencies in a matter of 
hours, confirming that the powder was harmless and it was not 
one of several possible biological agents such as anthrax or 
ricin.
    The funding has also helped us work more closely with other 
State agencies with the health care provider community and with 
the non-health care provider community such as the schools and 
business. For example, we've worked closely with hospitals to 
create a web-based hospital bed capacity system which provides 
real-time information concerning hospital bed capacity 24 
hours, 7 days a week. We use this system on a routine basis 
which ensures that the hospitals are able to utilize it more 
effectively during a major health incident.
    We work jointly with the Rhode Island Disaster Medical 
Assistance Team, DMAT, and the Medical Reserve Corps to develop 
a database to register health care volunteers who can assist 
during emergencies. This system allows us to check information 
and credentials on potential volunteers long before an 
emergency. With the next round of Federal funds, we'll be able 
to upgrade the system to include an automated 2A alert system 
that notifies and gives instructions to volunteers during an 
emergency.
    We've also worked with the Rhode Island Management 
Association to create a special needs emergency register. This 
registry targets Rhode Islanders with disabilities, chronic 
conditions and other special health care needs which comprises 
nearly 20 percent of the population in Rhode Island. This 
registry will allow us to better plan for, but also to ensure 
the delivery of needed services during emergencies. Future 
funding will help us actually pilot test and actually implement 
this.
    As you consider reauthorizing the funds for this program, I 
would recommend that you consider what you've heard here today. 
Hopefully, I've highlighted the importance of supporting an 
all-hazards approach to preparedness, rather than a focus on 
just pandemic or just specific bioterrorist events.
    Similarly, the training and equipment supported by these 
funds must be incorporated into the routine activities of 
agencies and tested on a regular basis, similar, Chairman, to 
your suggestion of testing pandemic flu during the seasonal 
influenza process.
    Otherwise, without that incorporation in our daily 
routines, it's much less likely that they will be utilized or 
will be as effective when implemented during an emergency. I've 
heard the military often say you should train the way you fight 
which applies aptly to emergency preparedness.
    In conclusion, I'd like to thank you and the committee 
Members for your continued support to ensure that the Nation is 
as best prepared as possible to respond to any incidents 
impacting our public's health. I can confidently say that I 
believe we as a State and for that matter as a Nation are 
better prepared today to deal with a myriad of natural and 
unnatural biological events. However, while the Nation has made 
tremendous progress in a short amount of time, continued 
support is necessary to ensure that we have the ability to meet 
the challenges associated with each new event affecting the 
citizens we all serve.
    Thank you, and I'll be available for questions.
    [The statement of Dr. Gifford follows:]

                 Prepared Statement of David R. Gifford
                             July 21, 2008

    Congressman Langevin and committee Members, as the Director of the 
Rhode Island Department of Health, an agency that is responsible for 
protecting and promoting the public's health in Rhode Island, I would 
like to thank you for continuing to focus on our Nation's health and 
safety. This hearing today on ``Emerging Biological Threats and Public 
Health Preparedness: Getting Beyond Getting Ready'' is just another 
example of the attention by Congress to emergency preparedness that has 
helped us become better prepared. The events of the world have not only 
changed our mindset but have changed how we do our business in public 
health. I can confidently say that I believe we as a State and as a 
Nation are better prepared today to deal with a myriad of natural and 
unnatural biological threats that we may encounter [Attachment A]. This 
is due in large part to the funding and leadership provided by Congress 
and the Federal agencies whom have worked in close partnership with the 
States and local public health agencies.
    All 50 States, the District of Columbia, five territories, three 
freely associated States and three large metropolitan areas (New York 
City, Chicago, Los Angeles County) receive Public Health Emergency 
Preparedness funding from the Centers for Disease Control and 
Prevention (CDC) and Hospital Preparedness Program funding from the 
U.S. Department of Health and Human Services (HHS) Assistant Secretary 
for Preparedness and Response (ASPR) through cooperative agreements. 
The CDC and ASPR cooperative agreements are the primary source of 
preparedness funding for State and territorial health agencies. Since 
1999, the Federal Government has invested more than $8 billion in 
public health and health system preparedness at the State and local 
levels.
    Public health agencies are often at the forefront of natural and 
unnatural events that impact our citizens. Core public health 
functions, such as disease outbreak investigations and prevention, are 
traditional responsibilities of State and territorial health agencies. 
Yet, health agencies play surprising--and critical--roles in all types 
of incidents. Natural disasters, environmental emergencies, 
infrastructure failures, foodborne outbreaks and mass acts of violence 
all have one thing in common--large numbers of people who must be 
protected.
    State health agencies have used Federal investments in public 
health and health system preparedness to not only prepare for 
biological threats which have a low probability of occurring, such as 
pandemic influenza or bioterrorism incidents, but to also enhance 
capacities, build new capabilities, and strengthen the overall public 
health infrastructure Nation-wide that can help us address more 
frequently encountered incidents that have a direct or indirect impact 
on the public's health. Federal funding and requirements have helped 
health agencies in 48 States plus the District of Columbia and Puerto 
Rico to adopt National Incident Management System (NIMS). NIMS is a 
systematic approach for seamless incident management at all levels of 
government. When responding to incidents, State and territorial health 
agencies follow the Incident Command System (ICS), an organizational 
structure that integrates operations, logistics, planning, finance/
administration, and command functions across all responders at the 
scene. The physical location where incident management activities are 
coordinated is the Emergency Operations Center (EOC). Depending on the 
scope of an incident, State health agencies may use their own agency-
specific EOC or they may be integrated into the EOC of another entity, 
such as that of a State emergency management agency. In Rhode Island, 
we have determined that all employees should have an understanding of 
the ICS system since any employee of the Rhode Island Department of 
Health may be called on to respond in an emergency. Therefore, every 
employee at the Department of Health is required to be trained at an 
ICS level that is commensurate with their job duties and 
responsibilities.
    Whether a federally declared disaster or an everyday occurrence, 
State and local public health agencies are now able to respond faster 
and more effectively to meet the health and medical needs of their 
populations because of national emergency preparedness efforts. During 
the 2007 calendar year, nearly 90 percent of State health agencies were 
involved in a response that required activation of their Incident 
Command System or participation in an Emergency Operations Center. More 
than a quarter did this six times or more. Emergency preparedness and 
response has become an integral service provided by State and 
territorial health agencies. Attachment B provides a brief description 
of some of the types of responses by our Nation's health departments in 
the past year to such threats as weather-related disasters (e.g., 
floods, hurricanes, blizzards, tornados, etc), infectious disease 
outbreaks (e.g., meningitis, measles, mumps, or TB), food-borne 
illnesses (e.g. salmonella, E. coli, etc), drinking water contamination 
(e.g. salmonella), technology disasters (collapsing bridges, dam/dike 
failures), acts of terrorism or acts of violence (e.g. Virginia Tech 
shootings). In Rhode Island, we have had to respond to several highly 
significant disease outbreaks, food-borne illnesses, contaminated 
drinking water and weather-related events, using our ICS. The funding 
for emergency preparedness has made us much more effective in our 
response to these situations; and our response to these situations has 
in turn made us much more effective for other potential emergencies.
    Over the course of the past few years, the Department of Health has 
utilized the Incident Command System (ICS) on average every 3 months. 
The Department maintains a low but appropriate threshold when 
determining whether to utilize ICS to respond to a health care issue or 
incident. Therefore, the ICS structure has been utilized not only in 
major regional incidents such as the Mycoplasma outbreak in January 
2006, but it also has been utilized in less widespread events such as 
the recent large scale TB skin testing at the Central Falls High School 
as part of an outbreak investigation and a hepatitis A exposure related 
investigation, leading to immunization of a large number of restaurant 
workers at two local restaurants. Not only has this allowed us to be 
more efficient and effective in our response but has provided us an 
opportunity to train HEALTH staff and improve our ability to utilize 
ICS. Consistent use of the ICS system when responding to major 
infectious disease outbreaks has built ICS skills and teamwork within 
the various units of the Department of Health that will assist in 
future disease outbreak responses that are either natural (e.g. 
pandemic) or unnatural (e.g. bioterrorism).
    Emergency preparedness funds and requirements have helped us 
develop stockpiles of critical equipment and supplies intended for use 
in a large-scale incident such as a bioterrorism event or pandemic and 
have been invaluable in helping our department respond to highly 
significant but smaller-scale events. Our department has utilized 
supplies stockpiled in response to public health emergencies such as a 
Mycoplasma related outbreak and the Central Falls High School TB 
outbreak. There have been enormous logistical benefits realized for 
responding in an expedient and efficient manner to such events, 
leveraging State-wide and departmental resources when the core unit 
responding to the situation had exhausted its resources. The Department 
of Health has created and equipped an operations center within the 
Cannon Building that can be utilized when responding to any public 
health emergency that does not rise to the level requiring activation 
of the State EOC. In addition another room in the Cannon Building has 
been equipped with phone lines and data ports that are utilized to 
house the Department's emergency hotline system. These resources are 
possible because of Federal funding and are utilized on a regular basis 
by response personnel, which as a result not only helps provide better 
care to the citizens of Rhode Island during health-related events but 
also make us better able to respond should we have some unusual natural 
(e.g. influenza pandemic) or unnatural incident (e.g. bioterrorism).
    In Rhode Island, the Department of Health works in partnership not 
only with other State agencies such as the Emergency Management Agency, 
but also the health care provider community such as hospitals and the 
non-health care community such as schools, integrating them in our 
planning, training, and our responses to events that have either a 
direct or indirect impact on the public's health.
    Using Federal funds, we have worked closely with hospitals to 
create a web-based Hospital Capacity System which has provided the 
State with a significant resource when dealing with emergency 
situations. This system operates 24/7 and provides real-time 
information concerning hospital bed capacity. In addition, this system 
supports an event calendar that details upcoming State-wide trainings, 
exercises and drills. In addition, interoperable communication 
mechanisms are being utilized on a daily basis by hospitals within the 
State. The hospitals currently have 6 redundant forms of communication. 
There will soon be an additional system with the addition of the 800 
MHz radios. Their daily use ensures that the system will be utilized 
correctly and effectively during a major health incident.
    Funds available through the Federal emergency preparedness grants 
have permitted significant upgrades and modernization of State 
laboratory equipment. The Division of Laboratories has been able to 
introduce rapid molecular methods of biological agent detection and a 
whole array of chemical detection equipment. These gains enhanced not 
just preparedness for emergencies, but also day-to-day laboratory 
operations. This equipment and training has also been used to help us 
better test for Pertussis (whooping cough) and mercury in cord blood. 
Such capacity development not only helps us serve to contribute to 
public health laboratory functions, thus benefits the public's health 
but also keeps our staff proficient, trained and ready to use the 
equipment whenever required. For example, we were able to respond 
recently to a ``credible'' white powder incident and provide an answer 
in a matter of hours, confirming that the powder was not one of several 
possible biological agents (e.g. anthrax) or biotoxins/poisons (e.g. 
ricin). This was only possible because of the equipment and training 
provided by emergency preparedness grants as well as the coordination 
we have with the FBI and other Law Enforcement agencies required to be 
developed through emergency preparedness training activities.
    We work with each municipality in RI to support a point of 
distribution (POD) plan that enables them to distribute medication or 
administer vaccines to their entire population. As part of a Medical 
Emergency Distribution System (MEDS) plan we provide municipalities 
with ``Go Kits'' to be used at Point of Distribution (POD) locations. 
``Go Kits'' are a conglomeration of supplies that would serve to 
facilitate the operation of an established POD site in a municipality 
that has been tasked to dispense medication. The ``Go Kits'' contain 
such items as office supplies (pens, highlighters, clipboards, etc), 
cleaning supplies (paper towels, garbage bags, etc), crowd control/
information dissemination items (bullhorn, whistles, lanterns, etc), 
medical supplies (disposable thermometers, stethoscope, etc), sign 
holders, communications devices (weather band radio, two-way radios, 
etc), and logistical support/utility devices (batteries, extension 
cords, etc).
    We have developed in partnership with the Rhode Island Disaster 
Medical Assistance Team (DMAT) and the Medical Reserve Corp (MRC), a 
database called State Emergency Registration of Volunteers in Rhode 
Island (SERVRI). The triad of resources from SERVRI, MRC and DMAT is 
called ``RI Responds'' and has the capacity to register, verify and 
mobilize health and medical volunteers in an emergency response 
scenario. ``RI Responds'' is an advanced registration system utilizing 
a secure database of verified information provided by health care 
professionals who have expressed an interest in assisting in the event 
of a public health emergency or other disaster requiring trained 
medical professionals. Once registered, volunteer professional 
information is immediately verified prior to an emergency, so that 
health care professionals may be deployed quickly and efficiently. When 
a decision is made to request the services of emergency volunteers 
registered within the system, they are presently notified manually (via 
e-mail and telephone). With maintenance of Federal funds we will be 
able to upgrade the system to include an automated two-way alert 
system. Volunteers will be able to receive instructions for response, 
when activated during a significant disaster or public health 
emergency, through the electronic notification system (ENS) that will 
be procured to facilitate deployment and utilization of all volunteers 
found within the database. This ENS system will also link to our 
program for tracking the deployment activations and locations of ``RI 
Responds'' volunteers to provide a comprehensive management tool.
    The Department of Health has establish a standing internal Special 
Populations Emergency Preparedness Workgroup (SPEP). The Special 
Populations Work Group is charged with: (1) Making recommendations 
about our Emergency Response Plan to reflect the needs of special 
populations; (2) coordinating activities related with special 
populations during public health emergencies; and, (3) participating in 
the Incident Command Structure. We also work with the Minority Health 
Promotion Centers (community-based organizations targeting primarily 
racial and ethnic minority populations) to assess community and agency 
preparedness for risk communication and response to public health 
emergencies.
    We have worked in partnership with the Rhode Island Emergency 
Management Agency, to create and implement a Special Needs Emergency 
Registry. This registry targets Rhode Islanders with disabilities, 
chronic conditions and/or other special health care needs. The primary 
objective of the registry is to develop a reliable system for the 
identification of Rhode Islanders who require special assistance during 
emergency events by collecting key information for use by emergency 
personnel to plan and respond to emergency events. Populated through 
the submission of online or paper enrollment forms, the system is being 
developed with the capability to generate electronic reports for 
individual city and town use for emergency planning and response and 
will be activated by the operation of the Incident Command System. 
Currently 20 percent of the total State's population fall into the 5 
areas the registry covers: Life support: includes dialysis, 
respirators, oxygen; Mobility; Hearing/visual related issues; Cognitive 
issues; Mental health-related issues. To date the registry has reached 
approximately 3,500 people.

                                SUMMARY

    Public health agencies are often at the forefront of natural and 
unnatural events that impact the health of our citizens. Health 
agencies play a critical role in all types of incidents: natural 
disasters, environmental emergencies, infrastructure failures, food-
borne disease outbreaks and mass acts of violence, all of which have 
public health impacts. The CDC and ASPR cooperative agreements are the 
primary source of preparedness funding for State and territorial health 
agencies but the proposed funding for the ASPR cooperative agreement is 
25 percent less over the same time period (see attachment C).
    State health agencies have used Federal investments in public 
health and health system preparedness to not only prepare for those 
threats which have a low probability of occurring such as pandemic 
influenza or bioterrorism events but to also enhance capacities, build 
new capabilities, and strengthen the overall public health 
infrastructure Nation-wide that can help us address more frequently 
encountered incidents that have a direct or indirect impact on the 
public's health. Strained economic conditions across the country 
combined with steadily decreasing Federal funding for public health and 
health system preparedness threaten the progress that State and 
territorial health agencies, along with their local, tribal and Federal 
counterparts, have made within the last decade.
    Rhode Island has used these funds to build capacity in both 
personnel training and equipment purchase both internally within the 
Department and with key partners in the community to not only be better 
prepared to respond to biological threats but to all types of natural 
and unnatural incidents as well as enhancing capacity for our core 
activities. Without this support, we would not have been able to 
address several health incidents as effectively or efficiently. As you 
consider reauthorizing funds for these programs, I would recommend that 
you consider what you have heard here today to not only make decisions 
on the funding level but on the requirements related to the use of 
these funds. Hopefully my testimony has highlighted the importance of 
supporting an all-hazards approach to preparedness, not restrictions 
that focus just on pandemic or specific biological threats. Similarly, 
the training and equipment supported by these funds must be 
incorporated into the routine activities of the agencies and tested on 
a regular basis. Otherwise they are much less likely to be utilized or 
effective when an unusual incident occurs. I have heard the military 
say one ``should train the way you fight,'' which applies aptly to 
emergency preparedness.
    In conclusion, I would like to thank you and the committee for 
their continued support in ensuring that the Nation is as best prepared 
as possible to respond to incidents impacting the public's health. The 
Nation has made tremendous progress in a short amount of time but 
continued support is necessary to ensure that we continue to have the 
ability to meet the challenges associated with each new event affecting 
the citizens that we serve.
       Attachment A.--State Health Agency Emergency Preparedness
    All 50 States, the District of Columbia, five territories, three 
freely associated States and three large metropolitan areas (New York 
City, Chicago, Los Angeles County) receive Public Health Emergency 
Preparedness funding from the Centers for Disease Control and 
Prevention (CDC) and Hospital Preparedness Program funding from the 
U.S. Department of Health and Human Services (HHS) Assistant Secretary 
for Preparedness and Response (ASPR) through cooperative agreements. 
The CDC and ASPR cooperative agreements are the primary source of 
preparedness funding for State and territorial health agencies. Since 
1999, the Federal Government has invested more than $8 billion in 
public health and health system preparedness at the State and local 
levels.
    The CDC began funding several State health agencies in 1999 and 
expanded its cooperative agreement to 62 grantees following the 
September 11, 2001 terrorist attacks and the anthrax attack that soon 
followed. The CDC Public Health Emergency Preparedness cooperative 
agreement supports more than 3,500 State and local public health agency 
staff working on preparedness activities Nation-wide. Funding under the 
ASPR Hospital Preparedness Program cooperative agreement to the same 62 
jurisdictions began following the 2001 terrorist attacks. While CDC and 
ASPR distribute preparedness funds to State and territorial health 
agencies and four large local health departments, 75 percent of the 
funds directly or indirectly support local public health departments 
and hospitals. State health agencies use ASPR cooperative agreement 
funds to support preparedness activities for more than 5,000 hospitals 
Nation-wide. Additionally, State health agencies provide non-financial 
support to many of the local health departments and other partners 
within their jurisdictions. According to a National Association of 
County and City Health Officials (NACCHO) survey of local health 
departments, ``64 percent received technical assistance for planning; 
56 percent received laboratory support; 55 percent received 
surveillance support; and 53 percent received support for exercise 
planning and administration.'' Thus, Federal public health and health 
system preparedness funds are used to improve response capabilities at 
all levels in communities across the country.
    State health agencies have used this investment in public health 
and health system preparedness to enhance capacities, build new 
capabilities, and strengthen the overall public health infrastructure 
Nation-wide. This investment has paid off. Whether a federally declared 
disaster or an everyday occurrence, State and local public health 
agencies are able to respond faster and more effectively to meet the 
health and medical needs of their populations.
    State and territorial health agencies have played integral roles in 
responding to a wide range of emergencies. In 2007 alone, there were 63 
federally declared disasters and health agencies played a role in 
responding to almost all of them. During the 2007 calendar year, nearly 
90 percent of State health agencies were involved in a response that 
required activation of their Incident Command System or participation 
in an Emergency Operations Center. More than a quarter did this six 
times or more. Emergency preparedness and response has become an 
integral service provided by State and territorial health agencies.
    Public health agencies are often at the forefront, just as anyone 
would expect. Core public health functions, such as disease outbreak 
investigations, are traditional responsibilities of State and 
territorial health agencies. Yet, health agencies play surprising--and 
critical--roles in all types of incidents. Natural disasters, 
environmental emergencies, infrastructure failures, foodborne outbreaks 
and mass acts of violence all have one thing in common--large numbers 
of people whose health must be protected.
    Health agencies at the State, territorial, local, tribal and 
Federal levels are incorporating emergency management principles into 
their activities to be consistent with the National Response Framework 
(NRF). The NRF details response principles, roles and structures for 
all-hazards national response and how they should be applied at the 
State, local, tribal and Federal levels as well as by private sector 
and nongovernmental partners. Health agencies in 48 States plus the 
District of Columbia and Puerto Rico have reached National Incident 
Management System (NIMS) compliance certification. NIMS is a systematic 
approach for seamless incident management at all levels of government. 
Incidents are natural or manmade occurrences or planned events that 
require a response to protect lives or property. When responding to 
incidents, State and territorial health agencies follow the Incident 
Command System (ICS), an organizational structure that integrates 
operations, logistics, planning, finance/administration, and command 
functions across all responders at the scene. The physical location 
where incident management activities are coordinated is the Emergency 
Operations Center (EOC). Depending on the scope of an incident, State 
health agencies may use their own agency-specific EOC or they may be 
integrated into the EOC of another entity, such as that of a State 
emergency management agency. In most States, the health department is 
the lead agency for Emergency Support Function 8 (ESF-8), meaning they 
are responsible for health and medical resources during an incident. 
Health agencies may also support some of the other 15 total functions, 
such as ESF-6, which is mass care, or ESF-10, which is oil and 
hazardous materials response. With trained staff who understand NIMS, 
health agencies are able to work side-by-side with their response 
partners, regardless of agency or jurisdictional boundaries.
  Attachment B.--Public Health Preparedness in Action: Examples From 
                  Other State or Local Health Agencies
    State and territorial public health agencies and the health care 
system are stronger today because of the investment in preparedness. 
State and territorial health agencies make a difference every day in 
protecting the health and preserving the lives of Americans across the 
country. Using Federal cooperative agreement funds provided through the 
Center for Disease Control (CDC) Public Health Emergency Preparedness 
Program and the Assistant Secretary for Preparedness and Response 
(ASPR) Hospital Preparedness Program, State health agencies 
strategically invest in personnel, equipment, supplies and training 
that are drawn on during critical incidents, whether they are 
infectious disease outbreaks, natural disasters, or foodborne outbreaks 
and Nation-wide product recalls. Public health agency personnel work 
with their response partners every day in all types of incidents and 
are therefore always simultaneously preparing for disaster through an 
all-hazards approach to emergencies.
    These are just some of the high-profile examples from last year.

                           DISEASE OUTBREAKS

    Recognition and response to agents of bioterrorism are predicated 
upon effective foundations of disease surveillance, outbreak 
investigation and response. These are core elements of public health 
practiced daily by departmental units of clinical epidemiology and 
infectious disease.
    Mycoplasma pneumoniae.--When five children in the community were 
diagnosed with severe neurological illnesses, the Rhode Island 
Department of Health [RIDOH] stopped a worrisome infectious disease 
cluster in its tracks by activating ICS and its mass dispensing plan to 
provide antibiotics to more than 1,000 at-risk individuals, launching 
an extensive public risk communication effort, and closing schools to 
encourage social distancing to interrupt disease spread. In December 
2006, RIDOH learned of five school-aged children with severe 
neurological illness, including one who died. The Rhode Island 
Department of Health contacted the Center for Disease Control (CDC) for 
assistance with the disease cluster on December 22, 2006. CDC 
laboratory testing confirmed the first positive results for Mycoplasma 
pneumoniae on December 29. Mycoplasma infection clusters are rare and 
there was an unusually large number of severe cases in a single school. 
As a precaution, the RIDOH activated Incident Command System (ICS) and 
with the assistance of State DMAT offered antibiotics via a mass 
dispensing clinic to all 275 students, 40 staff members and their 
families between December 31, 2006 and January 2, 2007. In total, 1,183 
people received medication.
    Operating within ICS, State health agency staff used the mass 
prophylaxis training they had received as part of their Strategic 
National Stockpile planning to dispense medication over the holiday 
weekend. One hundred percent of the affected population was accounted 
for and many participated in voluntary blood testing. State health 
officials and CDC personnel reviewed medical records from the school 
clinic and interviewed students and staff. Health officials, including 
the State health director, also held community information sessions 
with parents to address their concerns and set up a telephone hotline 
and Web site for those seeking additional information. The school was 
closed until January 8, 2007 to interrupt the transmission of illness 
and so that 5-day antibiotic treatment courses could be completed 
before students and staff returned to school.
    Health officials also investigated reports of higher-than-normal 
absenteeism in other schools in the area. On January 4, 2007, RIDOH 
recommended the closure of three school districts, impacting 20,000 
students and their families. This was a precautionary measure to 
control disease and give the State health agency and the CDC time to 
further investigate potential cases. The CDC is using this incident to 
study the social and economic effects of school closures as part of a 
community containment strategy in the event of an influenza pandemic.
    RIDOH's success in containing this outbreak was, in part, due to 
the investments made in its Medical Emergency Distribution plan, risk 
communication strategy, and ICS training of all staff as part of its 
all-hazards approach to emergencies.
    Meningitis.--When meningitis sickened ten young people and killed 
two, the Chicago Department of Public Health [CDPH] launched a mass 
vaccination campaign to boost coverage rates and provide years of 
health protection to more than 7,200 at-risk children. The Department 
also used the incident as an opportunity to test its mass vaccination 
planning.
    By April 23, 2008, the city of Chicago had ten cases of group C 
meningococcal invasive disease and two deaths for the year. The city 
only had 13 cases in all of 2007. Meningococcal disease is a bacterial 
infection that can cause meningitis and infect other tissues. The two 
individuals who died of the disease in Chicago lived in an area of the 
city with a low compliance rate for receiving the new vaccine. CDPH 
decided to pre-empt the situation to avert a potential epidemic. To do 
so, they launched a mass vaccination campaign to accelerate vaccine 
coverage rates in the community. Focused on children aged 11 to 18, 
vaccination teams targeted 10,000 children in 50 Chicago schools. Staff 
from the CDPH and five suburban health departments administered vaccine 
to 7,213 children in 2 weeks. The vaccine coverage rate of more than 70 
percent among the targeted population is an impressive improvement over 
the historic rate of 20 to 30 percent. No additional children died of 
the disease, and the success of the vaccine campaign will continue to 
protect the at-risk population from future outbreaks in the years to 
come.
    In addition to protecting the community's health, CDPH seized on 
the opportunity to use the vaccine campaign to implement their mass 
dispensing and mass vaccination planning it has developed with support 
from the Federal preparedness cooperative agreements. The ability to 
vaccinate or dispense medication to large numbers of people is one of 
the core capabilities that health agencies across the country are 
working to develop. Being able to implement a mass vaccination or mass 
dispensing plan would be essential during a bioterrorism attack with an 
agent such as anthrax or smallpox or a natural disease outbreak such as 
pandemic influenza. Prior to the heavy investment in public health 
preparedness, CDPH would not have been able to accomplish a response of 
this size in such a short amount of time.

                      DRINKING WATER CONTAMINATION

    A system that supports early detection and response to potential 
threats to our drinking water supply are critical public health 
functions.
    Salmonella.--When the water distribution system for the city of 
Alamosa became contaminated with salmonella, sickening more than 400 
people, the Colorado Department of Public Health and Environment 
[CDPHE] used all its resources to identify the source of the problem, 
provide extensive risk communications to the public, work with partners 
to implement a solution, and restore safe drinking water to homes and 
businesses. The first case of salmonella was reported in Alamosa on 
March 6, 2008. Through case interviews, epidemiologists discovered that 
breastfed infants were not getting sick while those fed formula mixed 
with tap water were. Laboratory samples collected from individuals, 
from water in homes and from businesses confirmed that the same strain 
of salmonella was present in all. Further investigation determined that 
the aquifer supplying the drinking water was not contaminated. 
Epidemiologists and water experts concluded that the source of 
salmonella was somewhere in the water distribution system.
    On March 17, Alamosa County established its Emergency Operations 
Center (EOC) and CDPHE notified Federal partners of the outbreak. CDPHE 
issued a bottled water order on March 19 and advised residents not to 
use their tap water. The health agency also activated its public 
information hotline and issued a mutual aid request for water experts. 
The State public health laboratory, with personnel and equipment 
supported by Federal preparedness funding, conducted sampling for 
salmonella, total coliform bacteria and heavy metals. This was the 
first time the laboratory had to conduct testing for human and 
environmental outbreaks at the same time.
    The Water Quality Control Division coordinated with the city to 
develop and implement a plan to flush the city municipal water system 
and conducted water sampling for bacteria and heavy metals before, 
during and after the system flushing. The division also provided 
guidance for water use during each stage of the system flush. CDPHE and 
the local Joint Information Center continually updated Web sites, 
issued news releases, developed information flyers and fact sheets, and 
worked with local officials to activate Reverse 911 to get the word 
out. Community volunteers delivered much of the information door-to-
door.
    The boil-water order was finally rescinded by CDPHE on April 11. As 
of April 30, there were 424 cases of salmonella, including 117 that 
were culture-confirmed. Twenty-two people were hospitalized and one 
death was attributed to the salmonella outbreak. The successful 
conclusion of this outbreak was made possible by the significant 
investment in laboratory services, epidemiology, Incident Command 
System (ICS) and communication through emergency preparedness.

                           NATURAL DISASTERS

    Natural disasters are predictably unpredictable in that we can be 
certain that they will occur varying by location, nature and severity. 
Natural disasters such as hurricanes, wildfires, earthquakes, tornados, 
snowstorms and floods can have catastrophic public health consequences 
and require a high level of preparedness.
    Wildfires.--Twenty-three wildfires struck southern California in 
October and November 2007. The wildfires caused ten deaths and 139 
injuries, and forced the evacuation of 321,500 residents--the largest 
evacuation in California's history. The California wildfires were just 
one of 63 federally declared disasters in 2007. State health agencies 
were on the front lines of most, if not all, of them. The California 
Department of Public Health (CDPH) responded to the wildfires 
immediately, deploying its 2,000 alternate care site bed cache to 
Qualcomm Stadium to support the primary shelter set up for evacuated 
residents. Health agency staff, including Director Mark Horton, were at 
Qualcomm Stadium to ensure the shelter operated smoothly and that 
medical needs were adequately met. At the same time, the CDPH 
coordinated evacuations from threatened health care facilities, 
including 12 nursing homes, two acute care facilities and a psychiatric 
hospital. Throughout the response, the CDPH provided critical 
information to local health agencies and providers through its Health 
Alert Network. When the fires were contained and people returned to 
homes and businesses, the CDPH and local health agencies evaluated 
drinking water systems potentially contaminated by the wildfires. 
Thanks to State health agency assets that were not available before the 
recent focus on preparedness, the CDPH now has increased capacity to 
respond to wildfires, earthquakes, hurricanes, tornados, blizzards and 
other natural disasters.
    Snowstorms.--When a record-breaking snowstorm dropped over 2 feet 
of snow in October and knocked out power to 400,000 homes and 
businesses, some for as long as a week, the New York State Department 
of Health successfully partnered with local health agencies to protect 
residents of western New York from carbon monoxide poisoning, food-
borne diseases, and other health threats while working with local 
hospitals to assure appropriate staffing by deploying volunteer nurses. 
The New York State Department of Health [NYSDH] activated its risk 
communication plan and jointly issued a press release with the New York 
State Emergency Management Office. The agencies cautioned the public on 
cardiac risks resulting from the physical exertion of shoveling snow, 
warned of carbon monoxide dangers due to the use of generators and 
alternate heating sources, reminded of the importance of the safe use 
of candles and heaters in preventing fires, and offered advice on the 
safety of refrigerated food unable to be kept cold due to electricity 
loss. As the extent of the storm damage became clear, NYSDH also issued 
advice for those with end-stage renal disease who might not be able to 
get to their dialysis treatments. Throughout the storm response, NYSDH 
monitored public water supplies, conducted water sampling, and provided 
guidance through county health departments to restaurants and food 
establishments on safe food handling. The State health agency activated 
its Emergency Medical Volunteer Database to identify and deploy nurses 
from other parts of the State. Using CDC cooperative agreement funds, 
NYSDH set up the database following the September 11 attacks. From the 
registry of 11,242 medical professionals throughout the State willing 
to volunteer during emergencies, the State health agency deployed 
nurses from unaffected areas of the State. The State-based Health 
Emergency Response Data System (HERDS) system was also widely used at 
the county level. The Erie County Health Department detected an 
elevated number of carbon monoxide exposures using HERDS. The Erie 
County Health Department worked with the media to publicize a carbon 
monoxide fact sheet.
    Tornados.--When a tornado killed 11 residents and destroyed the 
town of Greensburg, the Kansas Department of Health and Environment 
[KDHE] helped make the town habitable again by assuring access to 
health and medical services, restoring identities, and protecting 
residents and recovery workers from environmental and safety hazards. 
The Center for Public Health Preparedness was instrumental in helping 
to secure medical supplies, personal protective equipment and 
sanitation equipment for some of the response and recovery workers. One 
of the immediate needs of Greensburg residents was met by the 
Department's Center for Health and Environmental Statistics. The 
tornado destroyed approximately 95 percent of the town, including 
personal records such as birth and marriage certificates that people 
need to prove their identities. Set up at the Disaster Recovery Center, 
KDHE staff assisted Greensburg residents in filling out simple 
application forms that were printed and faxed to the Department's 
headquarters for overnight processing. KDHE reissued 355 birth and 
marriage certificates for Greensburg residents. The environmental 
component of the KDHE also played a major role. Staff from the Bureau 
of Air and Radiation inspected commercial and public buildings for 
asbestos. While not generally a health risk when used in building 
materials, asbestos can cause serious lung diseases if airborne 
particles from damaged buildings are inhaled. Bureau of Air and 
Radiation staff labeled risks with red tape to indicate the presence of 
asbestos. This triggered clean-up crews to use special precautions when 
removing debris within the marked boundaries. While the KDHE would have 
had the same responsibilities if the Greensburg tornado had occurred 10 
years earlier, what changed in 2007 was the way the Department was able 
to respond. Health agency staff trained in ICS with CDC preparedness 
funds were able to integrate into the emergency response structure 
alongside other responders such as police and firefighters who have 
been using Incident Command System (ICS) for years.
    Floods.--When flooding hit nine counties, the Ohio Department of 
Health [ODH] maintained State-wide situational awareness to support 
local public health agency response efforts and test new surveillance 
systems. As in other States, ODH works with local health departments on 
preparedness planning. This collaborative effort was effectively tested 
during flooding in nine Ohio counties in August 2007. In Allen County, 
the local health department used its upgraded communications equipment 
to share information with State and local officials about flood damage 
and the needs of the community. Public information staff, who had been 
trained with funding from the CDC cooperative agreement, worked with 
the media to get consistent health information to the public about 
building clean-up, mold prevention, and the appropriateness of tetanus 
and other vaccines. Mass dispensing plans developed as part of 
Strategic National Stockpile preparations were used to rapidly set up a 
tetanus vaccine clinic using volunteers from the Medical Reserve Corps. 
Mutual aid agreements established with other local health departments 
enabled a more efficient response to calls for assistance. All of these 
tools enabled the Allen County Combined Health District to maximize its 
personnel and other resources and to effectively determine resource 
gaps to be filled by the ODH and other local health departments.
    The flood also tested ODH's Real-time Outbreak and Disease 
Surveillance (RODS) System. RODS provides for real-time analysis of 
emergency department chief complaint data and over-the-counter drug 
sales information and may be useful for the early detection of clinical 
syndromes due to agents of bioterrorism. The system is used by more 
than 300 health department and hospital personnel to detect and track 
health events such as bioterrorism, outbreaks, influenza, and seasonal 
illness. Currently, more than 85 percent of Ohio's emergency department 
visits and approximately 70 percent of over-the-counter drug sales are 
captured and analyzed by the system.
    Using chief complaint data from the RODS system, the ODH's Early 
Event Surveillance Unit's analysis found a statistically significant 
five-fold increase in chief complaints related to insect bites in the 
flooded region 2 weeks after the flooding began--the approximate amount 
of time it takes for a mosquito to reach maturity. Public health 
officials have long known that many diseases, such as West Nile virus, 
are spread among the human population by mosquito bites. They also know 
that standing pools of water, which are common following floods, are 
major breeding sites for mosquitoes and other insects.

                        TECHNOLOGICAL DISASTERS

    The Minnesota Department of Health (MDH) activated its regional 
response plan following the August 2007 interstate bridge collapse that 
killed 13 and injured nearly 100. The MDH used its Health Alert 
Network, funded through the CDC cooperative agreement, to notify MDH 
staff, local health agencies, hospitals and emergency management 
partners of the bridge collapse, inform recipients to be ready to 
respond, and provide updates throughout the response. The MDH, 
hospitals and EMS used MNTrac, a decisionmaking tool implemented with 
ASPR cooperative agreement funds, to monitor ambulance runs, status of 
patients, and coordination of patient care transport and emergency 
room/trauma care. Based on information provided through MNTrac and the 
Health Alert Network, area hospitals activated their response plans and 
were able to handle all of the victims. Using its ESAR-VHP system, the 
MDH identified and credentialed behavioral health volunteers and 
provided their information to the city of Minneapolis and the family 
assistance center to be called upon to assist the victims, their 
families and first responders in the immediate aftermath and the weeks 
that followed. During the recovery phase, the MDH worked with 
environmental agencies to identify and assess potential health risks 
related to the air and water. As our physical infrastructure ages, 
State health agencies will likely have to respond to more technological 
disasters.

                          FOODBORNE OUTBREAKS

    Foodborne diseases cause approximately 76 million illnesses, 
325,000 hospitalizations and 5,000 deaths in the United States each 
year at a cost of $5 billion. State and territorial health agencies use 
Federal cooperative agreement funds to support food-borne outbreak 
response, including epidemiologists to conduct outbreak investigations, 
public health laboratory personnel and equipment to confirm outbreak 
causes and communications professionals to notify the public of risks.
    In July 2007, the Indiana Department of Health and the Texas 
Department of State Health Services independently notified the CDC of 
suspected food-borne botulism cases. In both States, epidemiology staff 
investigated patient food histories to determine the cause of illness, 
laboratory staff tested patient and food samples, and health agency 
officials requested and distributed botulinum antitoxin from CDC. Once 
CDC confirmed botulism as well as the source, the FDA issued a consumer 
advisory and the manufacturer voluntarily recalled its canned chili 
products from about 8,500 retail outlets. State health agencies across 
the country engaged in extensive public education campaigns to get the 
products off store shelves and out of people's homes to prevent 
additional botulism cases. Thanks to improvements made to the public 
health infrastructure with Federal preparedness funding, State health 
agencies and their partners limited the botulism outbreak to eight 
cases in three States.

                      TERRORISM & ACTS OF VIOLENCE

    In 2006, 20,000 deaths resulted from 14,000 terrorist attacks 
world-wide. The last acts of large-scale terrorism on United States 
soil occurred in 2001, but major acts of violence continue to occur. 
After these events, State health agencies and the health care system 
must mobilize to protect lives while coordinating with law enforcement 
officials to preserve evidence.
    The Virginia Department of Health (VDH) immediately responded when 
a gunman killed 33 and injured 27 others at Virginia Tech in April 
2007. Using CDC cooperative agreement funds, the VDH had established 
five regional response teams as part of its State-wide preparedness 
system. Under the Chief Medical Examiner, the VDH deployed three public 
information officers, a planner and a team of forensic scientists to 
assist the regional team already in place. With Assistant Secretary for 
Preparedness and Response (ASPR) cooperative agreement funds, the VDH 
set up Regional Healthcare Coordinating Centers in each of the State's 
six hospital regions. ASPR funds also support yearly upgrades to the 
WebEOC system installed in hospitals throughout Virginia, hospital 
staff training, purchase of redundant communications, and sustainment 
of the Regional Healthcare Coordinating Centers. Using the State-wide 
Web Emergency Response Center (WebEOC) system, the VDH, hospitals, the 
35 local health districts, and emergency management partners tracked 
the transport and condition of all injured victims, checked the 
diversion status of hospitals, and monitored and responded to resource 
needs of the affected hospitals. The VDH also provided risk 
communications to the public, identified victims, supported family 
services established by the university, and kept Federal and 
international entities informed. This tragic example is a reminder of 
the importance of coordinated, State-wide public health and health care 
preparedness systems for rapid responses to mass casualty incidents.
    While these incidents were among the most widely publicized of the 
last year, State and territorial health agencies respond to similar 
events around the country every single day. For more examples, please 
visit States of Preparedness on (Association of State and Territorial 
Health Officers) ASTHO's Web site at www.astho.org.
         Attachment C.--Federal Budget Appropriation Declining
    Continued cuts to State and territorial public health and health 
system preparedness programs threaten the ability of jurisdictions to 
respond as rapidly and effectively to future events as to those that 
occurred over the last year-and-a-half. Lives have been saved and 
diseases and injuries have been prevented through the significant 
support that the Federal Government has provided public health agencies 
through the CDC and ASPR cooperative agreements. However, the proposed 
fiscal year 2009 budget calls for a funding level for the CDC 
cooperative agreement that is 33 percent less than in fiscal year 2005. 
The proposed funding for the ASPR cooperative agreement is 25 percent 
less over the same time period.
    These continued funding decreases, combined with the difficult 
economic conditions in many States, will hinder the ability of State 
and territorial health agencies to sustain and continue the progress 
that has been made in public health and health system preparedness. 
State and territorial public health agencies are beginning to cut 
response personnel; limit opportunities for staff to train, plan and 
exercise with other first responders; lose their ability to maintain 
supplies and technology such as surveillance systems, laboratory 
equipment and communications devices; and decrease their capacity to 
produce and distribute public safety information. These changes will 
make it difficult for State and territorial health agencies to 
duplicate the successful responses seen to date. A sustained commitment 
to public health preparedness will ensure that health agencies will 
continue to be able to rapidly respond to all hazards by protecting the 
health and lives of the public.






    Mr. Langevin. Dr. Gifford, thank you for your testimony.
    I now recognize General Bray for 5 minutes.

 STATEMENT OF MAJOR GENERAL ROBERT T. BRAY, ADJUTANT GENERAL, 
RHODE ISLAND; COMMANDING GENERAL, RHODE ISLAND NATIONAL GUARD; 
    DIRECTOR, RHODE ISLAND EMERGENCY MANAGEMENT AGENCY; AND 
        HOMELAND SECURITY ADVISOR, STATE OF RHODE ISLAND

    Gen. Bray. Mr. Chairman, committee Members, thank you for 
the opportunity to provide testimony regarding National Guard 
planning and preparations to address emerging biological 
threats. In addition to my duties, roles, and responsibilities 
as the Adjutant General, you've noted many hats that I wear. 
This management structure provides one focal point for the 
Governor as well as for the Federal agencies.
    As of today, the Rhode Island National Guard's primary 
asset to assist local authorities is the Rhode Island National 
Guard 13th Weapons of Mass Destruction Civil Support Team. The 
Civil Support Team is a highly trained, full-time unit 
specifically designed to assist local authorities in the event 
of a chemical, biological, radiological, nuclear, or high-yield 
explosive incident. The team is available 24/7 and located 
centrally within the State to ensure maximum response times of 
no more than 90 minutes. The CST maintains a close working 
relationship with the first response agencies, including the 
hazardous material response units in the State as well as with 
CST units in other States for joint training exercises and 
mutual aid assistant.
    The National Guard is not intended to be a first responder 
or the lead agency. We are the State's larger response option 
and as such we remain proactive in providing support through 
training, preparation, and planning. The National Guard is 
committed to the fundamental principle that each and every 
State and territory must possess ten core capabilities for 
homeland readiness. Amidst the most extensive transformation of 
our Army and Air Force in decades, the National Guard intends 
that every Governor has each of these essential ten 
capabilities. Those capabilities are a Joint Force Headquarters 
for command and control element with immediate access to a 
quick reaction force; a Civil Support Team; engineering 
capabilities; communications capabilities; all-terrain ground 
transportation capabilities; aviation capabilities; medical 
capabilities; security forces capabilities; logistics 
expertise; and maintenance capabilities.
    The Rhode Island National Guard is uniquely situated to 
provide each of these ten core capabilities in support of civil 
authorities for responding to a biological or other domestic 
incident. Our ability to quickly assemble and deploy a critical 
mass of disciplined personnel is our greatest asset.
    Allow me to speak to this issue as I know there has been 
national concern about this capability given our robust 
operations template in support of the global war on terror. As 
of July 15, 2008, the assigned strength of the Rhode Island 
National Guard was 3,274 soldiers and airmen. As of July 15, 
2008, minus mobilized, deployed, and those in training, 71 
percent or 2,327 soldiers and airmen were available to support 
domestic operations if requested by civil authorities, 
exceeding the 50 percent threshold goal established by the 
Chief National Guard Bureau to respond to domestic incidents in 
support of civil authorities. Clearly, the Rhode Island 
National Guard provides the State of Rhode Island with a 
robust, all-hazard capability to include biological incident 
response. All is not perfect to be sure. At the core of 
capability is the need for clearly defined roles, missions and 
responsibilities. The default for response should not be the 
National Guard, due to a lack of capability at the local 
response level.
    Accordingly, local, State and Federal funding is essential 
for adequate personnel, equipment, training, facilities, and 
planning capabilities at these levels. Additionally, our 
ability to assist civil authorities is dependent on our being a 
properly- and full-resourced organization. We are now an 
operational force. As such, we need 100 percent full-time 
manning, 100 percent of authorized equipment, State, and 
Federal support for our military construction budget, and full 
funding of our operational and maintenance budgets. This will 
also best posture us for civil support and disaster response 
and recovery capabilities.
    Consequently, I support the National Governors Association 
letter to the Chairman and Ranking Member of the House and 
Senate Committee on Armed Services which opposes past House 
amendments to the Federal Insurrection Act. The National Guard 
must not be ordered to Title 10 duty without the consent of the 
Governor, particularly for natural disasters.
    In closing, planning, preparation, resourcing, and 
responding to a biological threat or other domestic incident is 
a continual process that must adapt to a complex and changing 
secured environment. The role and mission of the National Guard 
and the command and control of the Adjutant General with the 
Governor as Commander-in-Chief, past, present, and future, is 
essential to the success of domestic preparedness and response. 
Partnerships and resources at both the State and Federal level 
are vital in our efforts to ensure that we stand ready, 
relevant, reliable, and accessible in support of civil 
authorities in the event of a biological or other domestic 
incident.
    Thank you for this opportunity to testify and I am 
available for questions.
    [The statement of General Bray follows:]

                  Prepared Statement of Robert T. Bray
                             July 22, 2008

    Mr. Chairman, committee Members, thank you for the opportunity to 
provide testimony regarding National Guard planning and preparations to 
address emerging biological threats.
    It is expected that in the event of a biological incident such as 
pandemic influenza, the entire United States will be affected within a 
matter of days. The impact will likely affect all dimensions of our 
national infrastructure. In addition to actions at the local, State, 
and Federal Government level in a coordinated response to the needs of 
the public it should be noted that private sector resources will be 
expected and needed. Included in a response to a biological incident 
will be the National Guard of each State in concert with the Department 
of Defense (DoD) and other Federal agencies in both a Title 32 and 
Title 10 capacity.

                              INTRODUCTION

    As always by law, the National Guard's primary mission is support 
to local authorities in a domestic crisis. The National Guard is not 
intended to be a first responder or the lead agency for any emergency 
response effort. The National Guard will nevertheless be pro-active in 
providing support through training, preparation and planning. The close 
relationship, in the State of Rhode Island, between the Director of 
Military Support and the Emergency Management Agency through the Rhode 
Island National Guard Joint Operation Center and the State Emergency 
Operation Center under the organization of the Office of the Adjutant 
General facilitates the constant situational awareness required to 
alert and mobilize the National Guard in a timely manner.
    Presently, the Rhode Island National Guard Joint Operation Center 
is minimally staffed for 24/7/365 operation. The State Emergency 
Operation Center is presently staffed during regular business hours 
with a ``call service'' during other hours to key personnel, unless an 
anticipated situation demands that we implement 24-hour staffing. A 
model for merging the capabilities between the two entities to ensure a 
24/7/365 staffing of a single Joint Interagency Coordination Center for 
full situational awareness toward a State-wide common operating picture 
is being prepared for consideration. The limitations of facilities, 
personnel, funding, and statutes impede progress toward this necessary 
organization in support of the Homeland Security domestic response.
    The National Guard Bureau (NGB) and by extension the Rhode Island 
National Guard, is committed to the fundamental principle that each and 
every State and territory must possess ten core capabilities for 
homeland readiness. Amidst the most extensive transformation of our 
Army and Air Forces in decades, the National Guard intends that every 
Governor has each of these ``essential 10'' capabilities:
   A Joint Force Headquarters for command and control;
   A Civil Support Team for chemical, biological, and 
        radiological, nuclear and high-yield explosive (CBRNE) 
        detection;
   Engineering assets;
   Communications capability;
   Ground transportation;
   Aviation;
   Medical capability;
   Security forces;
   Logistics and maintenance capability.

               A RHODE ISLAND NATIONAL GUARD PERSPECTIVE

    The Rhode Island National Guard possesses all of these capabilities 
in the following organization:
   A Joint Force Headquarters for command and control located 
        at the Command Readiness Center in Cranston, Rhode Island under 
        the command of a Brigadier General.
   The Civil Support Team for chemical, biological, and 
        radiological detection, nuclear or high-yield explosive (CBRNE) 
        mission is assigned to the Rhode Island National Guard's 13th 
        Weapons of Mass Destruction (WMD) Civil Support Team (CST) 
        located in Coventry, Rhode Island.
   Engineering assets are provided by the 861st Engineer 
        Company located in East Greenwich, Rhode Island and the 143d 
        Civil Engineering Squadron in North Kingstown, Rhode Island.
   Communications provided by the 281st Combat Communications 
        Group and 282nd Combat Communications Squadron located in North 
        Smithfield, Rhode Island.
   Ground transportation capability is supported by all the 
        organic units of the Rhode Island Army and Air National Guard 
        with HUMMWV and medium truck assets.
   Aviation support is provided by the 143rd Airlift Wing and 
        the 1/126th Army Aviation Battalion located at Quonset Point, 
        Rhode Island.
   Medical capability is limited through the Rhode Island Army 
        National Guard Medical Command, the 143d Air Wing Medical Group 
        and unit assigned medical personnel.
   Security forces are supported by the 43rd Military Police 
        Brigade located in Warwick, the 143d Security Forces Squadron 
        in North Kingstown and through the detail of the Quick Reaction 
        Force.
   Logistics and maintenance capability is supported by the 
        United States Property Book Office located in Providence, Rhode 
        Island and the Combined Support Maintenance Facility, as well 
        as the Forward Support Company of the 1/103d Field Artillery 
        Battalion.
    The primary National Guard asset, in Rhode Island, to assist local 
authorities with their response to a biological incident is the Rhode 
Island National Guard 13th Weapons of Mass Destruction (WMD) Civil 
Support Team (CST). The CST is an operational, State-based, full-time 
unit specifically designed to assist local authorities in the event of 
a chemical, biological, radiological, nuclear or high-yield explosive 
(CBRNE) incident. The team is available 24/7 and located centrally 
within the State at the Coventry Air National Guard Station and is able 
to respond to a request by civil authorities within 60 to 90 minutes. 
The CST maintains a close working relationship with first response 
agencies, including the Hazardous Material Response units in the State 
as well as with the CST units of the other States for assistance.
    In the event of a biological incident, we anticipate that in 
addition to the 13th CST, civil authorities will request personnel, 
transportation and communications support to augment their response 
efforts. Additionally, the CBRNE Enhanced Response Force Package (CERF-
P) and the CBRNE Consequence Management Response Force (CCMRF) are two 
national assets supported by the National Guard and the Department of 
Defense designed to provide regional support for a catastrophic 
homeland event.
    As of July 15, 2008, the assigned strength of the RING was 3,274 
soldiers and airmen (2,107 Army National Guard and 1,167 Air National 
Guard). Mobilizations and training requirements reduce the amount of 
available personnel who are able to support domestic operations.
    As of July 15, 2008, 71 percent (2,327 soldiers and airmen) were 
available to support domestic operations if requested by civil 
authorities. This figure exceeds the threshold goal established by the 
Chief, National Guard Bureau when he ensured Governors that his goal 
was to maintain a minimum of 50 percent of a State's personnel and 
equipment in the State to respond to domestic incidents in support of 
civil authorities. We anticipate that civil authorities will request 
personnel to conduct security, logistics, transportation, and 
communications operations.
    In the planning process, we make the assumption that that 
individuals currently assigned to the RING and working in civilian 
health care, police, emergency medical service and fire professions 
will not be available for mobilization with the Rhode Island National 
Guard. The limited medical assets within the Rhode Island National 
Guard's current force structure will primarily support the medical 
needs of service members activated to conduct domestic support 
operations.
    The current force structure and projected force structure provides 
sufficient resources to conduct security and logistic operations. We 
anticipate that civil authorities will request personnel to man traffic 
control check points and establish area security. Our military police, 
security forces and other units provide the RING with sufficient 
capability to accomplish these operations. Additionally, we anticipate 
that civil authorities will require National Guard support to move 
supplies and manage points of distribution. Current personnel levels 
and the transportation assets described below provide sufficient 
capabilities to conduct these operational tasks.
    The RING maintains a variety of transportation assets which include 
wheeled vehicles, helicopters and fixed wing aircraft. These assets 
provide civil authorities with a capability to move personnel, supplies 
and equipment to critical areas. Additionally, the airstrip at the 
Quonset Air National Guard Base provides civil authorities with an 
alternate port of embarkation/debarkation for resources transiting in 
and out of Rhode Island.
    Communications assets within the RING provide a valuable capability 
to civil authorities. In addition to those assets assigned the 13th 
CST, the Joint Command, Control, Communications, and Computer (J4) 
Coordination Center, which is commonly referred to, as the JCCC is 
located in North Smithfield, Rhode Island. The JCCC is a sub-component 
of the Joint CONUS Communications Support Environment (JCCSE). The JCCC 
assists in maintaining situational awareness, planning, and 
coordination during homeland defense and civil support operations. The 
JCCC serves as a single control agency for the management and direction 
of the joint force command, control, communications, and computer 
systems. Rhode Island also has the capability of another component of 
the JCCSE which is the Joint Incident Site Communications Capability 
(JISCC). The JISCC is a satellite package that can be towed or 
airlifted to an incident site. It contains communications assets that 
can communicate via high-frequency radio, telephone, video and 
satellites to interface a variety of communications equipment used by 
first responders, State, and Federal agencies and can be operational 
within 90 minutes upon arrival at the incident site. Additionally, the 
NGB has the capability to deploy a Joint Enabling Team (JET) to the 
State. JETs assists in the collection, reporting and sharing of 
information in order to identify potential response needs, coordinate 
the response, and facilitate the support requested by civil 
authorities.

                      PARTNERING WITH STAKEHOLDERS

    While the RING has sufficient capabilities to support civil 
authorities in the event of a biological incident or other domestic 
support operation, we recognize the changing nature of the security 
environment. We recognize that gaps may exist between our capabilities 
and those needed by civil authorities. As we identify challenges and 
opportunities we continuously engage our strategic partners. For 
example, in an effort to engage our Emergency Management Assistance 
Compact (EMAC) and other strategic partners within FEMA Region I, we 
recently hosted the Regional Interagency Steering Committee (RISC) 
conference.
    The RING, specifically the 13th CST, is currently partnering across 
all sectors of the State in the areas of planning, training, and 
response thereby increasing the State's ability to respond to incidents 
of national significance. We are currently experiencing tremendous 
success at the second tier response level (State level) and have 
established partnerships with a myriad of State agencies and Federal 
agencies to include:
   RI Emergency Management Agency;
   RI Department of Health;
   RI Department of Environmental Management;
   Rhode Island State Weapons of Mass Destruction Tactical Team 
        (RI-WMD-TT);
   RI regional HAZMAT teams;
   RI regional DECON teams;
   RI HAZMAT Working Group;
   RI Disaster Medical Assistance Team (DMAT);
   RI State Police Fusion Center;
   U.S. Attorney's Office Anti-Terrorism Advisory Council;
   Newport Naval WMD Decontamination Team;
   Boston FBI Office, CBRNE Division, Hazardous Response Team;
   U.S. Army North;
   Northern Command;
   National Guard Bureau;
   FEMA Region I.
    Current examples of joint training conducted with these partners 
include the RING's recent hosting of the Defense Threat Reduction 
Agency (DTRA) CST Radiological Response Course, and the 13th CST 
Advanced Chemical Special Topics Laboratory Scale Preparation of Field 
Expedient and Improvised Chemical Weapons with Hazard Assessment 
Laboratory. In addition, the Rhode Island National Guard conducted 
numerous regional training exercises focused on support to civil 
authorities during which we exercised our collective response 
capabilities to include our National Guard Response Force (NGRF), WMD 
CST, Joint Operations Center (JOC) and Joint Incident Site 
Communication Capability (JISCC). Ongoing initiatives include 
participation in the Ingestion Pathway Response Plan Annual Review, CST 
Critical Facilities Informational Site Packets, the development of 
tabletop and situational training exercises with the Providence Urban 
Area Security Initiative (UASI), Transportation Security Administration 
(TSA), Army North (ARNORTH) and U.S. Northern Command (NORTHCOM). 
Additionally, three out of the four General Officers currently assigned 
to the National Guard are trained and certified as Joint Title 10 and 
Title 32 Task Force Commanders for domestic operations.

                TAG DUTIES, ROLES, AND RESPONSIBILITIES

    The duties, roles, and responsibilities of my position in the State 
create a positive environment for partnerships and cooperation. In 
addition to my duties, roles and responsibilities as The Adjutant 
General of Rhode Island and the Commanding General of the Rhode Island 
National Guard, I also serve as the Homeland Security Advisor for the 
State of Rhode Island and the Director of the Rhode Island Emergency 
Management Agency. This unique management structure provides one focal 
point for the Governor, as well as for the Federal agencies. 
Additionally, it helps to ensure a common direction for all 
stakeholders. Clearly defined goals and objectives facilitate a unity 
of effort, common operating picture and situational awareness.

                               CONCLUSION

    Clearly the Rhode Island National Guard provides the State of Rhode 
Island with robust all-hazard capability as well as for biological 
incidents. All is not perfect to be sure. At the core of capability is 
the need for clearly defined roles, missions, and responsibilities. The 
default for response should not be the National Guard due to a lack of 
capability at the local response level. Therefore, local, State, and 
Federal funding is essential for adequate personnel, equipment, 
training, facilities, and planning. As an operational war fighting 
organization, the Rhode Island National Guard must be properly 
resourced. The Rhode Island National Guard is an operational force. It 
is an all-hazard, full-spectrum force engaged today in combating 
terrorism, war fighting, and domestic support. The Rhode Island 
National Guard needs 100 percent full time manning, 100 percent of TO&E 
equipment, State and Federal support for our military construction 
budget, and full funding of its operational and maintenance budget. 
Consequently, I support the National Governors Association (NGA) letter 
to the Chairman and Ranking Member of the House and Senate Committees 
on Armed Services, which opposes House amendments to the Federal 
Insurrection Act. If enacted as part of the 2009 National Defense 
Authorization Act, these provisions would empower the President to 
order military Reserve components other than the National Guard to 
Title 10 duty for domestic missions, including natural disasters and 
emergencies for which States qualify for Federal funding under the 
Robert T. Stafford Act.
    In closing, planning, preparing, resourcing, and responding to a 
biological threat or other domestic incident is a continual process 
that must adapt to a complex and changing security environment. The 
role and mission of the National Guard under the command and control of 
The Adjutant General with the Governor as Commander-in-Chief, past, 
present, and future is essential to the success of domestic 
preparedness and response. Partnerships and resources at both the State 
and Federal level are vital in our efforts to ensure that we stand 
Ready, Relevant, Reliable, and Accessible in support of civil 
authorities in the event of a biological or other domestic incident.

    Mr. Langevin. Thank you, General Bray, for your testimony.
    The Chair now recognizes Tom Kilday for 5 minutes.

 STATEMENT OF THOMAS J. KILDAY, JR., HOMELAND SECURITY PROGRAM 
       MANAGER, RHODE ISLAND EMERGENCY MANAGEMENT AGENCY

    Mr. Kilday. Thank you, Mr. Chairman, and Members of the 
committee. I want to thank you for inviting me to speak with 
you today to discuss the current successes and on-going 
challenges in planning and preparing for all-hazard events here 
in Rhode Island.
    I need to share with you my dual perspective as a homeland 
security program manager for the Rhode Island Emergency 
Management Agency and a former public health response 
coordinator at the Rhode Island Department of Health.
    The Rhode Island Emergency Management Agency serves as the 
State's primary coordinating agency for State-wide preparedness 
and response to all-hazards events. Prior to 2001, preparedness 
efforts in Rhode Island, as in many other areas of the United 
States, were focused only in the State's Emergency Management 
Agency. Work was limited to the new domestic preparedness grant 
activities and preparing for natural disasters. The events of 
September 11, 2001 followed by the October 2001 anthrax attacks 
catapulted public health into the preparedness arena and forced 
cooperation with emergency managers and other first responders.
    Rhode Island EMA and Health, in coordination with Federal, 
State, and local partner agencies implemented many preparedness 
systems and response capabilities since that time. Rhode 
Island's small geographic size, diverse ideas, lack of county 
government, and close working relationships among government, 
public, and private sectors are some of the key agreements that 
enable Rhode Island to have an effective preparedness planning 
program.
    Rhode Island's EMA is currently working on multiple 
projects including developing situational awareness tools to 
common operating solutions in order to link numerous, disparate 
systems currently utilized in the State into a consolidated 
information hub to facilitate planning and response, building 
the Rhode Island communications network, RISCON, which is a 
border-to-border, 800-megahertz digital radio system designed 
to provide seamless digital voice communications to all 
responders. Most recently, we're in the process of purchasing 
1,400 radios for placement in front line fire, police, and EMS 
vehicles. State-wide continuity of operations planning, 
including the development of State-wide pandemic flu plan in 
cooperation with the Department of Health.
    In addition, Rhode Island EMA participates in Federal, 15 
Federal preparedness grant programs, including the application 
process, development, monitoring, and subgrant support. A 
common grant concept that has fostered interagency cooperation 
has been surge capacity management and planning over the years.
    In Rhode Island the Station Night Club fire served as an 
important event highlighting the need for improved coordination 
and management of surge capacity. In February 2003, the Station 
Night Club in West Warwick, Rhode Island caught fire with an 
estimated 400 persons attending a rock concern. Hundreds were 
sent or self-transported to area hospitals. The fast-moving 
fire caused 100 fatalities, making it the fourth-deadliest fire 
in the United States history at that time. This tragic event 
provided Rhode Island with a real-world mass casualty fatality 
response experience. Since then, the emergency planning 
community in Rhode Island continues to revisit actions and 
lessons learned from this incident and have, to date, 
established procedures and protocols for the activation of 
surge capacity plans, implemented bed tracking, web-based 
software, expanded interoperable communication system within 
the hospital and first responder community, redesigned our 
emergency operation center, expanded the State-wide mutual aid 
plan, established regional mass casual response teams, and 
enhanced the capability of the Rhode Island Disaster Medical 
Assistance Team.
    I want to talk a little bit about DMAT. Rhode Island DMAT 
is a category 1 team of the National Disaster Medical System. 
The team has more than 250 medical professionals and support 
personnel with its Federal cache of medical and logistics 
equipment and is prepared to deploy anywhere in the country 
within 6 hours' notice. The State has acquired a cache of 
medical and logistical equipment that will enable Rhode Island 
DMAT to act as an alternative care site, a stand-alone 
emergency department or a mass immunization and medication 
clinic within the State, even if the team has been deployed 
out-of-State with their Federal cache.
    NDMS recently regionalist DMAT Federal caches and closed 
multiple team warehouses throughout the country, including 
those of Rhode Island DMAT. This move effectively eliminates 
the ability of Rhode Island team to utilize their Federal cache 
to serve their own community during disasters and limits their 
maintenance and training capabilities. This is of special 
concern during a pandemic flu event when State borders may be 
closed and movement of materials is restricted.
    In conclusion, Mr. Chairman, efforts outlined in this 
testimony are just a snapshot of the numerous programs and 
activities designed to enhance the preparedness of Rhode 
Island. I ask for your support in leading congressional efforts 
to increase surge capacity management and response 
capabilities, enhance, interoperability among hospitals and 
first responders, encourage common operating picture solutions 
in place of disparate systems, emphasize the importance of 
developing nontraditional partnerships, and finally, continue 
support for the development of the Disaster Medical Assistance 
Team.
    Additionally, at this time, it is important to also mention 
that multiple grant programs, disparate time lines, numerous 
reporting requirements and a continually changing Federal focus 
detract from our programmatic preparedness efforts. It is 
critical that all Federal preparedness grant programs be more 
closely aligned and coordinated, while locally a larger grant 
management team would be helpful, Federal support, such as 
combining grants, multi-year funding, and alignment of program 
deadlines would allow for much more efficiency.
    Mr. Chairman and Members of the committee, I thank you for 
this opportunity to discuss these important issues with you 
this morning and I'd be happy to answer any questions.
    [The statement of Mr. Kilday follows:]

              Prepared Statement of Thomas J. Kilday, Jr.
                             July 22, 2008

    Mr. Chairman and Members of the committee, my name is Thomas J. 
Kilday, Jr. NREMT-P. I serve as the Homeland Security Program Manager 
for the State of Rhode Island Emergency Management Agency. 
Additionally, I serve as a practicing Paramedic for the Rhode Island 
Disaster Medical Assistance Team. I previously served as the Emergency 
Response Coordinator at the Center for Emergency Preparedness and 
Response, at the Rhode Island Department of Health where I worked on 
public health preparedness activities.
    Since 1999 I have worked in various capacities serving in local, 
State, Federal and international arenas. Most recently, I served as a 
public health preparedness manager who transitioned to working in the 
field of emergency management. This experience provides me with a broad 
perspective on the all-hazards approach to preparedness focusing on the 
collaboration between public health and emergency management, which is 
the focus of this testimony.
    I want to thank you for inviting me to speak with you today to 
discuss the current successes and ongoing challenges in planning and 
preparing for all-hazards events. I am eager to share with you my dual 
perspective as both the Homeland Security Program Manager and a former 
public health preparedness team member for our Nation's smallest State. 
As of today, although the progress made in preparing Rhode Island has 
been significant there is still considerable work that needs to be 
done, and there are challenges both of scope and depth of preparation 
that need to be addressed.

            RHODE ISLAND EMERGENCY MANAGEMENT AGENCY (RIEMA)

    The Rhode Island Emergency Management Agency serves as the State's 
primary coordinating agency for State-wide preparedness and response to 
all-hazards events. Rhode Island Emergency Management is provided 
authority under RI General Law 30-15 to provide the following:
   To reduce vulnerability of people and communities of this 
        State to damage, injury, and loss of life and property 
        resulting from natural or man-made catastrophes, riots, or 
        hostile military or paramilitary action or acts of bio-
        terrorism.
   To authorize and provide for coordination of activities 
        relating to disaster prevention, preparedness, response, and 
        recovery by agencies and officers of this State, and similar 
        State-local, inter-State, Federal-State, and foreign activities 
        in which the State and its political subdivisions may 
        participate .
   To provide the State with the ability to respond rapidly and 
        effectively to potential or actual public health emergencies or 
        disaster emergencies.
    Additionally ``The mission of the Rhode Island Emergency Management 
Agency is to reduce the loss of life and property in natural and man-
made incidents by utilizing an all-hazards approach to prevention, 
preparedness, response and recovery through a program of leadership and 
expertise in comprehensive emergency management while providing 
strategic partnerships, innovative programs, and coordination of State, 
regional and Federal resources.''
    The Emergency Management Agency provides this support to the 
citizens of Rhode Island through the efforts of our 27 employees led by 
its Director Major General Robert T. Bray, Adjutant General, Homeland 
Security Advisor and Executive Director J. David Smith who is 
responsible for day-to-day operations and agency coordination.

                 RHODE ISLAND'S HISTORY OF PREPAREDNESS

    Prior to 2001, preparedness efforts in RI were focused in the 
State's Emergency Management Agency. This work was limited to managing 
the new Domestic Preparedness grant program activities and the 
continuing mission to prepare for natural disasters. The events of 
September 11, 2001, followed by the anthrax attacks in October 2001 
catapulted public health into the preparedness arena and forced 
cooperation with emergency managers and other first responders. The 
Rhode Island Department of Health (HEALTH) was charged with managing 
both the CDC's Bioterrorism Preparedness Program and HRSA's National 
Hospital Bioterrorism Preparedness Program. With the implementation of 
the preparedness grant programs, the State and HEALTH, in coordination 
with Federal, regional, tribal, State, and local partner agencies, have 
implemented many preparedness systems and response capabilities.

                       A CULTURE OF PREPAREDNESS

    The strength of Rhode Island's preparedness efforts rests in the 
ability of the Government, public, and private sectors to organize and 
plan through multiple committees and working groups, all focused on the 
primary goal of preparing Rhode Island for the worst, most probable 
disaster. Rhode Island's small geographic size, diverse culture, lack 
of county government and the close inter-working relationships are the 
key ingredients that enable Rhode Island to have effective preparedness 
planning program. At the core of Rhode Island's preparedness program is 
the Emergency Management Advisory Council (EMAC). Chartered by statute, 
this group advises the Governor on preparedness activities within the 
State. EMAC is co-chaired by the Lieutenant Governor and the Adjutant 
General, who also serves as the Homeland Security Advisor for Rhode 
Island. The group has a total of 30 representatives from all sectors of 
Rhode Island. The challenge encountered with the above described 
committee is ensuring that all partners remain actively engaged in the 
planning process.

                    INTERSTATE REGIONAL COORDINATION

    Rhode Island has a strong relationship with our regional partners 
at many working levels. Given current systems and Government 
structures, these regional activities focus primarily on planning. 
Because no overarching governmental system and therefore, no oversight, 
exists at the regional level, there is great disparity in the types and 
levels of planning that occur at the regional level. Despite this lack 
of oversight, Rhode Island has forged forward to involve other New 
England partners in building relationships and discussing response 
mechanisms.
    Current agency goals pertinent to this testimony include the 
following:
   Development of Situational Awareness (SA) tools and Common 
        Operating Picture (COP) solutions linking the State and local 
        agencies with RI Emergency Management.
   Development of RI State-wide Communications Network (RISCON) 
        which is a border-to-border 800MHz Digital Radio System to 
        provide seamless digital voice communications to all 
        responders.
   Grant management activities including the coordination of 
        more than 15 Federal grant programs and their reporting 
        requirements.
   State-wide continuity of operations (COOP) planning 
        including the development of the State-wide pandemic flu plan 
        in cooperation with the Department of Health.

       SITUATIONAL AWARENESS (SA) COMMON OPERATING PICTURE (COP)

    Rhode Island's small geographic size, coupled with its ample supply 
of critical energy and transportation infrastructure, suggests that the 
State's first responders and public safety community would have 
seamless and discreet interoperable capabilities second to none. Yet, 
our 39 cities and towns, and a number of State agencies have fostered a 
stovepipe mentality with limited guidance for implementation of 
consistent and comprehensive technological systems and policies. To 
date a number of systems both linked and disparate have been created to 
enhance Rhode Island's operability and interoperability within the 
technological environment of day-to-day operations as well as systems 
designed to enhance emergency response capability. Examples include the 
following:
   Hospital Capacity System (HCS);
   Web EOC;
   Port Security Camera System;
   Traffic Management System;
   Mesh Network System.
    Many of these systems serve useful purposes, however; there is 
little integration of the systems currently in use in the State. RIEMA 
is working to link the disparate systems into a consolidated 
information hub to facilitate situational awareness and common 
operating picture for all responders and policy decisionmakers.

        RHODE ISLAND STATE-WIDE COMMUNICATIONS NETWORK (RISCON)
 
   The vision of the RISCON project is to have interoperable 
communications which will enable all public safety and first responder 
agencies to communicate within and across departmental and 
jurisdictional borders. The system is APCO 25 Compliant data capable 
system. The current capabilities of RISCON include 11 sites in the 
Washington County (southern) system and four in the North Providence 
system and five in the Providence system with three in construction 
stage and two in the site assessment stage. Over 2,500 subscriber units 
have been purchased for local, State, and tribal agencies. Radios have 
been purchased for each front line fire, police and EMS vehicle in the 
State. Also, both U.S. Coast Guard Stations in Rhode Island, Capitol 
Police, Regional Teams including the Urban Search & Rescue, Disaster 
Medical Team, HazMat, Decon and Law Enforcement WMD teams and cabinet 
level State agencies just to name a few have equipment and network 
access enabling them to operate on the RISCON network. Current funding 
will allow the system to expand to a total of 19 sites and provide 90+ 
percent coverage State-wide. The total users on the system will 
increase to close to 4,000 by 2009. Additionally, a cache of radios and 
repeaters are being developed.

                 GRANT MANAGEMENT AND FEDERAL REPORTING

    RIEMA currently facilitates numerous grant programs, has an 
established monitoring program and is able to assist sub-grantees with 
questions regarding allocated funds and also with the grant application 
process. Additionally, the agency is required to submit reports to 
Federal agencies describing current programmatic activities.
    As the State Administrative Agency (SAA) to over 15 grant programs 
the small team that is currently managing these funds is not 
sufficient. RIEMA aims to have a more robust grant management team who 
can accurately and fastidiously award and monitor grant funding and 
complete reporting requirements. Presently, we complete a number of 
Federal reports, of which the purpose is not clear. We are told we are 
completing them ``for Congress'', but are unsure if that is actually 
the case. We seldom receive constructive feedback on the reports that 
we submit, which would be helpful in evaluating our efforts and future 
planning. The multiple grant programs, disparate timelines and numerous 
reporting requirements detract from our programmatic preparedness 
efforts. Locally, a larger grant management team would help, but 
Federal support such as combining grants, multi-year funding and 
alignment of program deadlines would allow for much more efficiency.

           CONTINUITY OF OPERATIONS AND PANDEMIC PREPAREDNESS

    Over the past few months, the State of Rhode Island took 
unprecedented steps to enhance our pandemic flu preparedness. In 
response to the Federal Guidance to Assist States in Improving State-
Level Pandemic Influenza Operating Plans, the Rhode Island Emergency 
Management Agency and the Rhode Island Department of Health led a 
collaborative effort to respond to this request for submission.
    Under an unrealistic deadline, new partnerships were forged on the 
State level. Non-traditional partners such as the Department of Labor 
and Training, the Office of the General Treasurer, and the Department 
of Education were included in the planning effort and provided 
important insight on areas of responsibility which allowed them to 
learn more about emergency management. The relationships that were 
created have allowed for further offshoots of preparedness including 
training State workers in Incident Command System (ICS) and a Pandemic 
Flu/Continuity of Operations Working Group with the State's colleges 
and universities. This effort served as an important gap analysis and 
relationship builder. It now allows the State of Rhode Island to target 
our planning efforts to specific areas which will bolster overall State 
preparedness. Additionally, Rhode Island, along with many other States, 
has begun to focus heavily on our ability to provide continuity of 
operations (COOP) during a pandemic influenza event. This process has 
allowed us to produce many COOP plans for our various State government 
agencies and our critical infrastructure areas based on what appears to 
be the worst-case scenario threat of pandemic influenza.
    Despite the successes Rhode Island has enjoyed in State COOP and 
pandemic planning, considerable work needs to be done. The challenges 
include:
    1. Training and Exercising existing COOP and Pandemic Plans.
    2. Limited funding to purchase equipment needed to support COOP and 
        pandemic-related planning for information technology and 
        redundant systems.
    3. Inadequate Department of Homeland Security support for Critical 
        Infrastructure Protection programs as it relates to COOP and 
        Pandemic Preparedness.
    4. Guidance fails to take into account the unique organizational 
        environment found in States like Rhode Island.
    Mr. Chairman, in addition to the responsibilities that my agency is 
involved in, I also feel it is important to mention the following 
preparedness efforts that I have been involved in over the past several 
years.

                     MEDICAL SURGE CAPACITY EFFORTS

    From the beginning of the implementation of the Health Resources 
and Services Administration (HRSA) grant, surge capacity was identified 
as a planning priority. In Rhode Island, the Station Nightclub fire 
served as an important event highlighting the need for improved 
coordination and management of surge capacity and patient management. 
The Station Nightclub in West Warwick, RI caught fire at 11:12 p.m. on 
February 20, 2003 with an estimated 400 persons attending a rock 
concert. The fast-moving fire caused 96 immediate fatalities and 
hundreds were sent to or self-transported to area hospitals. Four 
victims subsequently died in hospitals making it the fourth-deadliest 
fire in United States history.
    The emergency planning community in Rhode Island continues to 
revisit actions and lessons learned from this incident. The response of 
the first responders and hospitals to the incident has provided Rhode 
Island with a real-world exercise of the capabilities of the first-
responder community and hospitals to a mass casualty/fatality event. 
RIEMA and HEALTH have worked with hospitals to establish procedures and 
protocols for the activation of surge capacity plans in the event of a 
similar incident. Over the last 5 years, the hospitals and health 
centers have established and exercised their plans for a surge of 
patients. HEALTH, in conjunction with RIEMA, has established 
notification procedures and communications protocols to activate a Mass 
Casualty Response. The Southern New England Mutual Aid Plan was 
established with support of RIEMA to coordinate a response by first 
responders to intra- and inter-State emergencies. A mutual aid 
agreement amongst all hospitals within the State to share personnel, 
supplies, and equipment during a public health emergency has been 
implemented.
    Pandemic flu planning has necessitated the expansion of hospital 
surge capacity planning to surge management of the entire health care 
system. HEALTH has established health care service regions to allow 
hospitals to facilitate the management of resources within their 
regions and to establish Alternative Care Sites (ACS).

        RHODE ISLAND DISASTER MEDICAL RESPONSE TEAM (RI-1 DMAT)

    The Rhode Island Disaster Medical Assistance Team (RI-1 DMAT) is a 
Category One team of the National Disaster Medical System (NDMS). The 
team consists of more than 250 medical professionals and support 
personnel, supported by a cache of medical and logistical equipment and 
is prepared to deploy anywhere in the country with only 6 hours notice. 
In the event of a Federal deployment of the team, approximately 35 
members would accompany the entire Federal cache for up to 2 weeks, and 
provide medical care to patients without outside support for up to 72 
hours. Until recently nearly all of the team's equipment was Federal 
property and, as such, would not be available for use within the State 
of Rhode Island if the team were deployed. This shortfall in equipment 
would leave the un-deployed 200 members of the team without the 
resources needed to care for patients within the State.
    Through efforts led by Department of Health the State acquired a 
comprehensive cache of medical and logistical equipment that will 
enable RI-1 DMAT to provide care to patients within the State even if 
the team has been deployed out-of-State with their Federal cache. The 
team is also able to deploy its field hospital as an alternative care 
site for a mass casualty incident, or situate it in the proximity of a 
hospital emergency department to care for patient overflow. The 
structure, its equipment and supplies could also be configured to serve 
as a mass immunization or medication distribution facility almost 
anywhere in the State or deployed through the emergency management 
assistance compact to other States. The RI Medical Reserve Corps is a 
Federal initiative which is managed in Rhode Island by the RI DMAT 
team. The addition of this corps of volunteer healthcare providers has 
had a positive impact on the team's ability to manage its mission in 
Rhode Island in the wake of the removal of the RI team's Federal cache 
and the current inability of HHS to enroll new members on the DMAT 
teams.
    Until recently, DMAT category one teams under the National Disaster 
Medical System (NDMS) have been supplied with a cache of logistics and 
medical equipment that they used to support the treatment of the 
victims of disasters in the country. This cache, termed the ``Basic 
Load'', was also available to be used by the teams to serve their local 
communities, and there are many positive examples of this from around 
the country.
    NDMS leadership has recently decided to regionalize DMAT caches & 
close multiple team warehouses throughout the country. The RI DMAT 
cache was relocated to north of Boston at the end of June and their 
warehouse was closed. This move effectively eliminates the ability of 
the Rhode Island team to utilize their cache to serve their own 
community during disasters, and denies them access to the equipment for 
maintenance and training. This is of special concern to State planners 
during a pandemic flu event when State borders are closed and movement 
of materials is restricted.
    While NDMS claims cost savings, in the case of the Rhode Island 
team, there is a GSA lease that will have to be paid for the next 4\1/
2\ years for a now empty building. The total bill to the Government for 
this lease will be more than $700,000, again, for an empty building. 
Apparently GSA will be responsible for the rent, but NDMS will see a 
positive impact on their budget. This development reinforces the 
foresight of Rhode Island in developing and supporting their DMAT 
team's local capability.

                               CONCLUSION

    Efforts outlined in this testimony are just a snapshot of the 
numerous programs and activities designed to enhance the preparedness 
of Rhode Island. There are many agencies and individuals that work hard 
each day to make Rhode Island a safer place to live and work.
    It is important to mention that the ever-increasing number of grant 
programs, reporting requirements and unfunded mandates all require 
considerable planning time and utilization of resources in order to be 
effective. In many cases, these resources are being stretched very 
thin, both at the State and local level. It is critical that all 
Federal preparedness grant programs be more closely aligned and 
coordinated so that we at the State level can more effectively develop 
an appropriate response to whatever emergency may occur.
    Lastly, we cannot discuss local, State and national emergency 
preparedness if we do not discuss the aggressive efforts needed to 
impress upon the American people the need and critical requirement for 
personal and family preparedness. I feel that personal and family 
preparedness is an integral part of the overall preparedness continuum.
    Mr. Chairman and Members of the committee, I thank you for the 
opportunity to discuss these important issues with you this morning and 
would be happy to answer any questions at this time.

    Mr. Langevin. I thank you for your testimony. The Chair now 
recognizes Peter Ginaitt for 5 minutes.

      STATEMENT OF PETER T. GINAITT, DIRECTOR, EMERGENCY 
            PREPAREDNESS, LIFESPAN HOSPITAL NETWORK

    Mr. Ginaitt. Thank you, Mr. Chairman and Members of the 
committee. Thank you for the invitation to be here today. I 
preface my remarks and I want to thank the Federal panel, the 
group that was here. They have made a difference. I will tell 
you, there's been an incredible difference that has been felt 
in the State of Rhode Island and I'm sure across this Nation, 
as well as my partners to the right. Our State agencies, the 
RIEMA and the Guard, have made a tremendous impact on our 
ability to respond.
    I'm here today representing hospitals. Hospitals are our 
lifeline within this country and there are many concerns out 
there, especially when we deal with major events such as 
pandemic influenza.
    Here in Rhode Island, we've strived to develop an 
integrated and coordinated system for the benefit of the public 
health and for the health of our health care system. We have 
worked toward a response to a pandemic influenza which has been 
both enlightening and to a degree somewhat daunting. The 
development of ten health care coordinating service regions in 
the State, through the Department of Health have been 
identified as an effective method of addressing the expected 
influx of patients throughout the State of Rhode Island. These 
hospitals would utilize the hospital incident command system 
and would manage health care within a prescribed region of the 
State. They would each report directly to the Department of 
Health which would be the coordinating entity for all ESFA 
activities.
    In a planning phase for any hazard where a mass casualty 
situation could exist it is imperative that the health care 
system remain functional and that the ability to deliver 
acceptable quality of care to preserve the greatest number of 
lives be preserved. This philosophy is made more challenging 
with the need to allocate scarce resources in a manner that 
will optimize the saving of lives.
    The challenge, however, is the allocation of these 
resources in a fair, open, and transparent way while 
maintaining a safe, infection-free environment for the delivery 
of care. These challenges have been discussed throughout this 
country and a solid understanding seems to be in place. 
Hospitals willingly accept challenges every single day and even 
more so as the impacts of reduced reimbursements affect 
hospitals, increased uncompensated care requirements, impact 
our community hospitals and our daily patient census numbers 
hit record levels.
    Rhode Island Hospital, just last week, had 355 patients 
come through its emergency room in one 24-hour period. That is 
an alarming number to manage. Granted, it's the largest 
hospital within the State and it is a Level 1 trauma system, 
but 355 patients and that is becoming a normal number.
    Hospitals attempt to organize their care through the 
sharing of resources and even attempt to merge operations in a 
further attempt to maintain their high levels of quality care 
through resource-sharing and functioning under economies of 
scale.
    It has been a practice to plan within a facility, but 
further encouraged to integrate these facility level plans into 
regional systems. The systems continue to build their plans 
through an expanded involvement of private and public community 
stakeholders and the need for a unified response continues to 
be stressed, since individual preparedness will stress rapidly 
during a major event. These plans must also be consistent with 
all integrated--integrated into all Federal, State, and local 
plans.
    Rear Admiral Vanderwagen alluded to the intersectoral 
interaction. It is very, very important that we regionalize all 
of our efforts and I feel that in Rhode Island we've done a 
very good job of that.
    Altered standards of care need to also take into 
consideration and recognition that a reduction in the work 
force will further complicate and compound the stresses in 
health care during major events. While identifying the needs of 
hospitals and the expected volumes of patients in both the 
clinical settings within the hospital, as well as the 
activation of an alternate care site, personnel will play a 
major role in the operational successes and/or failures of 
these types of events. It is estimated that staff reductions 
could reach upwards of 50+ percent in the case of pandemic 
influenza.
    This degree of clinical care reduction will further stress 
the actual health care delivery system and will require that we 
operate under different ratios to care for people. The 
expectations for current standards of care, while we strive to 
achieve these expected levels, will most likely be stretched 
during these labor- and care-intensive periods while 
experiencing large staff reductions and increased patient 
numbers.
    Hospitals face daily diversions of patients due to 
increased volumes within their facilities. Managing these 
influxes are extremely complicated while also maintaining the 
quality of care within these facilities. With the addition of 
alternate care sites, it is extremely difficult to predict the 
actual impact that will be felt within the system.
    Hospitals have experienced tragedies in the past and I can 
assure you through planning and professional level of these 
employees, responses have always been effective, well-
coordinated and resulted in good, patient care. However, the 
unexpected event that stresses an entire health care system due 
to sheer volume or resource limitations could be tantamount to 
the proverbial house of cards. I can assure you that readiness 
has been in the past effective. Readiness continues to be 
imperative and again I thank this body for addressing that.
    We must continue to build on these plans, but also the need 
to address the needs of these patients. The simple stockpiling 
of supplies needs to be further addressed by the Federal 
Government. The hospitals simply cannot support stockpiling of 
resources with limited storage as well as limited to no funding 
to support these caches of pandemic and all-hazards supplies. 
If these resources are identified as essential and I support 
that premise, assistance must be given by other agencies to 
purchase and support the delivery during a time of necessity 
and guarantee a timely delivery of the same. We have 
implemented the Chem Packs which is something that was exciting 
to do because we're putting nerve agent antidotes right into 
our backyards now, something the military has enjoyed for 30 
years. But up until the last couple of years we're starting to 
experience that.
    Representative Pascrell, you talked about the increase of 
antivirals. It is important that we have them within hospitals 
and have more than a thousand courses within our hospital while 
we're expected to deal with 150,000 patients in the city of 
Providence alone.
    We must move toward a clear and understandable goal within 
the Federal Government and support that goal with a plan of 
funding and implementation. Funding cycles must be beyond a 
single year and progressive buildout of a system of resources 
and staff support must be clearly delineated. While grant 
funding is essential, working under unrealistic time parameters 
with the hope of an extension or face loss of grant funding is 
all too often counterproductive and often results in quick 
fixes.
    Multi-year funding, while federally problematic to manage 
is the only real answer to build the structural framework for 
system saving response. We clearly understand that the plans 
will always be labeled with the word draft. As I talk to my 
senior management and I tell them our plans are always going to 
say the word draft, but that's because of the world that we're 
in. We're constantly improving our plans so therefore to put 
them back on the shelf and say that they're functionally 
finished and can sit there for 2 or 3 years is the wrong thing 
to do, so we're constantly working to improve.
    We realistically also comprehend that any reliable plan of 
action will take years to appropriately accomplish, but 
building toward those goals through planning and implementation 
is where we will succeed. I believe we are in that direction 
and I have offered my full testimony for the committee and I'm 
open to questions.
    Thank you very much.
    [The statement of Mr. Ginaitt follows:]

                 Prepared Statement of Peter T. Ginaitt
                             July 22, 2008

    Mr. Chairman and Members of the committee, my name is Peter 
Ginaitt, R.N., EMT-Cardiac. I serve as the Director of Emergency 
Preparedness for the Lifespan Health System and recently retired as a 
professional firefighter/EMT with the city of Warwick Fire Department 
after 21 years of service. Also, I served in an elected position as a 
State Representative from District 22 in Warwick for over 16 years 
until retiring from public office to assume my current position at 
Lifespan. My concentrations in public policy were both environmental 
protection and health care.
    I would like to thank you for inviting me to testify today to 
discuss the challenges that lie ahead of health care in preparation for 
the potential of emerging biological threats as well as the need to be 
better prepared for the ``all-hazards'' approach of preparedness within 
the health care community.
    While I would like to report that I feel we as a country are 
sufficiently prepared to handle a major biological outbreak, or even 
further, are ready to handle the influx of victims if a catastrophic 
event were to impact Rhode Island and Southern Massachusetts, I feel I 
cannot report complete success. I do however feel strongly that we have 
made major advancements in our levels of preparedness and are better 
off today then ever in the past.

                                LIFESPAN

    Lifespan, Rhode Island's first health system, was founded in 1994 
by Rhode Island Hospital which includes its pediatric division Hasbro 
Children's Hospital and The Miriam Hospital. A comprehensive, 
integrated, academic health system, today Lifespan partners also 
include Bradley Hospital and Newport Hospital.
    As a not-for-profit organization, Lifespan is overseen by a board 
of volunteer community leaders who are guided by its mission to improve 
the health status of the people it serves in Rhode Island and Southern 
New England. The mission of Lifespan is to improve the health status of 
the people whom we serve in Rhode Island and New England through the 
provision of customer-friendly, geographically accessible and high-
value services. We believe that this can best be accomplished within 
the environment of a comprehensive, integrated, academic health system.
    In September 2007, Lifespan President George Vecchione and senior 
leaders recognized the need to be better prepared for any threat that 
existed. The Office of Emergency Preparedness was developed and an 
emergency preparedness council of CEO's and senior leaders was 
developed. Preparedness within hospitals underwent a paradigm shift and 
emergency preparedness and protection of our facilities to protect the 
delivery of patient care became paramount. Recognizing the need to 
assist and coordinate, the office of emergency preparedness continues 
to develop its role of system support and resource building.
    In my role as Director of Emergency Preparedness, I serve as the 
Principal Investigator for a Hospital Preparedness and Healthcare 
Facilities Emergency Care Partnership Grant through HHS and under the 
Assistant Secretary for Preparedness and Response. The program 
administered will better prepare our State in the event of a disaster 
through the implementation of a robust patient tracking system that 
will track all EMS patients every day from the scene to the hospital, 
this program will be the first of its kind in the United States. The 
need for patient tracking was identified after the Station Nightclub 
fire on Feb. 20, 2003 in West Warwick, Rhode Island where over 400 
people were attending a rock concert. A fast moving fire caused 96 
immediate fatalities and hundreds were sent to or self transported to 
area hospitals. Four victims subsequently died in hospitals making this 
the fourth-deadliest fire in our country's history. The findings were 
referenced in the After Action report assembled by the Titan 
Corporation in the months following that deadly blaze and 
recommendations made for the tracking of patients. The program will 
also develop voice and data communications systems for health care and 
proposed alternate care sites, a current system whose frailties were 
evidenced during and after Hurricane Katrina when communications 
failed. Last, the program will promote Incident Command adoption and 
training to promote better unified responses within the State of Rhode 
Island.
    While pandemic planning continues to actively occur within all of 
the State's hospitals, it does present an ongoing challenge that 
requires constant planning and exercising in this and other areas. They 
continue to be better prepared as the State and Federal Government have 
requested but challenges are frequently discovered. The Lifespan system 
hospitals take particular pride in the planning efforts given to 
prepare for such an even as they work diligently to develop robust 
plans to deal with any ``all-hazard'' event.

                              RHODE ISLAND

    The successes to date in pandemic preparedness in Rhode Island have 
been successful due to the partnerships and working relationships 
within the State and the New England region. As partners here today at 
this very table, I must acknowledge the hard work and efforts on behalf 
of Dr. David Gifford, Director of the Rhode Island Department of 
Health. Dr. Gifford has been challenged with the task of pandemic 
preparedness and with the cooperation of the Center for Emergency 
Preparedness and Response (CEPR) under his leadership, hospitals have 
been provided an incredible amount of support through resource 
allocations and pandemic cache development. On-going subcommittee work 
dealing with all aspects of the pandemic influenza and our State's 
response continue as plans develop.
    Major General Robert T. Bray, the State's Adjutant General and 
State Homeland Security Advisor continues to work diligently in the 
development of plans to respond to catastrophic events within our 
State, including the support for a pandemic outbreak. This agency has 
made tremendous strides toward a robust response within this State to 
an event under an ``all-hazards'' scenario utilizing resources within 
our State military services and emergency management agency.
    And also, Mr. Thomas Kilday, as outlined within his testimony, I am 
sure you will notice that Mr. Kilday has assumed many roles which 
include health care response prior to his emergency management career 
as Homeland Security Program Manager. This broad knowledge provides a 
clear and educated perspective to the very events we are here to 
discuss today.
    In Rhode Island, we have strived to develop an integrated and 
coordinated system for the benefit of the public health and for the 
health our health care system. We have worked toward a response to a 
pandemic response which has been both enlightening and to a degree 
somewhat daunting. The development of ten health care coordinating 
service regions in the State through the Department of Health have been 
identified as an effective method of addressing the expected influx of 
patients throughout the State of Rhode Island. These hospitals would 
utilize the Hospital Incident Command System and would manage health 
care within a prescribed region of the State. They would each report 
directly to the Department of Health which would be the coordinating 
entity for all ESF-8 activities.
    While these regional plans are aggressive and require us to utilize 
all of the health care resources we as a State possess, we clearly 
understand that the scope of response will most likely overwhelm us as 
single facilities. We are better preparing by the use of shared 
resources, but we also recognize that the available on-hand resources 
may not be adequate if the event is as large as predicted. Many of the 
challenges we predict we will experience include:

                            EMERGING ISSUES

    As in any mass casualty, the ability to deliver customary care to 
everyone is just not possible. Hospitals today face increased census 
numbers and the availability of clinical space continues to be a 
challenging issue. Our challenges to these extraordinary situations 
should take into consideration our ability to:
   Be compatible with day-to-day operations;
   Be applicable to a broad spectrum of event types and 
        severities;
   Be flexible through a graded response for the circumstances 
        faced with;
   Be tested, to determine where gaps and improvements are 
        needed.
    In the planning phase for any hazard where a mass casualty 
situation could exist, it is imperative that the health care systems 
remain functional and the ability to deliver acceptable quality of care 
to preserve the greatest number of lives be preserved.
    This philosophy is made more challenging with the need to allocate 
scarce resources in a manner that will optimize the saving of lives. 
The challenge, however, is the allocation of these resources in a fair, 
open and transparent way while maintaining a safe, infection-free 
environment for the delivery of care.
    These challenges have been discussed throughout this country and a 
solid understanding seems to be in place but no real tangible cure to 
this challenge has been offered. Hospitals willingly accept challenges 
every day and even more so as the impacts of reduced reimbursements 
affect hospitals, increased uncompensated care requirements impact our 
community hospitals and our daily patient census numbers hit record 
levels. Hospitals attempt to optimize care through the sharing of 
resources and even attempt to merge operations in a further attempt to 
maintain their high levels of quality care through resource sharing and 
functioning under economies of scale.
    It has been a practice to plan within a facility but further 
encouraged to integrate these facility level plans into regional 
systems. The systems continue to build their plans through an expanded 
involvement of private and public community stakeholders. The need for 
a unified response continues to be stressed since individual 
preparedness will stress rapidly during a major event. These plans must 
also be consistent with and integrated into Federal, State and local 
plans.
    As with any major change in policy or practice, an adequate legal 
framework must be further developed, endorsed and placed into action 
due to the requests placed upon facilities when activating any regional 
plan of care. These should include rapidly instituted executive orders 
declaring a disaster with the enabling language to support altered 
standards of care. These changes either through executive order or 
statutory change must be clear and concise for ease of communication 
and implementation and should further be free of confusion through 
interpretation of meaning. As with any disaster, these directives 
should also take into account the need to accommodate the demands of 
varying sizes of events and should not be primarily based on 
catastrophic levels of need.
    These altered standards of care need to also take into 
consideration that a reduction in the work force will further 
complicate and compound the stresses in health care during major 
events. While identifying the needs of hospitals and the expected 
volumes of patients in both the clinical settings within the hospital 
as well as the activation of an alternative care site, personnel will 
play a major role in the operational successes and/or failures of these 
types of events. Estimates vary around the 50 percent staff reduction 
numbers. This degree of clinical care reduction will further stress the 
actual health care delivery system and will require that we operate 
under different ratios to care for people. The expectation for current 
standards of care, while we will strive to achieve these expected 
levels, will most likely be during these labor and care intensive 
periods while experience large staff reductions and increased patient 
numbers.
    Hospitals face daily diversion of patients due to increased volumes 
within their facilities. Managing these influxes are extremely 
complicated while also maintaining the quality of care within each 
facility. With the addition of alternate care sites, it is extremely 
difficult to predict the actual impact that will be felt within the 
system. While the State has adopted a memorandum of understanding 
between all hospitals to share staff and resources, a State-wide or 
regional event would render that agreement useless, not to mention that 
the capacities of these other hospitals are already stressed with their 
own patient census.
    Hospitals have experienced tragedies in the past and through 
planning and a professional level of employees, responses have always 
been effective, well-coordinated and resulted in good patient care. 
However, the unexpected event that stresses an entire health care 
system do to sheer volume or resource limitations could be tantamount 
to the proverbial ``house of cards''.
    We must continue to build on these plans but also the need to 
address the needs of these patients. The simple stockpiling of supplies 
needs to be further addressed by the Federal Government. The hospitals 
simply cannot support major stockpiling of resources with limited 
storage as well as limited to no funding to support these caches of 
pandemic and all-hazards supplies. If these resources are identified as 
essential, and I support that premise, assistance must be given by 
other agencies to purchase and support their delivery during a time of 
necessity and guarantee timely delivery of the same. The following 
continue to make planning problematic and they remain outstanding 
challenges.
    We must move toward a clear and understandable goal within the 
Federal Government and support that goal with a plan of funding and 
implementation. Funding cycles must be beyond a single year and 
progressive build-out of a system of resource and staff support must be 
clearly delineated. While grant funding is essential, working under 
unrealistic time parameters with a hope of an extension or face loss of 
grant funding is all-too-often counter-productive and often results in 
quick fixes. Multi-year funding, while federally problematic to manage, 
is the only real answer to building the structural framework for a 
system saving response. We clearly understand that the plans will 
always be labeled with the word ``draft'' since it will be a constantly 
improving tool. We realistically also comprehend that any reliable plan 
of action will take years to appropriately accomplish but building 
toward those goals through planning and implementation is where we will 
succeed.
    Beyond funding, I would further recommend that the Federal 
Government establish a smaller department within HHS or DHS to provide 
hands-on technical support in each of the States and regions that have 
realistic and attainable goals. I am not suggesting that this be the 
solution, but any interaction beyond paid consultants will be 
beneficial. Hospitals will respond well to systematic integration into 
a well-formatted structure of needs. I see the need to have designated 
Federal directors assisting the State governments and health care with 
the guidance necessary to achieve our goals and objectives. I further 
see the need for regular interaction with all regional partners while 
these systems further develop. I understand that this is currently 
being performed but see the need to better organize and deal with the 
``All-Hazards'' response.
    As stated earlier in this testimony, I feel strongly that the 
Federal, State and local plans and responses are better than ever 
before. Hospitals State-wide are better prepared and truly understand 
the impact that could face them if a major event ever occurred. It is 
further reinforced by The Joint Commission who accredits these 
facilities through recurring surveys and new standards currently placed 
in the survey tool. These new standards in place require increased 
readiness compliance in 2008 and expected newer standards for January 
2009 will only strengthen hospitals' preparedness and overall 
responses.
    Please accept my thanks for the opportunity to present this 
testimony before this subcommittee and I remain available for 
questions.

    Mr. Langevin. Very good. Thank you, Mr. Ginaitt. With that, 
I want to thank the panel for all of their individual 
testimonies and we look forward to learning more on the full 
testimony that you submitted for the record, but I just want to 
remind Members we'll each have 5 minutes for questions and I'll 
recognize myself for 5 minutes.
    Dr. Gifford, let me start with you. With respect to public 
health preparedness, being able to monitor day-to-day 
activities and to obviously be well aware of emerging threats 
that are actually occurring, in your opinion has bioterrorism 
preparedness been integrated with pandemic influenza 
preparedness and how have you been able to integrate these 
activities into the existing framework in Rhode Island for 
public health emergencies that occur more frequently or 
currently. Can you give us a few examples of how you've done 
that here in Rhode Island?
    Dr. Gifford. I applaud, Mr. Chairman, your desire to try to 
get us to integrate things in our daily activities and that 
includes the theme of my presentation.
    We have utilized some of the emergency preparedness 
funding, as many States, to implement what's called the ROD 
system which is a real time monitoring of diseases in the 
emergency room. So we actually have a--as individuals are 
registered in the emergency room for symptoms, we get actually 
a real-time alert into a database. We actually have an 
algorithm that screens that and looks for outlying events. When 
we see a certain number of people coming in with respiratory 
illness or high fever or diarrhea or some different symptoms, 
it triggers us an alert. We look at the individuals to see if 
they clustered by zip code. We look to see if they cluster by 
town, gender, any aspects. We contact the hospitals and begin 
to do a very quick investigation. I would say we get alerts 
about every other day. It's diminishing as we build the 
database and you get a better sense as to where they are, but 
that helps us look at what's going on out there.
    Some of that has actually helped us, in general public 
health activities, identifying outbreaks of strep throat or 
anything, a certain school district, so I think it not only 
helps us from a biosurveillance standpoint, but it helps us 
with our day-to-day activities.
    We have currently for influenza we have sentinel physicians 
that during the influenza season they report to us on the 
number of people they're seeing that have influenza-like 
illness and we're able to track and see when we need to put 
alerts out to think about using antivirals or boosting up the 
immunization rates as well as testing in our lab to see what 
the strains are--did they match with the vaccines or not?
    Those are some efforts that we have done. We can clearly do 
a lot more. I mean with the advent of technology and health 
information exchanges, we should be able to have a much better 
surveillance process that's out there. Currently all the labs 
report any incidents of any--about 85 different diseases. If 
they culture any of it, it gets reported to us. Certainly all 
the bioterrorism events are in that list, but we need a better 
system for symptoms early on. I think as you heard from the 
previous panel the exposure to these types of agents will not 
manifest symptoms for anywhere from a few hours to several 
days. It could be spread out and as we get the data 
electronically, to be able to monitor that it will not only 
help us with that bioterrorism, but will also help us in our 
day-to-day activities as we go on.
    Mr. Langevin. I couldn't agree more and the further out we 
can push this in terms of being aware of an emerging threat 
actually manifesting itself, the better we will be able to 
respond.
    Let me turn to you, Peter, on surge. You talked about that. 
What are the hospital system's plans for surge in the event we 
are overwhelmed?--and I recognize that on any good day a 
hospital system, the emergency room, in particular, can easily 
be overwhelmed with large numbers of patients, even just an 
average flu season.
    What are we doing in terms of being prepared for the 
potential of thousands of people coming down with an illness, 
whether man-made or natural disaster, and showing up at our 
hospitals? I'm not talking about just a couple of hundred, I'm 
talking about what if it were to occur in a thousand? How are 
we going to deal with this? What are the contingency plans that 
you're aware of in place and I also want to ask where the 
majority of extra hospital supplies, where are they being 
stored and are they being vendor-managed and do you think that 
they should remain at this location or at the hospitals 
themselves?
    Mr. Ginaitt. Mr. Chairman, bear in mind we started to deal 
with surge capacity back several years ago with the Department 
of Health and with the Federal Government in our level of 
preparedness and for the surge of people over and above our 
normal, daily census. We're experiencing surge every day now. 
We are actually actively going within surge capacity areas 
drawing down on expanded places to give clinical care that 
normally aren't being used and that's again a daunting task 
when it comes to personnel issues and it comes to physical 
space issues.
    We were challenged several years ago to increase our 
ability of surge for 500 people within 1 hour and we did that 
very effectively. In the case of Rhode Island Hospital we 
altered our surge capacity plan and identified 196 openings 
within 1 hour that we could surge people into. Bear in mind 
that means that we're not at capacity, that we're not drawing 
down on those surge numbers and that we're able to effectively 
deliver the same level of clinical care that's expected.
    It's interesting, as I travel around the country and I hear 
from other hospitals that have surge capacity plans and they're 
very proud of the fact that they can take an additional 25 
people in and I sit there and I look at the grand scene of what 
a major event could do to this nature and I break out into a 
cold sweat as far as where our pandemic plans are going. That's 
why I'd like to really stress the all hazards. While we do talk 
about pandemic influenza and we reference the 1918 pandemic 
outbreak, I think our biggest threat is going to be from 
something that will be--that will fall into the all-hazards.
    Hospitals around the State have individually addressed 
their surge capacity plans and have acknowledged that they 
needed to build out additional resources. Call-back, we have a 
new emergency notification system, thanks to the Department of 
Health and Federal granting and our Hospital Association of 
Rhode Island for rapid call-back of staff so that we can put 
surge capacity areas into action.
    So we're working very well with the increase, the influx of 
people, whether it's into the thousands is another issue. 
That's when we fall into an alternative care site. That's where 
we're challenged with taking our in-house current staff and 
deploying many of them into a free-standing alternative that in 
many cases could be a school, could be a convention center and 
dealing with those, the actual establishment of an alternative 
care site is not all that difficult. The concept of a 
freestanding hospital, but manning it, being able to deliver 
care. Being able to run laboratory tests, manage reports, 
manage the transfer of patients is the daunting task and again, 
I credit the Department of Health for having an on-going ad hoc 
committee through the hospital association also and identifying 
these scarce resources and our needs.
    We continue to work on that. I feel good about it. I cringe 
a little bit about the word thousands, but it is something that 
we're working toward.
    Your second question: What is the management of supplies? 
We've received tremendous number of supplies over the course of 
the last few years to deal with hazardous materials and 
decontamination. A lot of training. We do manage and do vendor 
management to the best of our ability when we can do that. I 
reference the fact that I have several hundred thousand doses 
of ciprovoxin and doxycycline. We can't get rid of enough 
doxycycline when you have 120,000 courses. We don't use it 
enough. Luckily, it's a very inexpensive drug. So we try to--
many of the products that are costly, we try to do as much VMI 
as we possibly can.
    Mr. Langevin. Thank you. With that, I now recognize the 
gentlelady from the Virgin Islands, Congresswoman Christensen 
for 5 minutes.
    Mrs. Christensen. Thank you, Mr. Chairman, and good 
morning, and thank you for being here.
    General Bray, I am in awe of how you manage four different 
responsibilities, especially looking at how you direct the 
local authority which is RIEMA and then the support authority, 
the Guard, and how you keep those two operational and separate 
is amazing.
    I wanted to ask a question about the--your ability to--your 
local response capacity. You say you're at 71 percent strength 
as of July 15. The National Guard has set a standard of at 
least 50 percent and you don't plan to call up your police, 
your fire, your first responders if an event occurs that is a 
disaster. Without calling up your first responders, can you be 
at 50 percent strength?
    Gen. Bray. Thank you for the question and I wear many hats. 
We have a system, a tiered system of responsibilities and I 
delegate a great deal of those authorities down to my 
subordinates who are very competent. Let me just say again, the 
Rhode Island National Guard is not the first responder in any 
event.
    Mrs. Christensen. Right.
    Gen. Bray. So the first-tier response is always the first 
response agencies, law enforcement, fire, emergency medical 
services. So they will usually almost always be deployed prior 
to the National Guard being called upon and then subsequently 
deploying within the State as well.
    So we will always augment those first responders in the 
event of an incident.
    The civil support team has a very close relationship and is 
probably more likely to be deployed in a case of a biological 
incident prior to the need for the total mobilization of the 
Rhode Island National Guard, both Air and Army. So again, in a 
tiered-level of response, we feel that we are more than able to 
support any needs of the State.
    Now I will tell you, that goes beyond that. We have the 
Emergency Management Compact with the other States. We also 
have a close regional relationship with the bordering States, 
and then we have several other capabilities at the national 
level that will augment the Rhode Island National Guard should 
not only its personnel assets be exceeded or close to being 
exceeded, but any other capability that might become a 
shortfall. So on a regular basis and I mean daily, my staff 
through our joint operations center senses that level of 
capability in the State and whether or not we need to use those 
other assets to support us.
    Mrs. Christensen. Thank you. Mr. Kilday, stovepiping is not 
unique to Rhode Island as I'm sure you have heard from some of 
us. How long has RIEMA been working to integrate across 
agencies and what are some of the barriers and when do you 
think it will be accomplished?
    Mr. Kilday. Over my years in the preparedness business here 
in Rhode Island, I think very early on we recognized that there 
was a great deal of stovepiping within agencies. It used to be 
called turf and I found over my experience over the years 
people have recognized that preparedness is important, that 
they need to put aside those turf issues and work on 
preparedness. It's about buy-in from the highest level down and 
I think we've achieved that.
    Unfortunately, we've achieved that at some level because of 
some of the tragedies we've had in the State and some that 
we've experienced nationally. It's unfortunate that it takes 
that level of experience to create that buy-in.
    I think in the State of Rhode Island what we've done is 
recognize the small size of our State, our limited resources 
and capabilities and forced a basis for regionalization. Most 
of our capabilities, recognizing that one department or one 
agency may be limited. We've regionalized those capabilities, 
whether it be hazmat and decontamination teams, whether it be 
urban search and rescue capabilities or the DMAT team.
    We've focused these regional capabilities in linking with 
emergency management and reaching out to these other agencies, 
whether they be Department of Ed., Department of Labor, 
training.
    Mrs. Christensen. Is it working?
    Mr. Kilday. I believe it is, ma'am.
    Mrs. Christensen. Thank you. Dr. Gifford, I'm very 
impressed with what you've been able to do based on your 
written and your oral testimony and if we were to consider what 
we have heard from you today, we probably wouldn't increase any 
public funding for public health because you've done so well, 
but as you interact with your counterparts across the country 
are you hearing the same kinds of success stories or are you 
hearing the need for more Federal funding?--and Director 
Ginaitt, the same thing with respect to hospitals. I get the 
sense that maybe public health funding is--it's not adequate, a 
little closer to where it needs to be, but hospital funding for 
preparedness is not. So if both of you could answer that.
    Mr. Kilday. Well, I think it is always a shame when you 
reward success by cutting funding.
    Mrs. Christensen. We're not going to cut it.
    Mr. Kilday. As you know from your public health background, 
the greatest threat in public health is that when we start 
making progress and we refocus elsewhere, we see many illness 
reemerge. We've seen syphilis. We've seen TB come back in this 
country, when we thought we were making progress on it because 
we said we were doing so well, now let's focus somewhere else.
    So I think that that is really, if we haven't learned from 
history and we keep making the same mistakes, I would say shame 
on us. I think that really applies to emergency preparedness.
    I think we run the risk of saying okay, we planned for 
pandemic. We stockpiled for it and we planned for bioterrorist 
agents, okay, a new agent, we'll get ready for that. Then we 
call it a day. I think that really underestimates the value 
that this has had. While many of the events that we've had to 
respond to, we had to respond to before 9/11, before anthrax, 
we are now much better, we're better integrated with EMA. We're 
better integrated with other agencies and we are much more 
effective and efficient, frankly, at responding to those events 
because of the emergency preparedness in those other areas.
    I think that's what we're seeing across the country is the 
whole incident command structure was foreign to the public 
health sector until the emergency preparedness funds. Now you 
have almost every State has been certified through the NIMS 
system and ICS now utilizes it and while we used to respond to 
disease outbreaks, infectious disease outbreaks with NICS, we 
did okay. We're now much more effective because of that.
    Now it also is clear that you need to integrate this to 
train and support this and as I think Mr. Ginaitt recognized by 
acknowledging that these plans are drafts, you need to always 
be revising and continually planning your drafts. So I think 
that there's a real need for it. As I meet with the other 
health directors, as I've talked with them, I think you'll see 
in my written testimony the many examples. Each of those 
examples was not something that was directly related to prior 
event, but it exercised a capacity or capability that was 
directly related to pandemic flu and elsewhere. I will tell you 
the first few times we stood up ICS in our department, it was 
disastrous and you heard about people losing sleep, I lost 
sleep saying oh my, if we had really had a pandemic, we're not 
ready. That's why we lowered the threshold and utilized ICS at 
a very low threshold in the department because we now have 
everyone trained in ICS. One hundred percent of the staff were 
trained in ICS. We utilize it all the time because we don't 
know who is going to be sick and absent. I mean we had a 
mycoplasma outbreak and I was on vacation in the Grand Canyon. 
I ended up flying back here, but we utilized a lot of the 
different aspects of it. But I think you need to have that 
training and that on-going funding. My concern, I think I have 
it in written testimony is you see a trending of the funding 
going down and I think that that puts us at jeopardy of 
watching some of the disease outbreaks coming back. So that's 
the same story I hear.
    All of us like to think we're unique. All of us have sicker 
patients. All of us have more problems, but I will tell you, 
everyone across the country whether it be California or Rhode 
Island or the Virgin Islands or Hawaiian Islands, we all have 
the same issues and concerns and I think really would benefit 
from it. So I would hate to see us declare victory and go home 
in this. I think we need, this is now a new way of responding, 
not just to the threats, but to our day-to-day activities.
    Mr. Langevin. Please be brief as possible, Peter.
    Mr. Ginaitt. Absolutely, Mr. Chairman. Hospitals are 
stressed. With all due respect, we do receive as much money as 
we can. We're very grateful for the grant funding that we do 
receive through the Federal Government and through the State, 
however, we're faced with daily challenges in hospitals. 
Emergency management is a new tool. As we all remember in 
emergency management agency not that many years ago was called 
civil defense and they bagged rivers when they were 
overflowing. Now it's taken on a whole new meaning in this 
Nation. Hospitals are taking it very, very seriously and we're 
trying to deal with what funds we do have. We're grateful for 
any of the funding that comes in. As an example, Rhode Island 
Hospital is a recipient of one of the ASPR grants, one of the 
five partnership grants to develop a patient tracking module 
that can be used as a model throughout this Nation, as well as 
a communication so that we can have sustainable communications 
as we saw fail down in Louisiana after Hurricane Katrina. We do 
try to manage those. We do try to take what money we can. It is 
difficult at best. We will make anything work that heads our 
way. However, we do need some, I think, some larger plans, 
larger plans of attack with some grant funding that we can look 
at through multi-year implementation.
    Again, we're willing to work with our partners. We've done 
a great job, but we also understand we have a daunting task 
ahead of us.
    Mrs. Christensen. Mr. Chairman, I'm going to probably leave 
at this point so I want to thank you at this time for inviting 
me to the hearing and for the opportunity to be here and be a 
part of this.
    Mr. Langevin. I'll see you tonight in Washington. Thank you 
for your questions.
    The Chair now recognizes the gentleman from New Jersey, Mr. 
Pascrell, 5 minutes.
    Mr. Pascrell. Thank you, Mr. Chairman. Mr. Ginaitt, you 
talked about the hospital stress. Hospitals are closing and if 
we're planning for huge service necessities, it would seem that 
that's not a very good idea. But they close not because they 
want to. They close because they don't--they can't pay their 
bills. I'm sure that you've had closings in Rhode Island. So 
that space, where the hospital sold it to some other entity or 
not, that space could be much more valuable down the line and I 
hope you've given thought to that.
    Mr. Ginaitt. Representative, we have. Every morning I drive 
down Warwick Avenue actually Representative Langevin's previous 
legislative district and I drive by a Wal-Mart--not a Wal-Mart, 
a drug store that formerly was a small community hospital that 
no longer exists and it's disheartening to see what is actually 
happening, the fleecing of the health care within the United 
States and hospitals trying to sustain themselves through poor 
economic times.
    It is cyclical and we see that, but many of the smaller 
community hospitals really do depend on those communities and 
those communities depend on them. Trying to operate a major 
initiative and controlling and being ready for emergency 
preparedness while you're trying to pay for the very people 
that keep the doors open in that hospital, again is a daunting 
task.
    Mr. Pascrell. Has anyone from the Homeland Security 
Department ever reached out to you personally?
    Mr. Ginaitt. No, other than through Homeland Security--
actually grants that we've dealt with, or the local. I will 
say----
    Mr. Pascrell. So no one has reached out to you?
    Mr. Ginaitt. Directly, no.
    Mr. Pascrell. How about you, Mr. Kilday?
    Mr. Kilday. We speak to the Homeland Security folks daily.
    Mr. Pascrell. I'm sorry?
    Mr. Kilday. We work very closely with Homeland Security 
from the Fed side on a daily basis for grant programs and other 
activities.
    Mr. Pascrell. Do you get the sense that they're attempting 
a bottom-up kind of situation which is remove ourselves from 
what we're doing 5, 6 years ago to now? You don't have that 
feeling, do you?
    Mr. Kilday. We've seen in the organization of DHS it's 
shifted, clearly as was talked about earlier in the previous 
panel over the years and we've seen from the top-down and now 
we are working with the regional focus where the regional 
planners are out in the community working with us out of FEMA 
Region 1 specifically, although we are concerned that the 
system will flex and change again and it takes a great deal of 
staff time to flex with them and it takes away from program 
activities.
    Mr. Pascrell. Dr. Gifford.
    Dr. Gifford. Most of our dealings are with the various 
agencies within HHS, but we do do some with DHS. They've 
reached out to----
    Mr. Pascrell. I didn't ask you who you dealt with. I asked 
you do they reach out to you?
    Dr. Gifford. Yes. They've reached out to both me and my 
staff. As we go forward, I would say there's been an evolution 
over time from more of a top-down to much more of a partnership 
activity. I think one would not want to see the pendulum swing 
from either top-down or bottom-up. I think a partnership where 
there's a co-working is better. I think as alluded to in the 
previous panel, things have gotten better. Could they continue 
to improve? I think we can always continue to strive to improve 
and make it better.
    Mr. Pascrell. All right.
    Mr. Ginaitt. Representative, I just want to give some 
clarification in my response. We do deal directly with our 
State emergency management agency which are the program 
managers for the Department of Health, Department of Homeland 
Security, so we have been able to work very, very successfully 
with the Emergency Notification System, the event calendar. We 
have a tremendous number of things within our hospitals which 
is directly related to Department of Homeland Security through 
our State-wide providers.
    Mr. Pascrell. Thank you. General Bray, you said you're at 
71 percent capacity, if I heard you correctly.
    Gen. Bray. Correct, sir.
    Mr. Pascrell. How many guardsmen do you have?
    Gen. Bray. We have just over 3,200. It varies on any given 
day.
    Mr. Pascrell. How many are deployed?
    Gen. Bray. At the present time we have approximately 350. 
Again, it varies every day. We try to maintain no more than 
about 500 at any given time deployed both air and Army, but 
again, depending on the mission, it varies on a regular basis.
    Mr. Pascrell. Not every State has incorporated the National 
Guard as you have here in Rhode Island into the emergency 
management scheme. To what extent have you done that in Rhode 
Island? Can you just briefly talk about that?
    Gen. Bray. What we have attempted to do is build on the 
relationship that the Rhode Island National Guard and Emergency 
Management have had for some time. Rhode Island is very unique 
in that there is no county government and so the default many 
times from the local is directly to the State and oftentimes 
the Rhode Island National Guard as well as the health 
department becomes the next stop for the first responder. So it 
has become absolutely essential that that relationship take 
place on a regular basis.
    So on a daily basis we have, as I mentioned, a joint 
operation center staffed 24/7 by the military and on the other 
side of my headquarters the State emergency operations center 
which we have a 24/7 capability, but only staffed during 
regular working hours and then a call waiting system after 
that. My attempt is to merge that capability into one standing 
joint interagency coordination center which I've been in 
discussion with for a concept of operations with the National 
Guard and try to work through the Title 32 issues that--and for 
that matter the labor issues on the State side that apply in 
that capability. That intent there is to give us full 
situational awareness, develop a common operating picture so 
that we can put critical assets at critical needs when we need 
them, as opposed to reacting to situations that might develop.
    Mr. Pascrell. Can you send me a summary of that operation? 
I'm interested in that.
    Gen. Bray. Yes, sir. I would just add that we have a great 
collaboration within the region and also amongst the Adjutant 
Generals, many of whom have the same dual hat capability that I 
have to discuss these very matters. General Tim Lowenberg, the 
Adjutant General for the State of Washington leads the 
Governor's Homeland Security Advisory Council and is the lead 
for much of that discussion. So a great deal of collaboration 
takes place on a daily basis.
    Mr. Pascrell. Thank you for your service to your country, 
as all the gentlemen. Thank you for your service to Rhode 
Island and the country, not just Rhode Island.
    Mr. Langevin. I thank the gentleman. One final question 
that I will pose to you, Mr. Kilday, since we're talking about 
getting beyond getting ready and actually being prepared, have 
the plans Rhode Island EMA produced been adequately tested and 
evaluated? If so, how and if not, why not?
    Mr. Kilday. Rhode Island maintains a comprehensive exercise 
program that involves the local agencies as well as a number of 
State agencies. We have a very small staff. We have a single 
individual who manages our exercise program and they receive 
support from other staff within the agency. Some of the 
challenges are the requirements under the homeland security 
exercise and evaluation program are quite arduous and the task 
of completing after action reviews as well as other plans and 
responses to preparedness.
    I think that we have done a really good job with exercise 
activities in the State in spite of our limited staff and 
capability and I owe this to the local resources, specifically 
the 39 local communities who often through their emergency 
management programs which are either paid, volunteer, or are 
part-time in some manner step to the plate, participate in the 
exercise programs and support emergency management in our 
efforts by participating in these exercises.
    I think we could have a more robust exercise program and 
hope to do that some day within the agency, but currently based 
on funding, staff requirements, caps on hiring, we do not have 
that.
    Mr. Langevin. With that, I do want to thank all of you for 
your testimony. I want to thank you for your service to the 
State, to the country. The issue of emerging biological threats 
is something we all take very seriously. It's a daunting task 
to try to protect our citizens from every contingency. We 
recognize perhaps that is not entirely possible, but to have 
plans in place and a robust system of prevention, detection and 
response is really the best strategy. Oversight sometimes is 
obviously, it is difficult, painful sometimes for those on the 
other side of the table to go through, but it's an important 
part of being able to evaluate where we are and where we want 
to get to. So I'm encouraged by what I've heard here today from 
the things that Rhode Island is doing and perhaps because we 
benefit always from being a small State, perhaps it's easier to 
coordinate and I hope that what we're doing right here in the 
State can serve as an example of what the rest of the country 
can and should do to better protect the rest of our citizens.
    Thank you all for your efforts and we stand ready to work 
with you as we go forward in trying to better protect the 
country from emerging biological threats and making sure that 
we have the most robust, strongest system of public health 
preparedness. So with that again I want to thank you all for 
your testimony and your valuable insights that you've given us 
today. Clearly, there are great challenges ahead. We're not 
there yet and more work needs to be done, but thank you for the 
work that you're doing.
    With that, I want to thank you again, the witnesses, for 
the valuable testimony, the Members for their questions. The 
Members of the subcommittee may have additional questions for 
the witnesses and we ask that you respond expeditiously in 
writing to those questions.
    Hearing no further business, this subcommittee stands 
adjourned.
    [Whereupon, at 1:04 p.m., the subcommittee was adjourned.]


                            A P P E N D I X

                              ----------                              

  Questions From Chairman James R. Langevin to Dr. Jeffrey W. Runge, 
   Assistant Secretary for Health Affairs and Chief Medical Officer, 
                    Department of Homeland Security

    Question 1. We know that you have considered the possibility and 
impact of bioterrorism and an event such as pandemic influenza 
occurring simultaneously or one right after another. This being the 
case, some have suggested that medical and public health resources 
should be held in reserve to address additional events. Do you think 
this is even possible? How do you believe the multiplicative threat can 
and should be handled?
    Answer. In the Department's planning and preparedness efforts, we 
have considered the potential impacts of both multiple and/or 
simultaneous bioterrorism attacks and other catastrophic events. The 
Department participates with its interagency, State and local partners 
in the annual TOPOFF national-level exercises, which specifically 
incorporate scenarios where multiple and/or simultaneous events occur. 
In this year's TOPOFF-4 exercise, Federal, State and local officials 
responded to three simultaneous Radiological Dispersal Device (RDD), or 
``dirty bomb'' attacks, causing casualties and wide-spread 
contamination in Guam and two U.S. cities. Given that virtually any 
catastrophic event will almost certainly include medical and public 
health consequences, we agree that medical and public health resources 
should be held in reserve in the event that there are multiple and/or 
simultaneous emergencies. The Department of Health and Human Services 
(HHS) serves as the lead Federal entity for Emergency Support Function 
8, Public Health and Medical Services: ``Public Health and Medical 
Services provides the mechanism for coordinated Federal assistance to 
supplement State, tribal, and local resources in response to a public 
health and medical disaster, potential or actual incidents requiring a 
coordinated Federal response, and/or during a developing potential 
health and medical emergency.''\1\ Under ESF-8, HHS serves as the lead 
Federal partner in ensuring that the Nation is maintaining appropriate 
levels of medical surge capacity, which is a critical element of our 
national, State and local resiliency. The Strategic National Stockpile 
(SNS), which is managed and overseen by HHS, is an example of 
maintaining a national stockpile, or reserve, of medical and public 
health resources. HHS also oversees the Medical Reserve Corps, the 
National Disaster Medical System, and other critical medical and public 
health resources that can and are activated during catastrophic events. 
DHS/OHA supports HHS's work with State and local governments to 
maintain their enhanced medical surge capacity. There are a number of 
ways to mitigate the risk of catastrophic outcomes resulting from 
multiple and/or simultaneous biological events, including maintaining a 
strong and well-trained cadre of medical first responders, developing 
and exercising well-coordinated plans and mutual-aid agreements among 
Federal, State and local governments, and establishing rapid 
distribution and deployment strategies of medical countermeasures.
---------------------------------------------------------------------------
    \1\ Emergency Support Function (ESF) 8: Public Health and Medical 
Services; National Response Framework; January 2008.
---------------------------------------------------------------------------
    Question 2. Please provide information regarding the increased 
efforts of Customs and Border Protection regarding identifying sick 
persons crossing the U.S. borders, and sending them to secondary 
screening.
    Looking back on your time with the Department, starting out with 
only yourself as Chief Medical Officer, and then growing the Office of 
Health Affairs to the larger entity it is now, tell us what you have 
learned and what you would have done differently in terms of helping 
the Nation to prepare for emerging biological threats. What advice do 
you have for your own Deputy, Dr. John Krohmer, who will be heading the 
Office of Health Affairs through the transition to the new 
administration, and for others that will be countering these threats?
    Answer. As was described during the hearings last summer regarding 
the procedures of CBP in the management of sick persons at borders and 
ports-of-entry, the policies, legal authorities, and spirit of 
cooperation between CBP and the Centers for Disease Control (Division 
of Global Migration and Quarantine) are well-developed, supportive, and 
appropriate. There were procedural issues, however, that produced sub-
optimal results. Specifically with regard to screening procedures 
regarding anyone identified as being a possible public health concern, 
CBP procedures and computerized screening support systems were modified 
to require that anyone so identified at primary screening must be 
referred to secondary screening for resolution of the issue. Using 
well-established procedures, CBP works jointly with health authorities, 
including CDC and the DHS Office of Health Affairs to get medically 
valid advice regarding the health status of the individual in order to 
reach a medically and legally valid determination on both admissibility 
and any necessary medical/public health requirements.
    Even prior to the incident of last summer, through a series of 
interagency efforts particularly addressing pandemic influenza, we 
learned that no one agency has the authorities, expertise, or 
capabilities to fully counter natural or intentional biological threats 
to the country. Such a proactive effort requires, for example, basic 
sciences expertise resident in CDC, applied sciences tools resident 
throughout HHS (especially the Office of the Assistant Secretary for 
Preparedness and Response), research and development efforts by both 
CDC and DHS Science and Technology, public health approaches involving 
State, local, tribal, and Federal public health agencies, and law/
border security efforts by several agencies within DHS. Amongst the 
most important lessons learned for the Office of Health Affairs is the 
critical importance of taking the ``50,000 foot'' view to help 
coordinate all of these efforts as there is no other office or agency 
as well-positioned to take on this critical role. While DHS has the 
overarching mission of coordinating preparedness and incident response, 
in the specialized area of public health and medicine, the uniquely OHA 
role has been to integrate understanding of the science of health and 
medicine, including biological threats, with an understanding of law 
and border enforcement, and applying this understanding to facilitate 
the interagency coordination and cooperation required to successfully 
prepare the Nation against biological threats.
    Question 3a. Aside from the National Response Framework, the 
Department of Homeland Security is responsible for creating operational 
plans that delineate what the Federal Government is going to do if each 
of the National Planning Scenarios were to occur. What is the status of 
getting those plans done?
    Answer. Planning to address Federal Incident Management activities 
for each of the National Planning Scenarios is currently underway. The 
effort, while coordinated through the Department of Homeland Security's 
Office of Operations Coordination and Planning (OPS), is truly an 
interagency effort.
    The Hurricane KATRINA Lessons Learned \2\ report published in 
February 2006 established the requirement for a permanent planning 
element located within the Office of Operations Coordination's (OPS) 
National Operations Center (NOC) and the need for a standardized 
Federal planning process. As a result, OPS established the Incident 
Management Planning Team (IMPT) \3\ in September 2006. The IMPT 
developed the National Planning and Execution System (NPES) \4\ as an 
interim process to standardize Federal planning as they developed 
operational level concept plans (CONPLANS) based on the 15 National 
Planning Scenarios (NPS). Over the next 16 months (SEP 06-DEC 07) the 
IMPT developed six plans based on the NPS. These scenarios included: 
Improvised Nuclear Device (IND), Radiological Dispersal Device (RDD), 
Improvised Explosive Device (IED), Cyber Attack, Major Hurricane, 
bioterrorism attack and Pandemic Influenza. In December 2007, the 
President approved Annex I (National Planning), to Homeland Security 
Presidential Directive 8 (HSPD-8). Annex I directed development of an 
Integrated Planning System (IPS) which replaces NPES. IPS was approved 
for interim Federal use in June 2008. [sic] edIn July 2008, the DHS 
Office of Operations Coordination became the DHS Office of Operations 
Coordination and Planning (DHS OPS).
---------------------------------------------------------------------------
    \2\ The Federal Response to Hurricane Katrina: Lessons Learned 
(February, 2006).
    \3\ The purpose of the Incident Management Planning Team (IMPT) is 
to support a unified inter-agency planning effort for incidents 
requiring a coordinated national response. The IMPT will support the 
development of strategic guidance, concept development, plan 
development, and plan refinement leading to publication of a series of 
plans for actual or potential domestic incidents. IMPT Charter, August 
21, 2006.
    \4\ The NPES was aligned with the National Incident Management 
System (NIMS) and the Department of Defense (DOD) Joint Operations 
Planning and Execution System (JOPES).
---------------------------------------------------------------------------
    [sic] was The planning process in IPS is based on best practices 
from planning systems used in civilian and military communities. The 
IPS calls for several layers of plans, each of which draws upon the 
plan above it for guidance and direction:


               FEDERAL INTERAGENCY PLANNING ARCHITECTURE

    Interagency planning is ongoing on the 15 National Planning 
Scenarios, which were compressed into 8 scenario sets and prioritized 
by HSC Deputies. On 09 OCT 08, the Homeland Security Council requested 
that by 20 JAN 08, the IMPT complete the Terrorist Use of Explosives 
(TUE), Improvised Nuclear Device (IND), and Biological Attack (BIO) 
Strategic Plans and begin work on the Radiological Dispersal Devices 
(RDD) and Chemical Attack plans. Currently steady progress is underway 
to meet this goal; the TUE is completed; the IND is in final 
adjudication; and the BIO planning process is already underway.
    While all interagency plans have not yet been produced under IPS, 
it is important to note that there is a great deal of planning and 
preparedness activities that addresses our readiness to address 
threats. NIMS, NRF and incident annexes provide doctrine and a 
framework for incident management, and Federal departments and agencies 
have procedures and plans in place to execute legal and policy 
responsibilities. As indicated in the chart below, the five biological 
national planning scenarios have been compressed into two separate 
scenario sets. 


                     IPS PLAN DEVELOPMENT PRIORITY

    Question 3b. In particular, have the material threat assessments 
been completed for pandemic influenza and other biological threat, and 
what is the status of the plans that addresses the pandemic influenza 
planning scenario and other biological planning scenarios? Please send 
us these material threat assessments, as well as the plans based on 
them. If the plans are not yet complete, please forward the plans in 
whatever draft state they are in now, and provide their expected 
deadlines for completion.
    Answer. (1) A Material Threat Assessment (MTA) has not been 
performed on pandemic influenza. The MTA and Material Threat 
Determination (MTD) process was established per the Project BioShield 
Act of 2004 (Pub. L. 108-276) to inform medical countermeasure 
requirements and acquisitions using the Special Reserve Fund for those 
chemical, biological, radiological, and nuclear agents identified 
through the MTD/MTA process. Funds to purchase medical countermeasures 
for pandemic influenza are separate from the Project BioShield Special 
Reserve Fund and thus pandemic influenza was not included in the MTD/
MTA process. MTAs have been completed on the following biological 
threat agents:
   Botulinum Toxin (Clostridium botulinum);
   Plague (Yersinia pestis);
   Anthrax (Bacillus anthracis);
   Tularemia (Francisella tularensis);
   Typhus (Rickettsia prowazekii);
   Q-fever (Coxiella burnetti);
   Rocky mountain spotted fever (Rickettsia rickettsii);
   Glanders (Burkholderia mallei);
   Melioidosis (Burkholderia pseudomallei); and,
   Viral Hemorrhagic Fevers--Filovirus (Marburg, Ebola); 
        Arenavirus (Junin, Lassa, Machupo, Guanito); Flavivirus 
        (Dengue, Yellow, Kyasanur Forest, Omsk); Bunyavirus (Rift 
        Valley, Crimean-Congo, Hantaan).
    These MTAs are classified at the SECRET level and are available 
upon your request. To date, the anthrax MTA is the first scenario 
established by the MTA process to be considered in facilitating the 
Federal Government's planning activities per HSPD-8.
    Question 4a. A strategy employed by many departments and agencies 
for increasing efficiencies for public health and emergency 
preparedness for emerging biological threats is to better align grants, 
grant cycles, grant deadlines, etc.
    Please describe the roles, responsibilities, and activities of the 
Grants Coordination Division in the Office of Health Affairs. How much 
progress has this Division made in better aligning grants, grant 
cycles, grant deadlines, etc. in this regard?
    Question 4b. It is possible for Federal Departments and agencies to 
issue grants, contracts, and cooperative agreements that extend over 
more than 1 year at a time. However, many grants, contracts, and 
cooperative agreements issued by the Department of Homeland Security do 
not cover multiple years. What do you think of the value and 
feasibility of multi-year funding for activities that relate to public 
health security and emergency preparedness for emerging biological 
threats?
    Answer. OHA leads the DHS effort to coordinate preparedness grants 
that have a health and medical nexus. Efforts are underway to align 
subject matter expertise in the synchronization of external grant 
programs (i.e. HHS) and align those efforts to evolving Homeland 
Security Presidential Directives; National Priorities; Target 
Capabilities; Emergency Support Functions; and program guidance to 
enhance national preparedness.
    OHA has been intimately engaged with FEMA/GPD in ascertaining 
health and medical readiness functions through guidance development 
(State Homeland Security Grant Program (SHSGP)/Urban Area Security 
Initiative (UASI)/Metropolitan Medical Response System (MMRS)). To that 
end, OHA has made an increasingly positive impact by providing subject 
matter expertise in the alignment of grant programs' health and medical 
capabilities.
    Currently, fiscal year 2009 grant guidance is in development and 
pending release once appropriations are passed. Grant deadlines are 
typically set through congressional appropriations and remain firm. 
However, OHA has taken proactive efforts to work with the health and 
medical community, professional organizations, and internal subject 
matter experts in the guidance development ahead of appropriation 
deadlines.
    In coordination with the Grant Programs Directorate (GPD) within 
FEMA, OHA communicates with stakeholders to enhance preparedness 
efforts with specific attention to health and medical surge capacity, 
response, and recovery. As a result of the Post Katrina Emergency 
Management Reform Act of 2006 (PKEMRA), OHA is the principal agent for 
all health and medical activities that affect our national ability to 
prevent, prepare for, protect against, and respond to natural 
disasters, acts of terrorism, and other manmade disasters. In this 
role, we believe it is critical to ensure that our medical first 
responders have the resources to respond to catastrophic incidents.
    The period of performance for most homeland security grant 
programs, including MMRS, is currently 36 months and extensions are 
routinely granted as necessary. There is incredible value to multi-year 
funding activities. As DHS/FEMA is actively promoting multi-agency as 
well as multi-jurisdictional capabilities, multi-year funding for these 
activities is paramount to meet the logistical challenges associated 
with planning, organization, development, execution, and evaluation.
    Activities relating to emerging biologic threats and public health 
security may benefit from multi-year funding. OHA and FEMA/GPD are 
working to prioritize grant funding for health and medical capabilities 
planning.
    Question 5. It has been stated that both the Secretary of Homeland 
Security and the Secretary of Health and Human Services would be co-
leaders during an influenza pandemic. You, as well as your respective 
secretaries, have also stated the same in previous testimony before 
Congress. Please describe specifically how they will actually lead at 
the same time. How do you see this working?
    Answer. As stated in the National Response Framework, HSPD-5, and 
other guiding documents, the Secretary of Homeland Security would serve 
as the leader of the Federal response, coordinating activities of all 
departments and agencies working through the ESF structure. DHS will 
work closely with all Federal partners that have responsibilities in 
preparing for and responding to a pandemic.
    The Secretary of the Health and Human Services will fulfill the 
major responsibility of overseeing the public health and medical 
response. DHS is responsible for the coordination of the overall 
Federal response during an influenza pandemic, including implementation 
of policies that facilitate compliance with recommended social 
distancing measures, development of a common operating picture for all 
Federal departments and agencies, and ensuring the integrity of the 
Nation's infrastructure, domestic security and entry and exit screening 
for influenza at the borders.
    DHS recognizes the key role of HHS in its responsibility to lead 
the coordination of the public health and medical emergency response 
activities during a pandemic under Emergency Support Function (ESF) 8, 
including the deployment and distribution of vaccines, antivirals and 
other life-saving medical countermeasures from the Strategic National 
Stockpile. DHS also recognizes the Department of State's role to lead 
the coordination of international efforts including U.S. engagement in 
a broad range of bilateral and multilateral initiatives that build 
cooperation and capacity to fight the spread of avian influenza and to 
prepare for a possible pandemic. USDA conducts surveillance for 
influenza in domestic animals and animal products, monitoring wildlife 
in coordination with the Department of the Interior, and working to 
ensure an effective veterinary response to a domestic animal outbreak 
of highly pathogenic avian influenza.
    Question 6. How has the Office of Health Affairs involved other 
high-level decisionmakers at the Federal, State, territorial, tribal, 
and local levels in planning efforts? How do you suggest that the 
processes by which this should occur be improved?
    Answer. The Office of Operations Coordination and Planning (OPS) is 
tasked by the Secretary of the Department of Homeland Security to be 
the lead for Federal Interagency Strategic Planning. The Deliberate 
Plans Branch within OPS coordinates these planning activities, with 
more than 53 Federal departments and agencies participating. 
Additionally, FEMA is responsible for the development of Concept Plans 
or CONPLANS that address interagency activities in greater detail. Each 
Department and Agency is then responsible to develop their own agency 
specific Operations Plan or OPLAN. Additionally coordination of 
planning activities with State and local governments happens primarily 
at the FEMA Region level. It is anticipated that regional plans will 
also be produced through the IPS.
    The Office of Health Affairs (OHA) is a very active partner in all 
levels of planning at DHS. OHA provides expert advice and works with 
subject matter experts at the Department of Health and Human Services 
(HHS), the Department of Agriculture (USDA), and the Environmental 
Protection Agency (EPA) to ensure that health and medical-related 
content for these planning efforts has the most current information 
available.
    The required improvement to Federal, State, territorial, tribal and 
local level planning is being addressed by the adoption of IPS. This 
system is a major step in the improvement of planning processes across 
the Federal Government. Additionally FEMA has recently released the 
interim Comprehensive Preparedness Guide (CPG) 101, ``Producing 
Emergency Plans: A Guide for All-Hazard Operations Planning for State, 
Territorial, Local, and Tribal Governments'' which provides communities 
with guidance for emergency operations planning. CPG-101 (interim) also 
describes how the State and local planning process will vertically 
integrate with the Federal Integrated Planning System. These two 
planning documents that were developed with the assistance of multiple 
departments and agencies at all levels of government have vastly 
improved emergency planning activities across the spectrum of homeland 
security.
    OHA is an integral component in the development of each Federal 
SGS, Federal Strategic Plans and Federal Concept Plans. Additionally, 
OHA supported the development of content for the National Planning 
Scenario No. 2: Biological Attack--Aerosol Anthrax.
    Question 7. Do you believe that mobile hospital assets should be 
deployed during an influenza pandemic? If so, how do you believe that 
should occur--how would they be most useful?
    Answer. The issue of providing care during a pandemic is a matter 
of surge capacity. Surge care must be delineated from disaster care in 
that it is not necessarily a space issue, but rather it is limited by 
available human resources. While it is accurate that there will likely 
be significant shortages of bed space in which to care for the 
population, our ability to provide care will be limited by the number 
of available health care providers. The deployment of mobile medical 
facilities will assist with the surge only if we are able to staff 
those beds. This differs from a disaster in that we generally have the 
ability to mobilize providers from outside of the affected area to 
bring in to staff a mobile medical facility. In the event of a pandemic 
all available providers will likely be tied up providing care in their 
normal institutions. It should also be understood that there will 
likely be a shortage of available providers due to their inability to 
report for duty due to illness. As such, we will be potentially facing 
an overwhelming population of patients seeking care in traditional 
hospitals while trying to maintain skeleton staffing due to health care 
provider absence due to illness. Successful mass care during a pandemic 
will be dependant upon creative use of limited human resources rather 
than adding mobile beds which may be difficult, if not impossible, to 
staff.
    Question 8. What is the status of the pandemic influenza exercises 
that were to be incorporated into the National Exercise Program? How 
many have occurred to date, and how many will occur in the future? What 
pandemic influenza exercises have you participated in or supported at 
the Secretary, Assistant Secretary, and Deputy Assistant Secretary 
levels (please provide dates and brief descriptions)? Are you satisfied 
that during these exercises that lessons learned are being adequately 
communicated and applied to bioterrorism preparedness?
    Answer. DHS participated in PLE 1-08, an Assistant Secretary level 
exercise conducted in Washington, DC on February 20, 2008. Assistant 
secretaries met to examine the Federal Government response to an 
influenza pandemic and consider 3 specific modules: Screening of 
inbound air travelers, distribution of anti-viral medications, Federal 
Government options if communities fail to implement effective 
mitigation strategies. The exercise also focused on effective 
communication strategies during a pandemic. An exercise covering 
communications coordination during a pandemic was conducted in November 
2007. This exercise included the pre-designated National PFO and 
Regional PFO Pandemic Influenza/Biological Threat Response teams, HHS 
and representatives from the Homeland Security Council. More exercises 
for the PFO Pandemic Influenza/Biological Threat Response teams are 
planned for 2009. DHS has an intradepartmental PI exercise scheduled 
for Oct 2008 that will primarily cover the specific roles and 
responsibilities of the DHS component agencies during a pandemic and 
will review and exercise parts of the DHS pandemic plan and specific 
DHS component PI plans. DHS is satisfied that lessons learned from all 
these exercises are being effectively implemented in guiding future 
policies and programs regarding pandemic and bio-terrorism scenarios.
    Question 9. GAO recently released a report on State and local 
pandemic planning and exercising, and recommended that the Secretaries 
of the Department of Homeland Security and the Department of Health and 
Human Services, in coordination with other agencies, convene additional 
meetings with the States and territories in the five Federal influenza 
pandemic regions to help them address identified gaps in their pandemic 
planning. We have heard that previously held meetings were of limited 
value to both the Federal and non-Federal Governments. Do you think 
that have additional meetings would be useful? Are you planning on 
holding additional regional meetings on pandemic influenza, and for 
what purposes?
    Answer. Additional regional workshops will have to be coordinated 
by DHS and HHS at some time after the current State plan review process 
has been completed. DHS concurs with HHS, that it would be impractical 
in the short term because of each department's current involvement in 
the update of the States' pandemic plans. The current timeline to have 
all of the updated reviews done, reconciled with States, and analysis 
of gaps will not likely occur until December 2008 or January 2009 at 
the earliest. It should be noted that the State plan review effort has 
also allowed DHS and HHS get a better understanding of what issues the 
States would like addressed and has provided us with an opportunity to 
make direct contact with States.
    Question 10. There has been a lot of discussion regarding altered 
standards of care, including in a recent GAO report on medical surge. 
You have said that the standard care always remains the same, but in 
the case when resources are limited, the type or amount of care may 
have to change. Please elaborate. How would you recommend that States 
and territories address this difficult issue?
    Answer. The most common legal definition of standard of care is how 
similarly qualified practitioners would have managed the patient's care 
under the same or similar circumstances; hence our comment that the 
standard of care would not change but rather would be evaluated in the 
context of the situation or circumstances. A mass casualty event 
involving thousands or tens of thousands, of injured or ill victims 
will require health care systems to quickly shift from routine 
operating practices to processes, procedures, and practices that can 
best support the additional emergent and urgent demand. When feasible, 
resources (people, equipment, space, supplies, etc.) used to provide 
certain types of care (e.g. preventive, screening, or elective) may 
need to be shifted to support the increased demands for emergent and 
urgent care. Another shift might incorporate the use of non-traditional 
providers to provide care for those with chronic conditions (e.g. 
hypertension and diabetes mellitus) that left untended could become 
urgent or emergent or the ``worried well.'' Examples of this might 
include:
   Shifting the resources that produce the 183,000,000 visits 
        to physician offices and hospital Out Patient Departments and 
        Emergency Departments for non-illness or non-injury conditions 
        (source: 2006 National Ambulatory Medical Care Survey (NAMCS) 
        and National Hospital Ambulatory Medical Care Survey (NHAMCS)).
   Shifting the resources used to provide the 1,615,100 
        screening colonoscopies performed annually (source: National 
        Cancer Institute Survey of Colorectal Cancer Screening 
        Practices).
   Having processes in place to effectively optimize the 
        expertise of other non-traditional medical disciplines:
     Approximately 161,000 and 95,000 medical, dental, and 
            ophthalmic laboratory technicians (U.S. Department of 
            Labor, Occupational Outlook Handbook, 2008-09 Edition).
     Approximately 62,000 veterinarians and 71,000 veterinarian 
            technicians and technologists (U.S. Department of Labor, 
            Occupational Outlook Handbook, 2008-09 Edition).
    To address this difficult issue, our recommendations to the States 
and territories would be to:
   Use data-driven processes, specific to the State or 
        territory, to understand their unique set of existing 
        requirements and capabilities.
   Support, facilitate, and fund coordination and collaboration 
        at the community, regional, and inter-State level.
   Provide information to the Department of Health and Human 
        Services to support its role in coordinating public health 
        emergency preparedness and response information.
    Question 11. In your position as Assistant Secretary for Health 
Affairs, it is often not as challenging to partner with another health 
entity such as the Assistant Secretary for Preparedness and Response at 
the Department of Health and Human Services, as it is with non-health 
entities within the Department of Homeland Security itself. How have 
you overcome these challenges, and what lessons have you learned that 
you would pass on to those that need to partner across sectors to 
prepare for emerging biological threats?
    Answer. Coordination within the Department of Homeland Security, as 
well as with other Federal partners is extremely important to ensure a 
cross-share of information and integration of resources and expertise 
on both health and non-health issues. A cross-sharing and integration 
of information and resources is critical because there are overlapping 
requirements and authorities that must be coordinated in response 
efforts. Without ongoing collaboration, information is not easily 
accessible and additional time may be necessary to obtain complete 
situational awareness. As with many other types of threats, 
bioterrorism can have wide-ranging consequences and require a multitude 
of response capabilities and expertise, including health, emergency 
management, law enforcement, intelligence and critical infrastructure/
key resources protection. As such, in the event of a biological attack, 
many components of DHS would play critical roles in a response.
    The Office of Health Affairs (OHA) regularly participates in 
working groups, strategic planning initiatives, training and exercises 
and other preparedness and response activities with other Department 
components to develop coordinated approaches to the various 
preparedness and response planning initiatives. As an example, the 
National Biosurveillance Integration Center (NBIC) coordinates and 
integrates situational awareness information within DHS and with 
Federal partners. During the recent salmonella saintpaul outbreak, NBIC 
participated with Federal partners to maintain current situational 
awareness of the disease outbreak trends. The salmonella saintpaul 
event is an example of the importance of collaboration by addressing 
potential issues, including economic effects, international relations, 
and border screening. In addition, the NBIS Interagency Working Group 
(NIWG) and sub-working groups meet on a regular basis to participate in 
biosurveillance conferences to address a broad range of interagency 
requirements and collaboration issues.
    Question 12. Please give us the status of the Department of 
Homeland Security's own pandemic influenza plan. Has this plan been 
finalized? If so, when--and how have they been circulated throughout 
the Department and the Executive branch? Please provide a copy of this 
plan and any other relevant plans regarding pandemic influenza and 
other biological threats that the Office of Health Affairs has 
developed.
    Answer. The DHS pandemic influenza (PI) plan will be revised during 
interagency planning under the IPS. DHS OPS intends to leverage the 
extensive previous pandemic planning efforts (which include a Federal 
Pandemic Influenza Concept Plan, a Federal Pandemic Influenza Border 
Management Plan and a DHS Pandemic Influenza Plan) to expedite the 
revision of the DHS PI plan. Current estimate for the completion of 
these revisions is early in 2009.
    Question 13. We have a lot of biosurveillance efforts going on 
throughout the Nation. The National Biosurveillance Integration Center, 
BioSense, BioFusion, the National Medical Intelligence Center are only 
a few of the many activities occurring in this arena. In your opinion, 
how do you think these efforts should be integrated?
    Answer. The mission of the National Biosurveillance Integration 
Center (NBIC) is to provide senior leaders and National Biosurveillance 
Integration System (NBIS) Member Agencies (NMAs) early cueing and 
increased situational awareness of biological events across all the 
biological domains.
    NBIS provides a collection backbone that supports cross-domain 
integration, unique analysis of information, and collaboration between 
the agencies. Through NBIS, NMAs and participating agencies can 
provide, share and receive early biological event cueing and bio-
situational awareness across all of the biological domains. NBIC serves 
as the operational hub for this community of member and participating 
agencies that leverages and integrates the various bio-surveillance 
efforts in support of the NBIC and NMAs missions. The expectation is 
that agencies will continue to collect their agency specific 
information, such as CDC using BioSense, will conduct their own data 
analysis of this information such as CDC intends to perform within 
BioPhusion, and then share this information with the NBIC. This is the 
same functional relationship being established between NBIC and the 
National Center for Medical Intelligence (NCMI). The NBIC provides the 
functional capability to collect bio-informational data, integrate 
those data via collaboration with the member and participating 
agencies, thus producing various NBIS products to provide early cueing 
and bio-situational awareness.
    For example, during the recent salmonella event, the NBIC provided 
inter-agency information integration, sharing, and awareness in support 
of the Food and Drug Administration (FDA). Additionally, the NBIC team 
is working closely with the CDC as it develops the National Bio-
Surveillance Strategy for Human Health and serves to facilitate the 
interagency and cross-domain collaboration for this important strategy 
effort.
    As mandated in Public Law, the various biosurveillance and 
intelligence data streams should be integrated leveraging the NBIS with 
the NBIC providing the keystone.

  Questions From Chairman James R. Langevin to Rear Admiral W. Craig 
  Vanderwagen, MD, Assistant Secretary for Preparedness and Response, 
                Department of Health and Human Services

    Question 1. We know that you have considered the possibility and 
impact of bioterrorism and an event such as pandemic influenza 
occurring simultaneously or one right after another. This being the 
case, some have suggested that medical and public health resources 
should be held in reserve to address additional events. Do you think 
this is even possible? How do you believe the multiplicative threat can 
and should be handled?
    Answer. Response was not provided at the time of publication.
    Question 2. Beginning in fiscal year 2009, the Pandemic and All-
Hazards Preparedness Act (PAHPA) of 2006 requires the Secretary of the 
Department of Health and Human Services to withhold some grant and 
cooperative agreement funding where a State has failed to develop an 
influenza pandemic plan that is consistent certain criteria, 
benchmarks, and standards established by the Department of Health and 
Human Services. Have the criteria, benchmarks, and standards been 
established by the Department of Health and Human Services? If so, 
when? What is the status of the Departmental review of State plans 
required by PAHPA to ensure that certain criteria are being met?
    Answer. Response was not provided at the time of publication.
    Question 3a. A strategy employed by many departments and agencies 
for increasing efficiencies for public health and emergency 
preparedness for emerging biological threats is to better align grants, 
grant cycles, grant deadlines, etc.
    Please describe the roles, responsibilities, and activities of 
those grant-making agencies and offices at the headquarters level of 
the Department of Health and Human Services, and at its subordinate 
agencies regarding grants alignment with those put out by other 
departments and agencies. How much progress has the Department of 
Health and Human Services made in better aligning grants, grant cycles, 
grant deadlines, etc. in this regard?
    Answer. Response was not provided at the time of publication.
    Question 3b. It is possible for Federal departments and agencies to 
issue grants, contracts, and cooperative agreements that extend over 
more than 1 year at a time. However, many grants, contracts, and 
cooperative agreements issued by the Department of Health and Human 
Services and its subordinate agencies do not cover multiple years. What 
do you think of the value and feasibility of multi-year funding for 
activities that relate to public health security and emergency 
preparedness for emerging biological threats?
    Answer. Response was not provided at the time of publication.
    Question 4. It has been stated that both the Secretary of Homeland 
Security, and the Secretary of Health and Human Services would be co-
leaders during an influenza pandemic. You, as well as your respective 
secretaries, have also stated the same in previous testimony before 
Congress. Please describe how they will actually lead at the same time. 
How do you see this working?
    Answer. Response was not provided at the time of publication.
    Question 5. How have you involved other high level decisionmakers 
at the Federal, State, territorial, tribal, and local levels personally 
in planning efforts? How would you improve the processes by which this 
should occur?
    Answer. Response was not provided at the time of publication.
    Question 6. Do you believe that mobile hospital assets should be 
deployed during an influenza pandemic? If so, how do you believe that 
should occur--how would they be most useful?
    Answer. Response was not provided at the time of publication.
    Question 7. The Assistant Secretary for Preparedness and Response 
has a unit that deals with exercises. Previous, your office reached out 
to the Department of Homeland Security regarding the use of the Lessons 
Learned Information Sharing system. Is the Department of Health and 
Human Services using the system yet? How are personnel in your office 
working with those in the Office of Health Affairs, the National 
Exercise Program, etc., to combine efforts and data?
    Answer. Response was not provided at the time of publication.
    Question 8. GAO recently released a report on State and local 
pandemic planning and exercising, and recommended that the secretaries 
of DHS and HHS, in coordination with other agencies, convene additional 
meetings with the States and territories in the five Federal influenza 
pandemic regions to help them address identified gaps in their pandemic 
planning. We have heard that previously-held meetings were of limited 
value to both the Federal and non-Federal governments. Do you think 
that have additional meetings would be useful? Are you planning on 
holding additional regional meetings on pandemic influenza, and for 
what purposes?
    Answer. Response was not provided at the time of publication.
    Question 9. There has been a lot of discussion regarding altered 
standards of care, including in a recent GAO report on medical surge. 
In this report, GAO recommended that the Department of Health and Human 
Services establish a clearinghouse for States and territories to share 
information regarding their current approaches to addressing this issue 
of altered standards of care. According to GAO, the Department of 
Health and Human Services was silent on that recommendation, although 
the Department did agree with GAO's findings. Why was the Department of 
Health and Human Services silent on that recommendation? How would you 
recommend that States and territories address this difficult issue?
    Answer. Response was not provided at the time of publication.
    Question 10. Please provide information regarding the consensus 
meeting run by the Department of Health and Human Services in 
Indianapolis regarding medical surge requirements.
    Answer. Response was not provided at the time of publication.
    Question 11. What has the Department of Health and Human Services 
done to examine what happened to the hospitals in the Gulf Coast during 
Hurricane Katrina, and how the Department of Homeland Security 
communicated that information to hospitals throughout the country?
    Answer. Response was not provided at the time of publication.
    Question 12. What types of assistance has the office of the 
Assistant Secretary for Preparedness and Response offered or is it 
planning to provide to the States, territories, tribes, and localities 
to help them in planning, exercising, and general preparedness for an 
influenza pandemic? Has the office of the Assistant Secretary for 
Preparedness and Response systematically asked the States, territories, 
tribes, and localities what type of assistance would be most helpful to 
them? If so, what did they say and what has been done to address their 
needs?
    Answer. Response was not provided at the time of publication.
    Question 13. Since pandemic-specific funding to the States and 
certain localities will be ending this year, and pandemic ``fatigue'' 
is setting, are you concerned about how the States, territories, 
tribes, and localities will maintain continuity in their pandemic 
preparedness? If so, is the Department of Health and Human Services 
taking any specific actions to help maintain this focus into the next 
administration and over the long-term?
    Answer. Response was not provided at the time of publication.
    Question 14. Are there any plans to provide additional pandemic-
specific funding to the States and certain localities for pandemic 
efforts?
    Answer. Response was not provided at the time of publication.

   Questions From Chairman James R. Langevin to Dr. Daniel M. Sosin, 
Director, Biosurveillance Coordination Unit, and Associate Director for 
 Science, Coordinating Office for Terrorism Preparedness and Emergency 
          Response, Centers for Disease Control and Prevention

    Question 1. We have a lot of biosurveillance efforts going on 
throughout the Nation. The National Biosurveillance Integration Center, 
BioSense, BioFusion, the National Medical Intelligence Center are only 
a few of the many activities occurring in this arena. In your opinion, 
how do you think these efforts should be integrated?
    Answer. The United States is confronted by an array of threats with 
natural, accidental and intentional origins. Numerous domestic and 
global biosurveillance capabilities exist across the human, plant, 
animal and environmental domains; these capabilities are distributed 
across levels of government and the private sector but are inadequately 
coordinated. Integrating biosurveillance capabilities requires 
investment in:
   A comprehensive Nation-wide focus embracing centralized and 
        collaborative planning and achievable standards while allowing 
        decentralized execution at all levels of government;
   Enabling existing systems and people to connect across 
        multiple platforms--a single infrastructure is not a viable 
        option;
   Building transparent communication and information-sharing 
        systems that balance interests of stakeholders at all levels of 
        government and distribute and receive information for 
        decisionmakers simply and comprehensively.
    Ultimately, biosurveillance addresses the management of an 
information supply chain for the control of acute health events of 
national interest through early detection and characterization for 
intervention.
    The National Biosurveillance Integration System (NBIS) has been 
established to integrate biosurveillance information from all available 
sources, including public and private entities and NBIS member 
agencies. NBIS is chartered to analyze the information, from a 
national/homeland security perspective, and to share and disseminate 
information and finished products to senior governmental leaders and 
contributing partner agencies. HSPD-21 directs the Centers for Disease 
Control and Prevention (CDC) to collect, assess, and share human health 
biosurveillance information with all levels of government and with the 
private sector. Similarly, other domain-specific agencies collect, 
process, and share biosurveillance information that is gathered from a 
broad array of domestic and global biosurveillance information sources 
across a range of biological domains, including food, wildlife, and 
domestic animals.
    NBIS provides a single point within the Federal Government for the 
integration of these agency-specific biosurveillance reporting streams. 
NBIS also provides the capability for the acquisition, integration, 
assessment, and sharing of biosurveillance-related data from 
intelligence, nongovernment, and other open source reporting systems 
across each of the domains, as well as those within the public health, 
food and agriculture, chemical, energy, transportation, and financial 
infrastructures. The National Biosurveillance Integration Center 
(NBIC), housed within DHS, provides NBIS community members with a 
unique environment for interagency cross-domain event cueing and 
situational awareness.
    The following graphic depicts the life cycle of biosurveillance for 
human health for CDC. The various health and health-related data and 
information resources from State, local, tribal, and territorial 
jurisdictions, and other national, Federal, and international 
biosurveillance entities are reflected at the base of the graphic. 
These resources may feed data through biosurveillance systems (e.g., 
BioSense) or through programs and people in search of information to 
guide actions. In the ideal State, each of these entry points to the 
agency is tightly linked for information exchange with the others and 
the BioPHusion program serves both to integrate information from the 
multiple streams and to improve cross-agency networking for information 
exchange. Fused information products, including electronic health data 
from direct clinical connections such as BioSense, national 
surveillance systems like NNDSS and LRN, and condition-specific 
surveillance conducted by prevention and control programs, are 
disseminated by BioPHusion back to providers to close the information 
loop and to customers of human health biosurveillance at the national 
and global levels (e.g., NBIS, WHO).


    The life-cycle of collection management, analysis, interpretation, 
and dissemination requires multiple systems and reciprocal 
relationships with all levels of government. Key functions of CDC's 
biosurveillance management depicted in this graphic are noted below:
   Human health.--CDC is responsible for leading 
        biosurveillance efforts for human health and providing a common 
        operating picture for human health to national and 
        international biosurveillance organizations.
   Reciprocal relationships.--CDC receives and disseminates 
        information to local, State, tribal, territorial, Federal and 
        global entities. Mutual benefit must be achieved wherein 
        national visibility and multi-sectoral context enhances 
        information value.
   Horizontal relationships.--Key biosurveillance activities at 
        CDC work collaboratively to integrate subject matter expertise 
        and information gathered from surveillance systems.
    Just as CDC's BioPHusion activity utilizes information from across 
formal and informal sources to combine and communicate this information 
for situation awareness for human health, the National Center for 
Medical Intelligence (NCMI), is a DOD/DIA organization serving to fuse 
classified medical intelligence. NCMI produces medical intelligence 
assessments, forecasts and databases on foreign military and civilian 
health care including worldwide infectious disease risks and global 
environmental health risks. CDC maintains public health liaison staff 
with the NCMI and the National Biosurveillance Integration Center 
(NBIC).
    CDC is a consumer of credible and coherent medical intelligence and 
not a source of this type of information. Through CDC's Office of 
Security and Emergency Preparedness (OSEP) information from the 
intelligence community is identified, acquired, and channeled 
appropriately to components of CDC that will benefit from the 
information.
    The primary objective of BioSense is to create a real-time picture 
of the health of Americans as seen through the lens of America's acute 
health care system, allowing decisionmakers to assess how well that 
system is performing in response to the challenges posed by an acute 
health emergency, to characterize evolving threats, to plan responses 
to threats and assess their impact. The information gathered through 
BioSense can provide complementary information to CDC programs, such as 
the Nationally Notifiable Disease Surveillance System or the National 
Healthcare Safety Network, and contributes to the daily situation 
awareness report produced by the BioPHusion Program.
    Question 2. Please describe the two CDC programs--BioSense and 
BioFusion. How are they similar and how do they differ? How do or will 
these programs interface and provide inputs into other agencies' 
programs, such as the National Medical Intelligence Center, the 
National Biosurveillance Integration Center, etc.?
    Answer. The need to develop and share critical information for 
decisionmaking within public health has increased markedly over the 
last few years. The ability to share this information, however, has 
decreased due to the proliferation of multiple data systems and 
fragmented knowledge exchange. CDC's BioPHusion program was formed in 
order to exploit the agency's unique information repositories and 
health-related subject matter capabilities and to allow the routine 
collection, monitoring, and synthesis of hundreds of disparate 
information sources to create actionable knowledge. BioPHusion, an 
analytic unit, merges information from a variety of sources, such as 
other Federal agency, media-related, non-governmental organizations and 
social network sources, and draws on these multiple data streams to 
produce an integrated view of health threats and events--in effect, the 
daily situational awareness needed for public health action. Since 
August 2008, BioPHusion has produced a preliminary daily public health 
situation awareness report.
    BioSense, a surveillance data system, collects de-identified health 
record level data from enrolled hospitals and health information 
exchanges across the Nation to identify anomalies in patterns of 
hospital visits and detect outbreaks of disease and maintain public 
health situation awareness.
    BioSense will include:
   Sensitive and timely detection of PH events through 
        monitoring of electronic data streams from emergency 
        departments, primary care, poison control centers, and other 
        data sources;
   Regional coordination of investigation of aberrancies in 
        real-time data and response through data sharing and electronic 
        communications;
   Electronic death notification and monitoring;
   Electronic case reporting and investigation;
   Tracking of outbreaks and forecasting of size, magnitude and 
        location of future spread of disease;
   Support of innovation, research and development to improve 
        the Nation's real time biosurveillance capabilities and work 
        force capacity development.
    Data received in the BioSense system are available simultaneously 
to State and local health departments, participating hospitals and CDC 
through a web-based application that is accessed through the CDC Secure 
Data Network. The BioSense application has over 800 users in 124 State 
and local public health jurisdictions. BioSense receives real-time data 
from over 570 non-Federal hospitals and batched data from over 1,200 
DoD and Veteran Affairs medical facilities. BioPHusion receives 
information about the anomalies in patterns of health visits detected 
by BioSense and incorporates this information into a common picture 
that contains information from other CDC surveillance systems and 
sources, such as news reports about disease outbreaks.
    CDC maintains public health liaison staff with other agencies' 
programs such as the National Center for Medical Intelligence (NCMI), 
formerly called the Armed Forces Medical Intelligence Center, and the 
National Biosurveillance Integration Center (NBIC). CDC liaisons sit in 
different programmatic areas of CDC but serve as CDC-wide resources for 
interfacing with the programs of other agencies. In this emerging and 
evolving role as a liaison, experts have provided epidemiologic 
expertise in the interpretation and analysis of health-related 
information for the NBIS daily report, served as a resource to DHS on 
the status of CDC surveillance systems, and consulted on medical and 
medical policy issues to prevent or address the exposure of Department 
of State employees and their families stationed overseas to infectious 
diseases, to name just a few examples.
    Question 3. We know that assays for avian influenza were put 
through the Laboratory Response Network for Bioterrorism (LRN). Why was 
this done, considering avian influenza is not an agent of biological 
terrorism? What other assays for non-bioterrorism agents have been put 
through the LRN? Is it the intention of CDC to put more assays for 
disease agents that are not agents of biological terrorism through this 
Network? Please explain the reasoning for these decisions.
    Answer. Assays for avian influenza were put through the LRN because 
of the need by the Department of Health and Human Service (HHS), DoD 
and Homeland Security Council to have a standardized assay deployed as 
soon as possible in support of coordinated preparedness and integrated 
response plans. The LRN was used because of its:
   Dual mission (i.e., high priority bioterrorism threat agents 
        as well as other high priority biological threats to public 
        health mandated by emergency preparedness or rapid response 
        needs);
   Efficacy of using the established LRN national and 
        international infrastructure asset to ensure standardization of 
        detection and response communications (i.e. notification and 
        lab result reporting);
   Unique capability of CDC collaborators to develop a high 
        quality test, expeditiously deploy the test reagents with 
        controls and ensure performance readiness through an ongoing 
        proficiency testing program.
    Planning to rapidly identify an emerging influenza pandemic is a 
public health priority and is a principle goal necessary for successful 
implementation of programs to mitigate a pandemic's impact. In a 
pandemic, all aspects of society will be affected, such as the public's 
health and economy, in addition to the possible security implications 
of widespread illness and work absenteeism in the population. Capacity 
for rapid detection of new pandemic strains in the LRN laboratories, 
with one or more laboratories in each State, is a critical component of 
U.S. pandemic planning. The LRN was also used for emergency response to 
SARS Coronavirus. CDC will include more assays for disease agents that 
are not agents of biological terrorism through the network only when 
emergency preparedness and response exigencies require it.
    Question 4. What can the Federal Government do to assist State, 
territorial, tribal, and local public health personnel strengthen and 
coordinate biosurveillance for emerging biological threats (including 
emerging and re-emerging infectious diseases, as well as bioterrorism) 
at those levels? How do you see information from localities throughout 
the country rolling up into a cohesive real-time disease surveillance 
picture?
    Answer. There will always be a need for hypothesis-driven analysis, 
human insights, and judgment in situational awareness activities. 
Professionals from diverse disciplines provide a range of skills 
necessary for the components of a biosurveillance system to work 
effectively to protect the Nation's health. Current and projected 
shortages in work force skills and capacities in addition to a dearth 
of trained workers and the inability of government to provide 
competitive salaries and benefits present serious challenges.
    A focus on the public health work force is part of CDC's mission; 
efforts to sustain and enhance biosurveillance capacity at the State, 
territorial, tribal and local levels must include support and funding 
for CDC's biosurveillance work force initiatives. These initiatives 
include:
   Developing public health workers who serve all levels of 
        government through fellowships and training programs;
   Defining the biosurveillance-related competencies and 
        integrating into health curricula;
   Placing CDC staff in the field to build biosurveillance 
        capacity at the State, local, tribal and territorial levels; 
        and
   Collaborating with partners to improve links between the 
        Nation's public health and clinical health care systems.
    The solutions to these challenges must create job opportunities and 
viable career paths for health professionals. A comprehensive Federal 
approach will ensure a prepared, diverse, and sustainable health work 
force--with the right number, mix, and disciplines--capable of meeting 
the challenges ahead, such as enhancing timely reporting from clinical 
settings to health departments and helping to ensure that information 
from localities can roll up into a cohesive, real-time disease-
surveillance picture.
    Additional strategies for enhancing the exchange of disease 
surveillance information include the following:
   Electronic Health Information Exchange.--While 
        biosurveillance encompasses many types of data, health care 
        data provide the most specific and direct representation of the 
        health of communities. The electronic health data-sharing 
        environment should allow appropriate access to health 
        information when it is needed, automated analyses that support 
        notifiable disease detection and outbreak cues, the ability to 
        query systems for addition investigation when warranted, and 
        feedback loops to validate findings and enact countermeasures. 
        Access to data will be increased through the development of 
        regional cooperatives, linkages with health information 
        exchanges and enhancing incentives for clinical providers to 
        transmit data to public health. Regional cooperatives will also 
        promote data sharing among States. Support for these systems, 
        combined with investments for a trained and competent work 
        force having outbreak detection and response skills, will 
        enhance real-time disease surveillance for rapid identification 
        of emerging threats.
   Electronic Laboratory Information Exchange.--The public 
        health laboratory remains an important agent for improvement in 
        public health practice. Rapid assays and genotypic/phenotypic 
        characterization have allowed public health experts to identify 
        subtle threats and respond more quickly, efficiently, and 
        effectively than has ever been possible before. Increasing the 
        connectivity of laboratories (public health, clinical, and 
        research) and their analysts through standards and technology 
        will also yield rapid and significant benefits in improved 
        biosurveillance.
   Unstructured Data and Data Mining.--Material obtained from 
        media, Internet, and informal communication sources is showing 
        promise as a valuable complement to more direct measures of 
        population health and is an underutilized resource. Successful 
        methods have been developed for aggregating and analyzing these 
        unstructured data so that they can be incorporated today as a 
        complementary health security resource for detecting potential 
        incidents that warrant investigation. Significant opportunities 
        to improve these data through rigorous research and experience 
        should be leveraged.
   Integrated Biosurveillance Information.--A commitment is 
        needed to develop tools, methods, and analyst capabilities, to 
        appropriately integrate information from multiple sources, and 
        to create more actionable information than is otherwise 
        available from individual sources and current information 
        products. The fusion model should address notification 
        protocols and effective communication of findings.
   Global Disease Detection and Collaboration.--Visibility of 
        emerging health threats around the world is contingent on the 
        local capability to detect and investigate and our connection 
        to the health work force. Developing international capability 
        through work force and infrastructure improvements will 
        increase global health awareness and our connection to it.
    Question 5. Please describe how you envision epidemiological 
investigations taking place when hospitals and other health care 
establishments are completely overwhelmed by a biological threat that 
sweeps the Nation, since we know that they will not have time for to 
use standard reporting mechanisms. What will CDC be able to do to help? 
How will we be able to get an accurate picture of what is happening 
with the disease?
    Answer. In the unfortunate circumstances of a significant 
biological event sweeping across the country, CDC will lead and support 
epidemiological investigation and response at all levels of government 
by focusing on the following activities:
   Preparedness.--As much as possible, CDC is working to 
        automate aspects of health information exchange. This is an 
        evolutionary process and we will have more automated electronic 
        resources next year than we have this year and more still in 5 
        years. Our preparedness goal is to prioritize and expedite the 
        implementation of automated resources and lessen the burden of 
        a pandemic when it arrives. The national planning effort of the 
        National Biosurveillance Strategy for Human Health is helping 
        to identify the priority targets for investment across the 
        Nation and program initiatives such as those sponsored by the 
        Office of the National Coordinator for Health Information 
        Technology, HHS (e.g., National Health Information Network) and 
        the National Center for Public Health Informatics, CDC, HHS 
        (e.g., BioSense) expedite implementation.
   Adaptation.--When collection cannot be automated, CDC will 
        adapt and scale back information requirements to those that are 
        most vital for saving lives and protecting health. For 
        instance, confirming a case at the onset of a pandemic will 
        require more specificity and rigorous validation, but as a 
        confirmed pandemic evolves the requirements can be simplified 
        (e.g., influenza-like illness counts).
   Investigation.--CDC will bring more public health expertise 
        directly to the clinical community. CDC will provide support to 
        State and local jurisdictions through the services of the 
        epidemiologic work force, such as members of the Epidemic 
        Intelligence Service and the Career Epidemiology Field 
        Officers. Through the provision of a surge work force, CDC 
        staff will assist with the information gathering, 
        identification of outbreaks, and inform the response planning 
        and implementation.
   Response Management.--CDC will serve a central role in 
        supporting the management of complex, distributed health 
        systems. CDC will utilize existing programs and relationships 
        with governmental entities to receive and disseminate 
        information. Key systems such as the Health Alert Network (HAN) 
        and Epidemic Information Exchange (Epi-X) provide CDC two tools 
        to disseminate information quickly to decisionmakers. HAN 
        includes a web-based connectivity and rapid communications 
        capability among CDC and local and State health departments and 
        health care providers. HAN has demonstrated effectiveness for 
        communicating urgent public health messages to the health care 
        community. Epi-X provides secure web-based communication 
        regarding outbreak and other acute or emerging health events 
        among public health officials from CDC, State, and local health 
        departments, and the military. Additionally, CDC will apply 
        information technology tools to the management of the response 
        as appropriate.
   Gathering Health-related Information.--Information sources 
        outside the clinical community will provide complementary 
        information. CDC will also have experts in the field conducting 
        various assessment activities, including environmental 
        monitoring and tracking patterns in vector-borne diseases.
    Through the implementation of these complementary efforts, 
decisionmakers will be able to ascertain an accurate picture of the 
health event.

  Questions From Chairman James R. Langevin to Dr. David R. Gifford, 
    Director of Health, Department of Health, State of Rhode Island

    Question 1. One of the emerging biological threats of current 
interest is Methicillin-resistant Staphylococcus Aureus (MRSA). We 
understand that we now have both institutional and community-based MRSA 
here in Rhode Island. Describe the steps you have taken to address this 
threat. What resources and guidance do you need to help you combat this 
threat?
    Answer. MRSA is a growing threat in communities and in health care 
settings, and it represents an enormous health and economic impact in 
the United States. It is estimated that MRSA is responsible for 19,000 
deaths per year; 4.5 out of every 100 hospital visits results in an 
infection and one study estimated that each infection costs an 
additional $37,000 per hospital stay.
    State health departments need increased funding to combat health 
care-acquired infections and decrease this burden. Increased resources 
would enable States to:
   fund programs to educate health care practitioners on 
        methods to decrease antimicrobial resistance and implement 
        better infection control measures;
   conduct surveillance; and,
   investigate and respond to outbreaks in hospitals, schools, 
        and other settings.
    In Rhode Island, we have been focusing on MRSA for the past couple 
of years which has included the following:
   In collaboration with hospital infection control 
        professionals we facilitated the development of infection 
        control best practice guidelines and standards for hospitals. 
        These 2001 published guidelines have received national acclaim 
        and have been a model for other States to adapt. The guidelines 
        were published in the national trade journal in 2002: Arnold 
        MS, Dempsey JM, Fishman, M, McAuley PJ, Tibert C, Vallande NC. 
        The Best Hospital Practices For Controlling Methicillin-
        Resistant Staphylococcus Aureus: On the Cutting Edge. Infect 
        Control Hosp Epidemiol 2002;3(2):69-76. They are currently 
        being implemented in Rhode Island. Individual hospitals track 
        their performance with success with implementing guidelines. 
        When uncontrolled outbreaks in hospitals occur they are 
        reportable to the Health Dept. None have been reported. Recent 
        surveys indicate hospital acquired MRSA rates in Rhode Island 
        are stable and nor growing.
   In collaboration with representatives from nursing home 
        (long-term care) infection control professionals we have 
        developed guidelines for the management of MRSA in Rhode Island 
        nursing homes (attached). The LTC surveyors use these 
        guidelines to review for deficiencies at LTC.
   In 2005 we sent an informational advisory on community 
        acquired MRSA to all Rhode Island physicians (content is 
        current and valid): See http://www.health.ri.gov/disease/
        communicable/providers_mrsa060705.php.
   We maintain a 24-hour on-call system to provide expert 
        consultation, assess needs and make recommendations to 
        institutions, facilities and professionals related to 
        prevention and control measures, as well as public risk 
        assessment and risk communications for various MRSA-related 
        issues, especially clusters--outbreaks or sustained 
        transmission. We provide such consultations on average once a 
        month.
   We have an active collaboration with the Rhode Island Dept. 
        of Corrections and have provided on-site consultations and 
        review of prevention and control measures at the ACI (adult 
        correctional institution).
   Our public health nurses are available to provide 
        information and guidance to members of the public by phone 
        (222-2577) daily. The office receives at least one or two calls 
        a day on this subject.
   We maintain an informational web page on the subject: http:/
        /www.health.ri.gov/topics/mrsa.php.
    Question 2. In your opinion, has bioterrorism preparedness been 
integrated with pandemic influenza preparedness? How have you been able 
to integrate these activities into the existing framework in Rhode 
Island for public health emergencies that occur more frequently or 
currently? Can you give us a few examples of how you have done that in 
Rhode Island?
    Answer. The bioterrorism Cooperative Agreement activities have 
prepared us well to meeting the planning challenges for pandemic flu 
head-on. In Rhode Island, the Cooperative Agreements led to the 
development of public health adopting the ICS structure, the 
construction of a Departmental Operations Center (DOC), the 
strengthening of disease outbreak protocols, and successful real-life 
responses to incidents that required isolation, mass vaccinations, 
medication distribution, medical surge, strong interagency 
interoperable communication, and large public information campaigns. 
For example, we were able to apply these new resources and training to 
situations related to:
   a case of active TB in Central Falls high school resulting 
        in over 500 students and teachers getting TB skin tests on a 
        single day;
   distribution of Hepatitis A vaccine to over 500 restaurant 
        workers as a result of exposure from a co-worker; and,
   closing of three school districts from a community outbreak 
        of Mycoplasma Pneumonia, which included the distribution of 
        antibiotics over the New Year's Day weekend to nearly 300 
        families.
    Question 3. What is your opinion of Federal regional offices of all 
types? Do you think that regionalization is a good model for Rhode 
Island?
    Answer. Regional collaborations and standing relationships clearly 
enhance multi-jurisdictional communications, planning and response 
capabilities. This is especially true as it pertains to mutual aid, 
whether it is between individual States or through a national system 
such as the Emergency Management Assistance Compact of which Rhode 
Island is a member.
    Traditionally, federally organized regional planning and 
coordination emanated from the Office of the Regional Health 
Administrator of the Department of Health and Human Services (we are in 
Region I which is headquartered in Boston). In recent years, and driven 
in large part by our shared mission to better prepare for public health 
emergencies, there has been a growing Federal presence in the regions 
not only as part of HHS (e.g. Regional Emergency Coordinators) but also 
from the Department of Homeland Security, such as the pandemic 
influenza pre-designated Principal Federal Official. Conceptually, this 
construct has great merit in that it provides direct linkages between 
States and key Federal agencies and a ready resource to support States 
without having to go directly to agency headquarters as long as they 
are informed and empowered to provide the necessary assistance and 
support.
    The recent consolidation and standardization of policy, program 
design and oversight to central Federal agencies has changed the role 
of Federal Regional Offices. The challenge is to manage the growing 
pains by clearly defining roles, responsibilities, and agency 
``lanes''; maintain open communications; and establish lines of 
reporting, to name a few. In the Northeast, with small States and 
frequent cross-border issues, efforts to coordinate regional activities 
and responses will be helpful. However, the current regional leadership 
could be more active in facilitating these discussions across State 
lines.
    Question 4a. DHS and HHS recently led a series of five workshops 
for States in the five Federal influenza pandemic regions primarily to 
discuss the current update of State and territorial pandemic plans. A 
Regional Principal Federal Official (PFO) and Federal Coordinating 
Officer (FCO) for pandemic influenza are pre-designated for each of 
these five pandemic regions.
    What was your impression of the DHS/HHS led workshop held in 
January 2007 for pandemic Region A? Did you find it helpful in planning 
for a pandemic? Should more regional meetings of State and Federal 
officials be held on pandemic influenza? How could they be made more 
useful?
    Answer. A half-day regional briefing was conducted to discuss the 
draft State Pandemic Influenza Operational Planning Guidance. It 
provided an opportunity for a cursory high-level discussion on the 
expected process for plan development and submission. Having the draft 
guidance well in advance of the meeting would have provided an 
opportunity for more substantive discussion on many of the key planning 
elements. We did appreciate the opportunity to submit follow-up 
comments and questions as the guidance was being finalized. Many of the 
States' concerns and comments were considered, making the final version 
more useful.
    Additionally, I think that regional meetings are helpful to bring 
together State teams to interact and learn from each other. However, 
many of the regional meetings do not provide enough opportunity for 
interaction and learning from our counterparts. Regional meetings that 
principally utilize PowerPoint presentations to convey information 
either by experts or by teams does not provide the opportunity for more 
meaningful interaction between State team members. I think regional 
meetings should be held but need to spend less time on transfer of 
factual issues more on regional planning between State teams.
    Question 4b. How has the regional PFO assisted with your pandemic 
preparedness efforts?
    Answer. The regional PFO has reached out to us to ask about our 
current process and has offered to bring State teams together.
    Question 5. What additional resources are needed for you to address 
emerging biological threats--including pandemic influenza, 
bioterrorism, etc.?
    Answer. Every year CDC State and local preparedness grant funding 
is reduced. States need a sustained commitment of Federal funds to 
recruit and retain highly qualified public health professionals to 
continue preparedness exercises, planning and other important 
activities. Reductions in the ASPR hospital preparedness grants are a 
major concern to State health officials.
    Emerging biological threats are also addressed through Epidemiology 
and Laboratory Capacity grants, which require continued support. For 
example:
   CDC funding for Epidemiology and Laboratory Capacity 
        decreased since 2002 from $78.5 million to $61 million in 2007.
   Epidemiology and Laboratory Capacity (ELC) is a funding 
        mechanism intended to address emerging threats by enhancing 
        investigation/surveillance capabilities and laboratory capacity 
        at State and local health departments.
   CDC's West Nile, Antimicrobial Resistance, Influenza and 
        Emerging Infections programs also support work at the State and 
        local level.
   ELC funding is declining because of budget cuts at CDC 
        making it harder for State and local health departments to 
        respond to new disease threats.
    Emerging biological threats are also addressed through Emerging 
Infections Programs, which require continued support. For example:
   There are 10 Emerging Infections Programs throughout the 
        Nation that collaborate among public health, academia and 
        clinical institutions to provide rapid and flexible response to 
        emerging disease threats.
   Although Rhode Island is not an EIP site, these programs 
        provide vital surveillance information about food-borne 
        infectious diseases, information about Creutzfeldt-Jakob 
        disease, and collected the data for the most recent study on 
        the burden of MRSA in the United States.
    Question 6. What problems do you face in spending Federal dollars? 
Is the Rhode Island State Budget cycle in synch with those of the 
Federal Departments and agencies?
    Answer. The Rhode Island State Budget cycle is not in synch with 
Federal grant years, which makes contracting more difficult, as well as 
having to close grants and the State budget 6 weeks apart. Also, each 
State has to follow its purchasing rules even for Federal funds. Thus, 
spending funds takes some time. Delays in the release of Federal 
Cooperative Agreement guidances, awards, and redirect request approvals 
therefore often hinder the timely spending of Federal funds at the 
State level.
    The other problem facing Rhode Island and many other States are 
hiring or spending freezes due to State budget issues as well as FTE 
caps. These ``freezes'' and CAPs are usually applied to all sources of 
funding including Federal sources. This then makes expending Federal 
funds in a defined budget cycle difficult.
    In addition, the fiscal year 2009 Hospital Preparedness report 
language and CDC State and local grant preparedness language proposed 
by the House Appropriations Subcommittee on Labor, Health and Human 
Services, Education, and Related Agencies that provides funding for ``a 
full year of grants rather than 9 months and 3 weeks of grants as 
proposed by the administration'' would be helpful.
    Question 7. Please provide your perspective on training and 
exercising. Do you believe your organization is training the way it 
fights (i.e., the way it would need to in order to respond to 
biological threats)?
    Answer. I could not agree more with the concept of ``training the 
way you fight''. Nationally, State health agencies participated in more 
than 700 exercises of all types in 2007 and many more took place at the 
local level. Exercises require significant time and effort to plan and 
execute. Most States faced at least one major emergency response in 
2007, and only 11 percent of States had no major emergency that 
required their response.
    We at the Rhode Island Dept. of Health have a low threshold to 
utilize ICS for many real-life incidents facing the Department. This 
helps us both better respond to these incidents but also serves as a 
real-life training opportunity for both primary and secondary staff 
within the Department. We have found that this is more helpful than 
some of the simulation exercises. Nonetheless, more mock exercises 
would also be helpful, especially when the simulations are treated not 
as exercise but a real-life response.
    In addition to training and exercising, States learn how to improve 
their systems through response to real-life events. These events offer 
opportunities for program improvement that are comparable to exercises. 
For example, in 2006, the Rhode Island Department of Health exercised 
the same capabilities that would be needed in a bioterrorism incident 
by successfully delivering antibiotics to 275 families following a 
mycoplasma outbreak.
    Question 8. The best preparation for public health emergencies 
involves public health workers who plan and exercise their plans for 
emergency response jointly with local elected officials, police and 
fire departments, emergency managers, the National Guard, hospitals, 
physicians, schools, businesses, and other community partners. Please 
describe how this has occurred in Rhode Island regarding emerging 
biological threats like pandemic influenza and bioterrorism.
    Answer. While all response planning in the State requires joint 
planning with partners and the Rhode Island Department of Health serves 
as the ESF-8 lead for State-wide planning, many of the Cooperative 
Agreement requirements have facilitated this process. Because Rhode 
Island has no local health departments, in order to meet the 
requirements of the SNS/CRI program, the Rhode Island Department of 
Health engages in contracts with each municipality in the State for 
SNS/CRI planning. This program has been the source of a tremendous 
amount of relationship building with emergency management directors, 
and police, fire, and EMS staff. This has proven to be a successful 
venture when real-life events occur and these plans must be called into 
action because the relationships and planning foundations are already 
in place.
    In addition, because the Rhode Island Department of Health acts as 
both a local and State health department for all jurisdictions in the 
State, it would become quickly overwhelmed in a pandemic situation. In 
order to appropriately plan for a pandemic, ten acute care hospitals 
have been deputized to serve as local health departments within the 
State during a pandemic, allowing them the authority to direct all 
public health and medical activities within their regions. Each of 
these healthcare service regions has a planning committee, comprised of 
hospitals, health centers, first responders, and community partners to 
address the utilization of medical and non-medical assets within the 
region.
    Question 9a. Recently, GAO released a report on the status of State 
and local planning and exercising for an influenza pandemic. GAO found 
that while all 50 States have developed an influenza pandemic plan in 
accordance with Federal pandemic funding requirements, a review 
conducted by the Department of Health and Human Services concluded that 
these plans had ``many major gaps'' in 16 of 22 priority areas, such as 
the policy process for school closures and communications, community 
containment and medical surge capacity. GAO also found that all States 
and localities that had received pandemic funds met the requirements to 
conduct a pandemic exercise to test their plans. We know updated plans 
were due in July for a second round of reviews led by the Department of 
Health and Human Services.
    What is the current status of planning and exercising for an 
influenza pandemic in Rhode Island?
    Answer. As referenced in your question, every State and territory 
was recently required to submit comprehensive details of their Pandemic 
Influenza Operations Plans for U.S. Government review. The Federal 
planning guidance was released on March 11 and identified three 
strategic goals:
    (1) Ensuring Continuity of Operation of State Agencies and 
        Continuity of State Government;
    (2) Protect Citizens; and,
    (3) Sustain/Support 17 Critical Infrastructure and Key Resource 
        Sectors.
    It contained over 400 operating objectives and sub-objectives to be 
in one way covered or addressed in the State Plans. Rhode Island filed 
its submission on time. The plan was more detailed and advanced 
compared to the first round of plan reviews referenced in the question, 
and we await the preliminary assessment that we believe will be 
available in the next couple of months.
    Question 9b. What were the identified gaps in Rhode Island's 
pandemic plan from the HHS-led interagency review conducted in 2007? 
How did you address those gaps in the current update to your State plan 
and how do you plan to address them in the future?
    Answer. For Rhode Island, the HHS-related issues, which required an 
additional response, were in the areas of COOP and Community 
Containment. While HEALTH still awaits feedback on these resubmissions, 
the requirements for the 2008 State Pan Flu Operations Plan led to 
further development of the Department's COOP and has helped facilitate 
COOP planning State-wide, since many of the gaps in the Department's 
plan were due to lack of policy decisions at a higher level than 
individual departments. This process is ongoing.
    HEALTH's Community Containment plan was modified to include the 
guidance from ``Community Strategy for Pandemic Influenza Mitigation''. 
HEALTH is currently working to continue improvement on this plan 
through work with the Department of Education, and is also preparing a 
regional survey that would develop triggers for the region as to when 
certain non-pharmaceutical interventions should be implemented.
    Question 9c. Please describe the pandemic exercises that Rhode 
Island has held or participated in and whether any changes were made to 
the State's pandemic planning as a result of these exercises. Do you 
plan to hold any pandemic exercises in the future at the State and/or 
local levels? If yes, please describe the exercises you have planned.
    Answer. Five of the ten health care service regions have conducted 
functional and/or full-scale alternate care site exercises. The 
remaining five regions will conduct their alternate care site exercises 
within the current grant year. In order to fully examine the capacity 
to track and provide vaccine during a pandemic, three municipalities 
conducted combined CRI/CRA POD exercises utilizing seasonal flu vaccine 
during the last flu season. State-wide tabletop exercises on antiviral 
distribution and community containment have been conducted.
    Question 10a. While the Federal Government has provided pandemic 
influenza guidance to the non-Federal public and private sectors, non-
Federal officials have told GAO that they would welcome additional 
guidance from the Federal Government in a number of areas to help 
better plan and exercise for pandemic influenza.
    What Federal assistance have you asked for, or do you need, to 
address the identified gaps in Rhode Island's pandemic plan?
    Answer. Rhode Island has asked for clearer guidance and additional 
planning support regarding Public Health COOP, prioritization of 
antivirals during a pandemic (and whether or not antivirals can/should 
be used for prophylaxis vs. treatment), the use of masks, triggers for 
the use of non-pharmaceutical interventions, especially school closures 
and social distancing.
    Question 10b. What other planning guidance do you need?
    Answer. There are three guidance documents currently in Federal 
clearance, which, when released, will provide important planning 
assistance to the States. The pending documents are:
   Proposed Guidance on Antiviral Drug Prophylaxis during an 
        Influenza Pandemic;
   Proposed Considerations for Antiviral Drug Stockpiling by 
        Employers in Preparation for an Influenza Pandemic; and,
   Proposed Guidance on Workplace Stockpiling of Respirators 
        and Facemasks for Pandemic Influenza.
    There has been a strong emphasis on planning for stockpiling, 
distribution and administration of pharmaceutical countermeasures for 
pandemic flu (vaccines and antivirals). While these interventions are 
an important defense against a pandemic threat, States would benefit 
from additional focus on non-pharmaceutical countermeasures. The 
document released in February 2007, Interim Pre-Pandemic Planning 
Guidance: Community Strategy for Pandemic Influenza Mitigation in the 
United States, was an excellent starting point for planning in this 
area. States would benefit from further discussion on some key points 
such as school closures and social distancing, and the intricacies of 
avoiding unintended consequences from these control measures. Examples 
include optimal methods for providing meals when schools are closed to 
children who depend on subsidized school lunch programs and providing 
guidance to the public on home care of sick individuals (when to seek 
care, proper infection control practices, etc.).
    It should be noted, however, that sustained funding to support 
State pandemic planning will be necessary to operationalize existing 
and new guidance documents.
    Question 11. According to the Implementation Plan for the National 
Strategy for Pandemic Influenza, ``State, local, and tribal law 
enforcement agencies should coordinate with appropriate medical 
facilities and countermeasure distribution centers in their 
jurisdictions to coordinate security matters, within 6 months'' of when 
the Plan was released--so the deadline would have been October 2005. To 
your knowledge, has this coordination taken place? If so, how, and if 
not, how would you recommend this happen?
    Answer. Yes, we have done some coordination has taken place but the 
process is ongoing. Rhode Island plans and responds in accordance with 
the National Response Framework's Emergency Support Function (ESF) 
structure. The State Police lead ESF-13 and provide assistance in 
planning with local law enforcement agencies. Through the SNS/CRI 
program, the Rhode Island Department of Health has engaged in contracts 
with each municipality in the State for SNS/CRI planning. The security 
issues faced at the local level are addressed by the State Police in 
coordination with HEALTH. Currently, plans are available for 37 of the 
State's 39 municipalities. These plans would be used in coordination 
with the health care service regions' plans for countermeasure 
distribution.
    Each of these health care service regions has a planning committee, 
comprised of hospitals, health centers, first responders, and community 
partners to address the utilization of medical and non-medical assets 
within the region.
    Question 12. The Implementation Plan for the National Strategy for 
Pandemic Influenza provided this task, ``All Federal, State, local, 
tribal, and private sector medical facilities should ensure that 
protocols for transporting influenza specimens to appropriate reference 
laboratories are in place within 3 months''--which would have been July 
2006. Are these protocols in place in Rhode Island? What challenges did 
you face in executing this task?
    Answer. Yes, these protocols are in place. We have an established 
courier system to deliver influenza specimens to the State Health 
Laboratory, which is the only reference laboratory in the State. Given 
the small geographic area involved and the concentration of the 
majority of facilities submitting specimens in relatively close 
proximity to the lab, there have not been any particular challenges 
associated with implementing this plan.
    Question 13. What is your opinion of the decision to centralize 
Disaster Medical Assistance Team assets in your region? What problems 
do you see with this approach; especially in the context of a 
biological threat that sweeps the entire region?
    Answer. The National Disaster Medical System (NDMS) and one of its 
components parts, DMAT, is a cornerstone of our country's mass casualty 
system. The public health community supported the decision to return 
management and oversight responsibilities of the NDMS to the Department 
Health and Human Services and commends HHS's efforts to systematically 
identify and address gaps. Regarding centralization, the challenge is 
to strike the careful balance between bringing about material 
management and human capital efficiencies that may come about with 
centralized services with the assurance of State partnership and ready 
availability of the assets when needed. We cannot afford unintended 
consequences that could possibly delay response time and effectiveness.
    Rhode Island has a particularly strong DMAT and the regionalization 
has stripped the RI-1 DMAT of independent funding, causing them to lose 
the space that NDMS paid to have refurbished as a warehouse, training, 
and administrative space. The RI-1 DMAT was deployed in two teams 
during the recent hurricanes and was faced with the inability to 
utilize their own cache, which was designed, organized, and trained 
with to meet the needs of the team specifically. These changes impact 
not only the RI-1 DMAT's ability to respond efficiently and effectively 
in a Federal deployment, but also in their ability to provide medical 
assets within the State during a local/State emergency.
    Question 14. It is clear that we need to increase efficiencies in 
public health preparedness. How do you suggest that be done?
    Answer. Within Rhode Island efficiency can be gained through 
continued efforts to support the intrastate regional team models. Rhode 
Island has organized a robust hazardous materials and decontamination 
team capability. Additionally, Rhode Island has used this same model to 
support law enforcement WMD tactical teams, Urban Search and Rescue and 
Disaster Medical Response resources. The in-State regionalization 
provides an efficient platform for use of grant funds, it provides for 
standardized equipment and model training programs while avoiding 
duplication of effort across multiple jurisdictions.
    Question 15. Do you think that the Federal Regional Planning/
Coordinating Committee meetings are useful? If not, why not?
    Answer. Conceptually, yes, but they have yet to be executed in a 
manner that allows for useful collaboration throughout the region.
    Question 16. As you know, public health has been identified as one 
of the critical infrastructures of our Nation. Have you been included 
in the planning undertaken by the Department of Homeland Security to 
protect the public health infrastructure? From what you know about this 
work, how does it affect what you are trying to accomplish in your 
position? What more do you think needs to be done in this regard, 
especially in advance of an influenza pandemic?
    Answer.
   Homeland Security Presidential Directive 7 (HSPD-7) and the 
        National Infrastructure Protection Plan (NIPP) provide the 
        overarching framework for a structured partnership between 
        Government and the private sector for protection of Critical 
        Infrastructure and Key Resources (CI/KR).
   The Healthcare and Public Health (HPH) Government 
        Coordinating Council (GCC) brings together Federal, State, 
        local, tribal and territorial interests to identify and develop 
        collaborative strategies that advance critical infrastructure 
        protection. The overall vision of the HPH Sector is to prevent 
        or minimize damage to, or destruction of, the Nation's health 
        care and public health infrastructure.
     The private sector members comprise the Healthcare and 
            Public Health Sector Coordinating Council (SCC), while the 
            public sector comprises the GCC. The lead for the HPH 
            Sector is the Department of Health and Human Services 
            (HHS), serving as the Sector-Specific Agency (SSA).
     Current State health agencies serving on the GCC on behalf 
            of ASTHO: the Alaska Department of Health and Social 
            Services, Michigan Department of Community Health, and the 
            Washington State Department of Health. Members from these 
            State health agencies provide the State perspective on 
            issues related to health care and public health in relation 
            to CI/KR. These members also sit on workgroups associated 
            with the GCC to identify core metrics to measure critical 
            infrastructure and key resource capabilities as well as 
            research and development initiatives. Participation is 
            mainly through conference calls either on a monthly or 
            quarterly basis, and possibly one in-person meeting.
   Goals of the Sector specific to Public Health include 
        Workforce Sustainability, Physical Security, Cyber Security, 
        and Service Continuity.
   Path Forward: Moving forward, the Healthcare and Public 
        Health Sector will focus on:
     Assessing procedures for collecting, validating and 
            updating CI/KR protection and preparedness-related data to 
            assure that the processes are cost-effective, meet HSPD-7 
            needs, and are not burdensome.
     Identifying a process for coordinating with other sectors 
            to implement cross-sector programs.
     Developing a methodology to measure and assess the 
            effectiveness of the HPH Sector's preparedness and response 
            capabilities to various threat scenarios or real events.
    Unfortunately, due to staffing shortages, the Rhode Island 
Emergency Management Agency does not currently have an individual 
supporting DHS's Critical Infrastructure/Key Resources planning. While 
public health is invited to the planning and response table, we have 
yet to begin working with our partners who manage the State's Homeland 
Security Grant on the steps to be taken to protect the public health 
infrastructure.
    Question 17. From the public health perspective, there are certain 
similarities and differences between disasters and pandemics. Can you 
describe a few of both, and talk about the implications you see for 
Federal support from both DHS and HHS?
    Answer. Pandemics are widespread epidemics affecting large 
populations throughout the world. Disasters (such as hurricanes or 
release of an infectious agent in a jurisdiction) and pandemics have 
impacts on health, critical infrastructure, the economy, and 
(potentially) national security. In most localized disasters, resources 
can be redirected from non-affected areas to affected areas, including 
first responders (through mechanisms such as EMAC), countermeasures and 
medical supplies, and other infrastructure-related support. The 
availability of this support enhances the response and often speeds up 
the recovery process.
    A pandemic is a worldwide outbreak of an infectious disease that 
will have broader and potentially longer term impacts on health, 
critical infrastructure, the economy, and national security. In the 
case of an influenza pandemic, all jurisdictions will be affected 
within a relatively short time frame making it difficult to share 
resources. As a result, systems will become progressively overwhelmed 
for longer periods of time. There may also be increased absenteeism, 
from critical infrastructure and response-related jobs, due to fear of 
the virus or the need to care for a loved one who cannot obtain care in 
a traditional medical setting. The Federal Government has been clear 
that States and local areas should not anticipate receiving Federal 
support during a pandemic, as it is not possible to provide support to 
all States at the same time.
    It is important for DHS and HHS to provide sustained funding to 
States to build response capabilities, conduct exercises and then 
refine pandemic influenza and all-hazards preparedness plans. These 
capabilities will enable States to better respond on their own when a 
pandemic strikes.
    DHS and HHS should also provide guidance on whether and how 
reimbursement may be available through the Stafford Act for infectious 
disease-related response activities.

 Questions From Chairman James R. Langevin to Major General Robert T. 
  Bray, Adjutant General, State of Rhode Island; Commanding General, 
     Rhode Island National Guard; Director, Rhode Island Emergency 
    Management; and Homeland Security Advisor, State of Rhode Island

    Question 1. As a military officer, you are well aware of the 
military approach to planning. Given all of your experience with 
operating in the civilian context, though, you are also well aware that 
most civilians, including the Federal Government, do not use the 
military approach. What advice would you give your civilian 
counterparts? How have you been able to get other civilian agencies 
here in the State to come on board?
    Answer. The Military Decision Making Process (MDMP) provides a 
formal, interactive and dynamic way to generate feasible, acceptable 
and supportable courses of action to solve problems, but it is not 
unlike other methods used by other entities. When developing a plan to 
adequately accomplish a goal or solve a problem, the process matters 
more than the model used. An effective planning model must contain 
processes that facilitate the examination of all factors that will or 
may affect an organization's attempt to solve a problem.
    The Rhode Island Emergency Management Agency (RIEMA) offers and 
conducts numerous courses on the Incident Command System (ICS) to 
educate responders and response agencies on the methodology for an 
organized and coordinated response to emergencies. Additionally, RIEMA 
engages agencies and stakeholders through participation in numerous 
committee meetings. Education and consensus building is our primary 
tool for gaining cooperation and coordination toward integrated 
emergency management.
    Question 2. Describe the challenges of being triple-hatted as the 
Adjutant General, EMA Director, and Homeland Security Director. How do 
you think holding these and other positions simultaneously has helped 
you to address threats to the State and its citizens?
    Answer. There are many challenges associated with being triple-
hatted but they are not uncharacteristic of a chief executive's 
position. In Rhode Island form fits function due to the inter- and 
intra-agency connection, as well as the common strategic nature of 
emergency management. In order to effectively meet these challenges, it 
is essential to have a competent staff and a solid adherence to core 
organizational competencies relating to span of control, chain of 
command, and unity of command.
    The ability of the Adjutant General as a federally recognized 
General Officer of the United States military to function in several 
authoritative statuses (Title 32, Title 10, State Active Duty, and as a 
State employee) provides and allows for bridging requirements and 
institutions in the interest of responsive emergency management. An 
Adjutant General with Emergency Management experience may be the only 
official who can effectively communicate strategically with Federal 
agencies such as, USNORTHCOM, USARMYNORTH, NGB, DHS, and FEMA.
    Question 3. Not every State has incorporated the National Guard, 
emergency management, and homeland security to the extent that you have 
here in Rhode Island. Please explain how this works in the State of 
Rhode Island. Is this something that you would recommend all States 
doing? If so, why, and if not, why not?
    Answer. The incorporation of the agencies is statutory according to 
Rhode Island State law. Approximately 12 other States incorporated the 
responsibility for these agencies under their Adjutant General. While 
many Federal laws apply to provide a measure of continuity, the 
uniqueness of each State's laws provides significant diversity. 
Integration of the agencies for emergency response, which includes 
training, planning, and preparation, is what may be most unique. It has 
been my initiative to merge agency capabilities as much as regulations 
will allow. The challenges to that initiative have been internal 
personalities and turf, labor laws, Federal regulations and not 
surprisingly, paradigms. Integration of capabilities between the 
agencies make sense corporately, reduces duplication of effort, 
increases efficiency, maximizes resources and streamlines the process 
of delivering limited resources in a timely manner, where and when they 
are needed. Consequently, I highly recommend incorporation as an 
organizational format. Essential, however is the need for statutory 
authority as well as responsibility. The incorporated agency must have 
the statutory authority to affect and ensure coordination, cooperation, 
and compliance within the agency as well as among the multiple agencies 
and jurisdictions receiving support.
    Question 4. Do you believe that the Rhode Island Emergency 
Management Agency has enough funding to cover planning efforts? How 
much more funding do you think is necessary? What other planning 
resources do you need?
    Answer. The RIEMA does not have sufficient funds to accomplish its 
statutory obligations because of the Federal grant process and State 
budget deficit. The FMA/DHS grant application process and format does 
not adequately provide for a uniquely governed State, like Rhode 
Island, to promote its hazards and infrastructure to compete for 
funding. Additionally, the percentage share of the grant funding that 
the State is eligible for limits the agencies' performance. Second, the 
budget deficit in Rhode Island limits the amount of funds available to 
the agencies. Therefore, support for both the dollar and ``in-kind'' 
funding required to match and fully utilize Federal grant dollars is 
limited.
    Question 5. What additional resources are needed for you to address 
emerging biological threats--including pandemic influenza, 
bioterrorism, etc.?
    Answer. Effectively addressing emerging threats within the full 
spectrum of CBRNE, including biological threats, requires adequate 
situational awareness (SA) and the ability to work within a common 
operating picture (COP). In order to obtain SA and COP, personnel, 
funding, knowledge, authority, equipment, and logistical support are 
essential. The best way to address emerging biological threats is to 
prevent them from happening. A proactive approach requires an inter-
agency fusion cell, intelligence, communication, a well-trained staff 
capable of processing SA into a COP which facilitates mitigation. In 
order for Rhode Island to achieve that level of capability, the RIEMA 
needs additional trained personnel, better two-way intelligence sharing 
between State and Federal agencies, statutory enforcement authority for 
local inter-agency cooperation, and the equipment and statutory 
authority to support a joint inter-agency coordination center.
    Question 6. What problems do you face in spending Federal dollars? 
Is the Rhode Island State Budget cycle in synch with those of the 
Federal Departments and agencies?
    Answer. There are two primary problems in spending Federal dollars. 
The first is the ability of the municipalities supported by RIEMA to 
both appropriately spend their grant funds and execute their grant 
funds in a timely manner. Some local agencies have limited accounting 
ability to execute large sums of Federal grant dollars within the 
specified time once a project is approved limit. The second problem is 
the ability to produce either the dollar or in-kind State match, given 
both the nature of the State budget and the unique local government 
dependence upon State support. The State of Rhode Island's budget cycle 
differs from the Federal Government's by beginning on July 1 instead of 
October 1.
    Question 7. How has the State Fusion Center assisted in State 
efforts to address emerging biological threats?
    Answer. The State Fusion Center works well with other law 
enforcement agencies, local and Federal, to address potential or 
emerging threats. The State Fusion Cell coordinates and communicates 
across State lines for SA. The State Fusion Center is law enforcement-
centric.
    Question 8. Please provide your perspective on training and 
exercising. Do you believe your organization is training the way it 
fights (i.e., the way it would need to in order to respond to 
biological threats)?
    Answer. There are several levels of competency for emergency 
response and degrees with each of them. The RIEMA provides training and 
exercises, as well as support to local and Federal agencies in the 
conduct of training and exercises. The RIEMA supports a robust training 
and exercise regimen, which is necessary to accommodate new 
initiatives, as well as to train a constantly rotating response force. 
First responders are very competent at the tactical level.
    Question 9. The best preparation for public health emergencies 
involves public health workers who plan and exercise their plans for 
emergency response jointly with local elected officials, police and 
fire departments, emergency managers, the National Guard, hospitals, 
physicians, schools, businesses, and other community partners. Please 
describe how this has occurred in Rhode Island regarding emerging 
biological threats like pandemic influenza and bioterrorism.
    Answer. The Rhode Island Department of Health serves as the State 
lead agency for all matter of emergency planning relating to threats 
that may result in a public health emergency. Most notable is their 
membership in the Emergency Management Advisory Committee. Dr Gifford 
and I co-chaired the recent State multi-agency effort to complete the 
State's Pandemic Influenza plan, which focused on the continuity of 
government through the COOP site. The State Health Department has 
involved all public and private health agencies in National Incident 
Management System Incident Command training. They are a model agency 
for preparation and support.
    Question 10a. Recently, GAO released a report on the status of 
State and local planning and exercising for an influenza pandemic. GAO 
found that while all 50 States have developed an influenza pandemic 
plan in accordance with Federal pandemic funding requirements, a review 
conducted by the Department of Health and Human Services concluded that 
these plans had ``many major gaps'' in 16 of 22 priority areas, such as 
the policy process for school closures and communications, community 
containment and medical surge capacity. GAO also found that all States 
and localities that had received pandemic funds met the requirements to 
conduct a pandemic exercise to test their plans. We know updated plans 
were due in July for a second round of reviews led by the Department of 
Health and Human Services.
    What is the current status of planning and exercising for an 
influenza pandemic in Rhode Island?
    Answer. The Office of the Adjutant General, including the Rhode 
Island Emergency Management Agency and the Rhode Island National Guard 
is the lead coordinating agency for emergency planning, preparation and 
response to emergencies and disasters of all types in the State of 
Rhode Island. With respect to the remaining questions, the Adjutant 
General is not the subject matter expert or lead technical agency. The 
Rhode Island Department of Health is the primary subject matter expert 
for matters of health, including the DMAT and the Pandemic Influenza. 
Therefore the remaining questions are respectfully deferred to the 
Rhode Island Department of Health.
    Question 10b. What were the identified gaps in Rhode Island's 
pandemic plan from the HHS-led interagency review conducted in 2007? 
How did you address those gaps in the current update to your State plan 
and how do you plan to address them in the future?
    Answer. The Office of the Adjutant General, including the Rhode 
Island Emergency Management Agency and the Rhode Island National Guard 
is the lead coordinating agency for emergency planning, preparation and 
response to emergencies and disasters of all types in the State of 
Rhode Island. With respect to the remaining questions, the Adjutant 
General is not the subject matter expert or lead technical agency. The 
Rhode Island Department of Health is the primary subject matter expert 
for matters of health, including the DMAT and the Pandemic Influenza. 
Therefore the remaining questions are respectfully deferred to the 
Rhode Island Department of Health.
    Question 10c. Please describe the pandemic exercises that Rhode 
Island has held or participated in and whether any changes were made to 
the State's pandemic planning as a result of these exercises. Do you 
plan to hold any pandemic exercises in the future at the State and/or 
local levels? If yes, please describe the exercises you have planned.
    Answer. The Office of the Adjutant General, including the Rhode 
Island Emergency Management Agency and the Rhode Island National Guard 
is the lead coordinating agency for emergency planning, preparation and 
response to emergencies and disasters of all types in the State of 
Rhode Island. With respect to the remaining questions, the Adjutant 
General is not the subject matter expert or lead technical agency. The 
Rhode Island Department of Health is the primary subject matter expert 
for matters of health, including the DMAT and the Pandemic Influenza. 
Therefore the remaining questions are respectfully deferred to the 
Rhode Island Department of Health.
    Question 11a. While the Federal Government has provided pandemic 
influenza guidance to the non-Federal public and private sectors, non-
Federal officials have told GAO that they would welcome additional 
guidance from the Federal Government in a number of areas to help 
better plan and exercise for pandemic influenza.
    What Federal assistance have you asked for, or do you need, to 
address the identified gaps in Rhode Island's pandemic plan?
    Answer. The Office of the Adjutant General, including the Rhode 
Island Emergency Management Agency and the Rhode Island National Guard 
is the lead coordinating agency for emergency planning, preparation and 
response to emergencies and disasters of all types in the State of 
Rhode Island. With respect to the remaining questions, the Adjutant 
General is not the subject matter expert or lead technical agency. The 
Rhode Island Department of Health is the primary subject matter expert 
for matters of health, including the DMAT and the Pandemic Influenza. 
Therefore the remaining questions are respectfully deferred to the 
Rhode Island Department of Health.
    Question 11b. What other planning guidance do you need?
    Answer. The Office of the Adjutant General, including the Rhode 
Island Emergency Management Agency and the Rhode Island National Guard 
is the lead coordinating agency for emergency planning, preparation and 
response to emergencies and disasters of all types in the State of 
Rhode Island. With respect to the remaining questions, the Adjutant 
General is not the subject matter expert or lead technical agency. The 
Rhode Island Department of Health is the primary subject matter expert 
for matters of health, including the DMAT and the Pandemic Influenza. 
Therefore the remaining questions are respectfully deferred to the 
Rhode Island Department of Health.
    Question 12. According to the Implementation Plan for the National 
Strategy for Pandemic Influenza, ``State, local, and tribal law 
enforcement agencies should coordinate with appropriate medical 
facilities and countermeasure distribution centers in their 
jurisdictions to coordinate security matters, within 6 months'' of when 
the Plan was released--so the deadline would have been October 2005. To 
your knowledge, has this coordination taken place? If so, how, and if 
not, how would you recommend this happen?
    Answer. The Office of the Adjutant General, including the Rhode 
Island Emergency Management Agency and the Rhode Island National Guard 
is the lead coordinating agency for emergency planning, preparation and 
response to emergencies and disasters of all types in the State of 
Rhode Island. With respect to the remaining questions, the Adjutant 
General is not the subject matter expert or lead technical agency. The 
Rhode Island Department of Health is the primary subject matter expert 
for matters of health, including the DMAT and the Pandemic Influenza. 
Therefore the remaining questions are respectfully deferred to the 
Rhode Island Department of Health.
    Question 13. What is your opinion of the decision to centralize 
Disaster Medical Assistance Team assets in your region? What problems 
do you see with this approach, especially in the context of a 
biological threat that sweeps the entire region?
    Answer. The Office of the Adjutant General, including the Rhode 
Island Emergency Management Agency and the Rhode Island National Guard 
is the lead coordinating agency for emergency planning, preparation and 
response to emergencies and disasters of all types in the State of 
Rhode Island. With respect to the remaining questions, the Adjutant 
General is not the subject matter expert or lead technical agency. The 
Rhode Island Department of Health is the primary subject matter expert 
for matters of health, including the DMAT and the Pandemic Influenza. 
Therefore the remaining questions are respectfully deferred to the 
Rhode Island Department of Health.

Questions From Chairman James R. Langevin to Mr. Thomas J. Kilday, Jr., 
 Homeland Security Program Manager, Rhode Island Emergency Management 
                                 Agency

    Question 1. What is your opinion of Federal regional offices of all 
types? Do you think that regionalization is a good model for Rhode 
Island?
    Answer. In my opinion the Federal Regional offices provide a 
valuable link for Rhode Island Emergency Management Agency and other 
State agencies to seek advice, work on planning issues and coordinate 
grant activities. A regional office understands the local challenges 
unique to the region in question rather than viewing each State as just 
another State from the national level. Additionally, the regional 
office understands the Federal policies and the State polices for their 
constituent States; this knowledge allows the regional offices to help 
States interpret policy. Often the regional office serves as a mediator 
on issues that require further clarification with the Federal offices. 
The only gap lies in the area of funding and planning actions. 
Currently the funding is provided at the Federal, State, and local 
level. There is not a mechanism to ensure regionally based program 
funding and these programs are often the first programs cut during a 
budget crunch or a department re-organization. During my time serving 
the State I have personally seen the Federal regional model bear the 
effects of budget constraints and reorganization.
    Question 2a. DHS and HHS recently led a series of five workshops 
for States in the five Federal influenza pandemic regions primarily to 
discuss the current update of State and Territorial pandemic plans. A 
Regional Principal Federal Official (PFO) and Federal Coordinating 
Officer (FCO) for pandemic influenza are pre-designated for each of 
these five pandemic regions.
    What was your impression of the DHS/HHS led workshop held in 
January 2007 for pandemic Region A? Did you find it helpful in planning 
for a pandemic? Should more regional meetings of State and Federal 
officials be held on pandemic influenza? How could they be made more 
useful?
    Question 2b. How has the regional PFO assisted with your pandemic 
preparedness efforts?
    Answer. The answer to question No. 2 part A & B will be provided by 
Dr. Gifford from the Rhode Island Department of Health. Rhode Island 
Emergency Management has partnered with Rhode Island Health Department 
on pandemic planning over the years and has collaborated on the answers 
to the pandemic questions related to this testimony.
    Question 3. How would you recommend that entities within the 
Federal Government better align and coordinate the grants that they put 
out to the States and territories?
    Answer. The Federal Government could improve the grant process by 
aligning programs and requirements across Federal departments and 
agencies. In Rhode Island we establish stakeholder committees to 
facilitate the planning and grant processes to ensure alignment with 
programs ongoing in the State. This coordination is required within the 
grant guidance for each Federal program whether it is a DHS or DHHS 
program. I find it interesting the States are required to plan with 
intra- and inter-State stakeholders although we often find that this is 
not the case with the Federal departments. There are conflicting 
timelines, program requirements and duplication of programs across a 
number of Federal agencies often with extremely compressed timelines.
    Question 4. Given the decision to centralize the DMAT in the 
region, what do you think needs to be done? Do you think that the State 
needs to develop its own disaster medical assistance assets?
    Answer. I feel that this decision by the ASPR validates Rhode 
Island's decision more than 5 years ago to go forward with plans to 
build a cache of response equipment and capacity to stand up a Field 
Hospital and other response capabilities independent of the team's 
Federal Cache. With more than 200 RI DMAT members, and more than 400 
Medical Reserve Corps members, the RI DMAT Team has depth in every 
position on the team. They have demonstrated many times that they can 
deploy assets on both Federal deployments and calls for assistance from 
Rhode Island public health and emergency management officials for in-
State needs. The team now has a substantial cache of equipment and 
mechanisms in place to train and deploy credential-verified volunteer 
health care providers and support personnel to respond to extraordinary 
medical needs. Other States that have come to depend upon the National 
Disaster Medical System (NDMS) DMAT teams should look to Rhode Island's 
model in this area.
    Question 5. How do you think decisions will be made when medical 
professionals are in the National Guard, and would need to be called up 
for Guard service and medical service simultaneously?
    Answer. The question may be moot in the sense that when the 
National Guard deploys any of its assets, the members have no choice 
when it comes to deploying. They are obligated to go. This has resulted 
in medical personnel shortages in every State as National Guard and 
Reservists have been deployed to the wars in Iraq and Afghanistan. 
Health care providers at many levels are already in short supply, and 
their deployment will only make adequate staffing more difficult. 
Recruiting health care providers for volunteer service from non-acute 
care facilities is one answer as to how to fill vacancies left by 
deployments of the Guard and Reserve. The Medical Reserve Corps is an 
ideal organization to provide this recruitment and training, as has 
been demonstrated in Rhode Island.
    Question 6. Is there funding provided to the Rhode Island EMA to do 
critical infrastructure and/or continuity of operations planning?
    Answer. Critical infrastructure planning in Rhode Island is 
considered one of the responsibilities of the Homeland Security Program 
Manager and other staff. There is not anyone specifically tasked to 
work on critical infrastructure planning at this time. The funding is 
provided in part through the Department of Homeland Security grant 
program funds that Rhode Island receives. Ideally Rhode Island would 
have a single individual working on critical infrastructure planning 
and Continuity of Operations Planning but budget constraints and 
resource allocation has not allowed this to happen. There are programs 
such as the Buffer Zone Protection Program that provide funding to 
support critical infrastructure efforts although this funding goes 
directly to the critical infrastructure owner to provide for protective 
measures against attacks.
    Question 7. What do you think can be done to increase efficiencies 
in emergency preparedness?
    Answer. Within Rhode Island efficiency can be gained through 
continued efforts to support the intra-State regional team models. 
Rhode Island has organized a robust hazardous materials and 
decontamination team capability. Additionally, Rhode Island has used 
this same model to support law enforcement WMD tactical teams, Urban 
Search and Rescue and Disaster Medical Response resources. The in-State 
regionalization provides an efficient platform for use of grant funds, 
it provides for standardized equipment and model training programs 
while avoiding duplication of effort across multiple jurisdictions.

    Questions From Chairman James R. Langevin to Peter T. Ginaitt, 
      Director, Emergency Preparedness, Lifespan Hospital Network

    Question 1. What is your opinion of Federal regional offices of all 
types? Do you think that regionalization is a good model for Rhode 
Island?
    Answer. Response was not provided at the time of publication.
    Question 2a. DHS and HHS recently led a series of five workshops 
for States in the five Federal influenza pandemic regions primarily to 
discuss the current update of State and territorial pandemic plans. A 
Regional Principal Federal Official (PFO) and Federal Coordinating 
Officer (FCO) for pandemic influenza are pre-designated for each of 
these five pandemic regions.
    What was your impression of the DHS/HHS led workshop held in 
January 2007 for pandemic Region A? Did you find it helpful in planning 
for a pandemic? Should more regional meetings of State and Federal 
officials be held on pandemic influenza? How could they be made more 
useful?
    Answer. Response was not provided at the time of publication.
    Question 2b. How has the regional PFO assisted with your pandemic 
preparedness efforts?
    Answer. Response was not provided at the time of publication.
    Question 3. We understand that a decision has been made that for 
mass casualties, the hospitals will take over the Convention Center. 
What happens when this private sector entity wants and needs its asset 
back to start their business enterprise again?
    Answer. Response was not provided at the time of publication.
    Question 4. Please give us your perspective on altered standards of 
care. How do you recommend that the necessary discussions take place 
and difficult decisions be made--in the State of Rhode Island and 
throughout the Nation?
    Answer. Response was not provided at the time of publication.
    Question 5. What additional guidance do you think the Federal 
Government still needs to provide to the States and territories--
regarding altered standards of care, pandemic influenza, emerging 
biological threats, bioterrorism, etc.?
    Answer. Response was not provided at the time of publication.
    Question 6. What additional resources are needed for the hospital 
network in Rhode Island to address emerging biological threats--
including pandemic influenza, bioterrorism, etc.?
    Answer. Response was not provided at the time of publication.
    Question 7. What problems does the hospital network in Rhode Island 
face in spending Federal dollars? Is the Rhode Island State budget 
cycle in synch with those of the Federal departments and agencies?
    Answer. Response was not provided at the time of publication.
    Question 8. Please provide your perspective on training and 
exercising. Do you believe your organization is training the way it 
fights (i.e., the way it would need to in order to respond to 
biological threats)?
    Answer. Response was not provided at the time of publication.
    Question 9. The best preparation for public health emergencies 
involves public health workers who plan and exercise their plans for 
emergency response jointly with local elected officials, police and 
fire departments, emergency managers, the National Guard, hospitals, 
physicians, schools, businesses, and other community partners. Please 
describe how this has occurred in Rhode Island regarding emerging 
biological threats like pandemic influenza and bioterrorism.
    Answer. Response was not provided at the time of publication.
    Question 10. According to the Implementation Plan for the National 
Strategy for Pandemic Influenza, ``State, local, and tribal law 
enforcement agencies should coordinate with appropriate medical 
facilities and countermeasure distribution centers in their 
jurisdictions to coordinate security matters, within 6 months'' of when 
the Plan was released--so the deadline would have been October 2005. To 
your knowledge, has this coordination taken place? If so, how, and if 
not, how would you recommend this happen?
    Answer. Response was not provided at the time of publication.
    Question 11. The Implementation Plan for the National Strategy for 
Pandemic Influenza states that, ``All health care facilities should 
develop, test, and be prepared to implement infection control campaigns 
for pandemic influenza, within 6 months'' of when the Plan was 
released--so the deadline was October 2006. Hospitals and other health 
care facilities in Rhode Island are more than familiar with infection 
control measures. Can you describe the specific challenges in 
identifying and implementing infection control measures for pandemic 
influenza?
    Answer. Response was not provided at the time of publication.
    Question 12. What is your opinion of the decision to centralize 
Disaster Medical Assistance Team assets in your region? What problems 
do you see with this approach, especially in the context of a 
biological threat that sweeps the entire region? Or will having those 
assets centralized help with a widespread biological event? If so, how?
    Answer. Response was not provided at the time of publication.

                                 
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