[Senate Hearing 110-465]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 110-465
 
         PANDEMIC INFLUENZA: STATE AND LOCAL EFFORTS TO PREPARE

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

                                HEARING

                               before the

                  AD HOC SUBCOMMITTEE ON STATE, LOCAL,
                    AND PRIVATE SECTOR PREPAREDNESS
                            AND INTEGRATION

                                 of the

                              COMMITTEE ON
                         HOMELAND SECURITY AND
                          GOVERNMENTAL AFFAIRS
                          UNITED STATES SENATE


                       ONE HUNDRED TENTH CONGRESS

                             FIRST SESSION

                               __________

                            OCTOBER 3, 2007

                               __________

       Available via http://www.gpoaccess.gov/congress/index.html

       Printed for the use of the Committee on Homeland Security
                        and Governmental Affairs


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        COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS

               JOSEPH I. LIEBERMAN, Connecticut, Chairman
CARL LEVIN, Michigan                 SUSAN M. COLLINS, Maine
DANIEL K. AKAKA, Hawaii              TED STEVENS, Alaska
THOMAS R. CARPER, Delaware           GEORGE V. VOINOVICH, Ohio
MARK L. PRYOR, Arkansas              NORM COLEMAN, Minnesota
MARY L. LANDRIEU, Louisiana          TOM COBURN, Oklahoma
BARACK OBAMA, Illinois               PETE V. DOMENICI, New Mexico
CLAIRE McCASKILL, Missouri           JOHN WARNER, Virginia
JON TESTER, Montana                  JOHN E. SUNUNU, New Hampshire

                  Michael L. Alexander, Staff Director
     Brandon L. Milhorn, Minority Staff Director and Chief Counsel
                  Trina Driessnack Tyrer, Chief Clerk


 AD HOC SUBCOMMITTEE ON STATE, LOCAL, AND PRIVATE SECTOR PREPAREDNESS 
                            AND INTEGRATION

                   MARK L. PRYOR, Arkansas, Chairman
DANIEL K. AKAKA, Hawaii              JOHN E. SUNUNU, New Hampshire
MARY L. LANDRIEU, Louisiana          GEORGE V. VOINOVICH, Ohio
BARACK OBAMA, Illinois               NORM COLEMAN, Minnesota
CLAIRE McCASKILL, Missouri           PETE V. DOMENICI, New Mexico
JON TESTER, Montana                  JOHN WARNER, Virginia

                     Kristin Sharp, Staff Director
                Michael McBride, Minority Staff Director
                        Amanda Fox, Chief Clerk


                            C O N T E N T S

                                 ------                                
Opening statements:
                                                                   Page
    Senator Pryor................................................     1
    Senator Akaka................................................    10
    Senator Sununu...............................................    15
Prepared statement:
    Senator Obama................................................    33

                               WITNESSES
                       Wednesday, October 3, 2007

Rear Admiral William C. Vanderwagen, M.D., Assistant Secretary 
  for Preparedness and Response, U.S. Department of Health and 
  Human Services.................................................     3
B. Tilman Jolly, M.D., Associate Chief Medical Officer for 
  Medical Readiness, Office of Health Affairs, U.S. Department of 
  Homeland Security..............................................     4
Paul K. Halverson, DrPH, MHSA, FACHE, Director and State Health 
  Officer, Arkansas Department of Health.........................    16
Christopher M. Pope, Director, Homeland Security and Emergency 
  Management, State of New Hampshire.............................    18
Yvonne S. Madlock, MAT, Director, Memphis and Shelby County 
  Health Department, Memphis, Tennessee, on behalf of the 
  National Association for County and City Health Officials......    20

                     Alphabetical List of Witnesses

Halverson, Paul K., DrPH, MHSA, FACHE:
    Testimony....................................................    16
    Prepared statement...........................................    56
Jolly, B. Tilman, M.D.:
    Testimony....................................................     4
    Prepared statement...........................................    49
Madlock, Yvonne S., MAT:
    Testimony....................................................    20
    Prepared statement...........................................    75
Pope, Christopher M.:
    Testimony....................................................    18
    Prepared statement...........................................    66
Vanderwagen, Rear Admiral William C., M.D.:
    Testimony....................................................     3
    Prepared statement...........................................    34

                                APPENDIX

Questions and responses for the Record from Dr. Jolly............    84
Chart submitted for the Record by Senator Pryor..................    90


         PANDEMIC INFLUENZA: STATE AND LOCAL EFFORTS TO PREPARE

                              ----------                              


                       WEDNESDAY, OCTOBER 3, 2007

                                   U.S. Senate,    
               Ad Hoc Subcommittee on State, Local, and    
             Private Sector Preparedness and Integration,  
                      of the Committee on Homeland Security
                                        and Governmental Affairs,  
                                                    Washington, DC.
    The Subcommittee met, pursuant to notice, at 2:35 p.m., in 
Room SD-342, Dirksen Senate Office Building, Hon. David Pryor, 
Chairman of the Subcommittee, presiding.
    Present: Senators Pryor, Akaka, and Sununu.

               OPENING STATEMENT OF SENATOR PRYOR

    Senator Pryor. I call the Subcommittee to order. Senator 
Sununu is on his way, but he wanted us to go ahead and get 
started, so he will join us and probably have some questions in 
a few moments.
    Let me thank everyone for being here and welcome everyone 
to the Senate and specifically to our Ad Hoc Subcommittee on 
State, Local, and Private Sector Preparedness and Integration. 
I know everybody is busy, has a lot going on, but to come and 
talk about something as important as a flu pandemic, I think it 
is a very important part of the process to make sure that we 
are prepared. We hope that day never comes, but we hope that 
this country is prepared if that day should come.
    I would especially like to welcome Dr. Paul Halverson. 
Thank you for coming up from Arkansas and I look forward to 
hearing from you in the second panel.
    Let me just make a few opening comments and then I would 
like to jump right in with our first panel. The first thing I 
would say is that for most Americans, the idea of a flu 
pandemic is abstract. When we hear about it on the news, it 
seems to be pretty much in birds and on the other side of the 
world. I think for a lot of people in this country, even though 
they know it is a potential threat, it is not real, and I think 
we, as leaders and as planners, need to make sure that we are 
ready in the event that it does come.
    The thing that concerns the experts about a flu pandemic is 
when you look at bird flu around the world, the numbers are 
startling. How rapidly it spreads through an avian population 
is very alarming, but also when you look at the humans who have 
been infected--there have been 329 infected with bird flu and 
201 have passed away. So 61 percent of the people that have had 
it have died from it. Those are very alarming numbers.
    You can see this chart here with the confirmed cases by age 
and outcome and you see some very disturbing numbers there 
because it is not one of those diseases that hits young people 
and old people.\1\ If you get it, you have a very real chance 
of not surviving contact with bird flu.
---------------------------------------------------------------------------
    \1\ The chart referred to appears in the Appendix on page 90.
---------------------------------------------------------------------------
    So the concern would be is if you have a flu with these 
characteristics and it mutates into a contagious human disease, 
the consequences could be very dire. I don't want to talk like 
a science fiction movie here, but some of the scenarios that 
people have talked about really cause great concern. The number 
of Americans who could not survive this, what it could do in 
terms of overwhelming our health care infrastructure, the 
restrictions on travel, maybe having to institute some sort of 
quarantine or martial law, there are a lot of ramifications of 
this that we need to think through and be prepared for in the 
event that it does come.
    The other thing that we see is that a flu pandemic is 
problematic for the government because there are so many 
different levels of the government that have to deal with it. 
Just on the Federal level, you look at DHS, HHS, Homeland 
Security, and other agencies, but it is also a State and local 
issue, as well. Health officials are involved, as are first 
responders. It is a lot of local officials that have to make 
very critical decisions in a short period of time.
    That is why we keep coming back to planning and being able 
to test our planning. Today, Senator Sununu and I wanted to 
encourage dialogue and make sure that everybody is planning 
like they should be, and we are working through this in 
preparation for that day, if it ever comes.
    With that, let me go ahead and introduce our first panel. 
Again, Senator Sununu may have an opening statement in a few 
moments. We will have probably one or more Senators in addition 
to Senator Sununu that come in throughout the course of this 
hearing. We have votes and a lot of other committee hearings 
going on right now, so it is a pretty hectic day in the Senate.
    But let me go ahead and introduce our first panel. First we 
have Rear Admiral William Vanderwagen, who serves as Assistant 
Secretary for Preparedness and Response at the U.S. Department 
of Health and Human Services. His office is charged with 
leading the Nation in the prevention, response, and reduction 
of adverse health effects of public health disasters. He is the 
Department's senior advisor to the Secretary for matters 
relating to bioterrorism and public health emergencies and he 
will be discussing the progress his office has made as well as 
efforts they are making in coordinating public health 
preparedness across all levels of government.
    Our second panelist will be Dr. Tilman Jolly. He is the 
Associate Chief Medical Officer of the Office of Health Affairs 
at the Department of Homeland Security. Dr. Jolly brings an 
extensive background in emergency medicine and medical 
operations, planning, and consulting. In addition to practicing 
emergency medicine and serving on the medical planning staff of 
events, including five Super Bowls and the U.S. Open Golf 
Championship, he has spoken and published extensively on these 
subjects. Today, he will report on the progress of the DHS 
Office of Health Affairs in coordinating with relevant DHS 
Departments as well as other Federal, State, and local 
agencies.
    Admiral Vanderwagen, would you like to go ahead and start, 
please.

  TESTIMONY OF REAR ADMIRAL WILLIAM C. VANDERWAGEN, M.D.,\1\ 
    ASSISTANT SECRETARY FOR PREPAREDNESS AND RESPONSE, U.S. 
            DEPARTMENT OF HEALTH AND HUMAN SERVICES

    Admiral Vanderwagen. Thank you, Mr. Chairman, and it is a 
real pleasure to be here. I think you spoke to partnerships and 
I think there is a partnership between the Legislative and the 
Executive Branch that has to be strengthened and built upon.
---------------------------------------------------------------------------
    \1\ The prepared statement of Admiral Vanderwagen appears in the 
Appendix on page 34.
---------------------------------------------------------------------------
    Let me submit my written testimony for the record and I 
will speak for a few minutes and summarize.
    As you noted, the Assistant Secretary for Preparedness and 
Response is the responsible party for Health and Human Services 
(HHS) in coordinating medical and public health responses. It 
was established about 10 months ago, December 19, 2006, with 
the signing of a law, the Pandemic and All Hazards Preparedness 
Act, that transferred many authorities to our responsibility, 
including NDMS, the hospital preparedness programs, enrollment 
of volunteers, and so on, various authorities related to the 
Medical Reserve Corps, partnerships with the Centers for 
Disease Control (CDC), etc., and many new authorities related 
to the development of medical countermeasures, and that would 
include such things as vaccines, anti-virals, diagnostics, etc. 
And in August, we assumed leadership in our office for pandemic 
flu for HHS.
    As you noted, pandemic flu really could be quite a 
catastrophic event and it will affect all sectors of our 
society, and it involves planning and interoperability between 
a wide variety of many sectors in this country. Public safety, 
energy, transportation, commerce, labor, all have a role in 
addressing the issues and preparing for a pandemic flu.
    About a year and a half ago, Congress and the Executive 
Branch did lay out a plan for how we would try and address 
issues with pandemic flu--a strategy. That strategy was based 
on a theory of victory that was not with the expectation that 
we could absolutely stop dead in its tracks this disease, but, 
in fact, we could delay its emergence and we could reduce the 
number of people who became ill with this disease. And the 
critical elements of that strategy was the development of 
vaccine capability, anti-virals for treatment, and recall at 
that time production capability for anti-virals was relatively 
small. In addition to that, there were commitments to community 
mitigation strategies and the development of surge 
capabilities, including additional facility space and people 
with skills who could be employed in addressing this illness as 
it hits in many communities around the Nation.
    We have made pretty good progress, and I think we will hear 
from some of our State and local colleagues today about the 
progress they have been making. I would report to you, sir, 
that I made numerous visits to States. I was in North Carolina 
last week and in North Carolina last year, they did 87 
exercises involving about 7,000 people in preparing for a 
pandemic flu. So there is a great deal of activity that is 
going on at the community level where it really needs to be, 
particularly in a pandemic flu.
    This really highlights, as you suggested, the shared 
responsibility that prevails, particularly as we look forward 
to future steps. Early in this course, the last year or two, 
the Federal Government and State Governments have been the lead 
players. Vaccine infrastructure development, anti-viral 
infrastructure development, expanded bed capacity, initial 
planning and training, these were all roles for the Federal and 
State Governments. The next steps will have to build on the 
successes, including anti-viral prophylaxis, but this will 
require wider application of shared responsibilities among 
businesses, the health care industry, individuals, and 
families.
    There are new developments that need to be taken advantage 
of. We need a cheaper, less labor-intensive ventilator for the 
kind of respiratory support we may need. We need additional 
guidance--and we are working on these issues--additional 
guidance is needed for augmentation of community mitigation 
strategies using respiratory protection, such as M-95 
respirators. The science doesn't give us a clear answer on many 
of these issues, but we will have to find solutions to these 
gaps and we will have to find them in concert with our State, 
local, business, and individual colleagues.
    In summary, our office is functional. The Pandemic and All 
Hazards Preparedness Act is being implemented. Pan flu 
preparedness has moved along pretty smartly and we have made 
pretty good progress, not only in pan flu, but on a variety of 
hazards. Gaps still exist and additional steps will and must be 
taken, but they must be done in the context of shared 
responsibility. We will continue to consult with our State, 
local, business, and private sector partners as we develop 
actions to address this next set of gaps. Without that 
consultation, we will not have an effective plan and a 
comprehensive capability to respond when the Nation needs us.
    I thank you for the opportunity to be here today.
    Senator Pryor. Thank you. Dr. Jolly.

TESTIMONY OF B. TILMAN JOLLY, M.D.,\1\ ASSOCIATE CHIEF MEDICAL 
 OFFICER FOR MEDICAL READINESS, OFFICE OF HEALTH AFFAIRS, U.S. 
                DEPARTMENT OF HOMELAND SECURITY

    Dr. Jolly. Mr. Chairman, thank you for the opportunity to 
testify before the Subcommittee today to discuss our efforts 
toward overall pandemic flu preparedness. Before I begin, I 
would like to take the opportunity to thank you and the Members 
of the full Committee on behalf of Secretary Chertoff for your 
continued willingness to work alongside the Department to 
provide leadership in protecting and ensuring the security of 
our homeland. I would also like to thank our partners at HHS 
and others with whom we work every day.
---------------------------------------------------------------------------
    \1\ The prepared statement of Dr. Jolly appears in the Appendix on 
page 49.
---------------------------------------------------------------------------
    A pandemic is unique. It is likely to come in waves, 
passing through communities of all sizes across the Nation and 
the world simultaneously. But then it may last as long as 18 
months. An unmitigated pandemic--and I emphasize unmitigated--
could result in 200,000 to two 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 you have said, based on the illness and related 
absenteeism.
    DHS has been and remains actively engaged with its Federal, 
State, local, territorial, tribal, and private sector partners 
alongside HHS to prepare our Nation and the international 
community for an influenza pandemic. As outlined in the 
implementation plan, DHS is responsible for the coordination of 
the overall domestic Federal response during an influenza 
pandemic, including implementing policies that facilitate 
compliance with recommended social distancing measures, 
developing a common operating fixture 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 our borders.
    In working with our partners, such as HHS, the State 
Department, and USDA, DHS has developed and implemented a 
number of initiatives and outreach to support continuity of 
operations, planning for all levels of government and private 
sector entities. I will highlight a few noteworthy 
accomplishments and responsibilities under the implementation 
plan particular to DHS.
    DHS produced and released the ``Pandemic Influenza 
Preparedness, Response, and Recovery Guide for Critical 
Infrastructure and Key Resources.'' The Guide has served to 
support business and other private sector pandemic planning by 
complementing and enhancing but not replacing their existing 
continuity planning efforts. With that in mind, DHS and its 
partners developed the guide to assist businesses whose 
existing continuity plans generally do not include strategies 
to protect human health during emergencies like a pandemic. As 
a next step, DHS is currently leading the development of 
specific guides for each of the 17 critical infrastructure and 
key resource sectors using the security partnership model.
    In coordination with other Federal departments and 
agencies, DHS is developing a coordinated government-wide 
planning forum. An initial analysis of the response 
requirements for Federal support has been completed. From this 
analysis, the national plan defining the Federal concept for 
coordinating response and recovery operations during a pandemic 
has been developed and will be undergoing interagency review. 
Utilizing this planning process, a coordinated Federal border 
management plan has been developed and is currently also under 
review. This process included a wide range of partners.
    DHS has also conducted or participated in Federal and State 
interagency pandemic influenza exercises and held workshops and 
forums with critical infrastructure key resources owners and 
operators. Consistent with this role under Homeland Security 
Presidential Directive 5 (HSPD-5), as it is known, Secretary 
Chertoff pre-designated Vice Admiral Vivien Crea, Vice 
Commandant of the Coast Guard, as the National Principal 
Federal Official (PFO), for pandemic influenza and has pre-
designated five regional PFOs and 10 deputy PFOs. Likewise, our 
partners have pre-designated infrastructure liaisons, Federal 
coordinating officers, senior officials for health, as well as 
defense coordinating officers. Vice Admiral Crea and the 
regional PFOs have participated in multi-agency training and 
orientation sessions regarding preparedness duties. 
Additionally, the PFO teams have begun outreach both nationally 
and in their regions in advance of a more formalized exercise 
program which is being developed at DHS.
    On an ongoing basis, DHS participates in interagency 
working groups to develop guidance, including community 
mitigation strategies, medical countermeasures, vaccine 
prioritization, and risk communication strategies.
    In closing, significant progress has been made in national 
preparedness for pandemic influenza. DHS looks forward to 
continuing its partnership with the Federal interagency, State, 
local, tribal, territorial, and private sector stakeholders to 
complete the work of pandemic preparedness 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 today on 
behalf of the Department of Homeland Security and I would be 
happy to answer any questions you might have.
    Senator Pryor. Thank you, and I appreciate again both of 
you being here and your testimony. We will submit your written 
testimony for the record.
    Let me ask just on the front end about roles and 
responsibilities, basically who is in charge, and I guess the 
way I would--did you say that he is in charge? Is that what you 
are saying? [Laughter.]
    That is like the old ``Far Side'' cartoon. But I guess what 
I might do is ask this of both of you, and if one wants to 
answer or one wants to add something to the other, that would 
be great.
    There was a study done, an evaluation done by GAO not too 
long ago, of the Homeland Security Council's National Strategic 
and Pandemic Influenza Plan. Basically, it says that 
responsibilities in a crisis are split between HHS and DHS with 
HHS taking responsibility for health issues and DHS directing 
in ``emergency situations.'' But since a pan flu crisis is both 
by definition, do you all feel comfortable that the two 
departments have worked it out in terms of that happens if a 
decision is made that we have a flu pandemic coming? Who wants 
to take that?
    Dr. Jolly. I will begin. I believe we both do feel 
comfortable and all of our teams feel comfortable. Pandemic 
influenza is unique, but in fact, every crisis has health 
implications and HHS has an important role to play in public 
health and medical response to almost any crisis you can name.
    Under Homeland Security Presidential Directive 5 and under 
other authorities, the Secretary of Homeland Security is 
responsible for the overall incident coordination, and that is 
well accepted throughout the government, and the Secretary of 
Health and Human Services is responsible for the specific 
public health and medical responsibility, which is quite large 
in this situation.
    Senator Pryor. Do you want to add anything to that?
    Admiral Vanderwagen. No, I would just affirm what he said. 
There are 15 useful emergency support functions. Health is one 
of them. In this case, it has a big role. I think the health 
messaging and the health interventions and so on are our 
responsibility, but it is under the overarching direction of 
DHS.
    Senator Pryor. This same report I referred to a few moments 
ago talked about how there only has been one national multi-
jurisdictional exercise as kind of a run through on our 
response, and as I understand it, I guess that was done before 
there was a National Response Plan. Do we have plans for 
further national or multi-jurisdictional exercises that would 
coordinate all the various levels and people that have to be 
coordinated?
    Dr. Jolly. We certainly do have plans for those and that 
report does discuss that exercise initially done. Since then, 
there have been a number of exercises at the State and local 
level and those are quite important to exercise those roles, 
and we do have ongoing plans in the coming months for exercises 
of our Principal Federal Official structure and the interagency 
structure and then the national structure. It is a complex set 
of exercises. I don't think that one exercise of the structure 
would do it, but a complex set, and yes, we will be advancing 
with those and HHS has also had exercises to inform that 
process.
    Senator Pryor. What is your time frame on doing those? Are 
you doing those now?
    Dr. Jolly. We are beginning the planning of those now. We 
have been working through--as I said in my testimony, one of 
the important things to develop those exercises is to develop 
strategic and then operational plans that you would then 
exercise rather than just designing the exercises off a 
scenario. And so those are being completed now and we hope that 
in the coming months--I don't have a specific date scheduled 
that I can announce, but we hope that in the coming months, we 
will start that process and build to an exercise that goes from 
the cabinet level down.
    Senator Pryor. OK. Let me also ask about something that is 
part of the nature of a pandemic flu epidemic. Generally when 
there is a national disaster or regional disaster, the Stafford 
Act gets triggered and States help neighboring States and there 
is often a regional approach. But I can see in a flu epidemic 
or pandemic where governors, for example, might be reluctant to 
send his or her people to a nearby State to help because they 
may be next, and plus they may be spreading the virus back and 
forth across State lines. So to me, that seems to be something 
that is--I don't know if I would say unique, but certainly a 
characteristic of a pandemic--a flu pandemic. How do you adjust 
your overall planning for that contingency, that this just 
behaves differently than most national disasters?
    Admiral Vanderwagen. Well, let me speak to the health 
segment of that, and you may recall that Secretary Leavitt back 
in 2005 started--he went to every State for a summit on pan flu 
and his message was pretty much the same, and that is you need 
to be prepared to take care of yourself because the very 
circumstance you just described is highly likely.
    So I think in our work with the States and localities, the 
notion here is how much capacity can we build locally and 
within a State in order to fill as many gaps as we can 
internally, not relying on the EMAC or the Federal system as a 
means to fill gaps. Very difficult, particularly if we are 
talking about facilities and personnel which will be in short 
supply in just about every location. But it is the best way we 
can plan, and that is try and build from the base of making the 
localities as self-sufficient as you can in the event.
    Senator Pryor. And do you feel like we are making progress 
along those lines?
    Admiral Vanderwagen. Yes. What are some objective measures? 
The Medical Reserve Corps, which is a way of organizing 
community-based volunteers into identifiable teams, has 
expanded up to over 650 units and 120,000 individuals, and that 
is just one approach to organizing volunteers. States have 
local programs, as well. We are seeing a real increase in pre-
identified volunteers with skill sets needed to fulfill roles 
that the States and localities have identified as being in need 
during an event like this.
    Senator Pryor. Let us stay with that general line of 
questioning--how a flu pandemic behaves and how it unfolds 
across the country. In this chart here,\1\ the one with the 
black background, that is a scenario that the Los Alamos 
National Lab came up with where 10 avian flu individuals get 
off the plane at LAX, Los Angeles, and then you can see the 
sequence of how it spreads across the country and runs its 
course through the country. Do you all generally agree that is 
a realistic model? Does that model ring true to you, or is that 
fair?
---------------------------------------------------------------------------
    \1\ The chart referred to appears in the Appendix on page 90.
---------------------------------------------------------------------------
    Dr. Jolly. I think it probably is fair. There are a lot of 
modelers who have done a lot of models based on where the first 
case is or where first clusters are and how it spreads, 
depending on the disease characteristics and travel 
characteristics and behavioral characteristics. I think that is 
a reasonable assumption of one possibility of a model and how a 
disease might spread that is largely based on history from 1918 
and the other couple of pandemics of the last century.
    Admiral Vanderwagen. Let me add one other comment to that.
    Senator Pryor. Yes, go ahead.
    Admiral Vanderwagen. I think that is an unmitigated or 
unintervened-upon event that we see unfolding there, and again, 
the modelers, given this as the base, what can we do to 
intervene, the community mitigation strategies that were 
employed, for instance, by St. Louis in 1918----
    Senator Pryor. Where they basically quarantine the city and 
more or less quarantine----
    Admiral Vanderwagen. Respiratory protection and slow down, 
get social distancing, and so on, they were able to reduce by 
50 percent the number of cases and the mortality associated 
with it, and so the community mitigation strategies using 
fairly simple community social distancing practices, could give 
us--some people in the modeling world say as high as 70 
percent. We operate on a more conservative notion that it will 
reduce it 50 percent, and that is without adding anti-viral 
prophylaxis and without really having a vaccine in play.
    Senator Pryor. OK. So you are saying that HHS, DHS, State, 
and local people might take some steps to make sure that we 
don't see the rapid spread across the country?
    Admiral Vanderwagen. Yes. That is the planning that most 
communities are doing, and in fact, now we are looking to 
invest in new vaccines, and we should make that investment here 
in the next month or two, that may reduce the production time 
from 20 weeks, which is the current production time for a 
vaccine, down to 8 weeks. So there are a number of strategies 
that technologies will allow us to bring into play so that we 
can put more tools in the hands of communities. If they use 
just the community mitigation without these other 
interventions, they will get a certain reduction. And as we are 
able to give them more tools, like faster turnaround on vaccine 
production, anti-virals for prophylaxis, we may be able to 
reduce the rate of this spread even more significantly.
    Senator Pryor. And let me ask this quickly about vaccines. 
I want to leave plenty of time for Senator Akaka to ask 
questions. But in terms of the vaccine, as I understand it, 
medically and scientifically, you need samples of the real 
strain, and so once you get those samples, then it is just 
going to take you some time in order to develop enough vaccine 
to get it out to the public. Is that right?
    Admiral Vanderwagen. Yes. In the stockpile, we have a 
significant number of doses of pre-pandemic vaccine based on 
the current H5N1s that have been present in Asia. But you are 
absolutely right. If that is not the particular strain, we will 
have to produce a different vaccine and production time right 
now is about 20 weeks from identification of the specific virus 
to the time that you are in full production of a vaccine.
    There are other things on the horizon that make this a very 
positive picture, and that is testing that currently shows that 
with adjuvants, that is things that augment the ability of the 
vaccine to increase your immune response, we may have 20-fold 
the amount of vaccine that we currently have in the stockpile 
by adding adjuvants to the existing vaccines, which would give 
us enough probably to cover everybody in the country if it was 
an H5N1 as we have developed the vaccine for at this point.
    There are lots of technological activities that in the next 
year or two give us much hope that we can intervene and slow 
this thing down very dramatically.
    Senator Pryor. Let me ask one more question before I turn 
it over to Senator Akaka, and that is in terms of our health 
care infrastructure, when I see a map like that, I look at the 
Los Angeles area. To me, it seems the Los Angeles area medical 
infrastructure could be totally overwhelmed, whereas in other 
parts of the country, they are not feeling any stress from this 
at all. Is that part of our planning, to figure out how to 
allocate those resources nationally? Do you just have some 
concrete limitations on the number of hospital beds available? 
I guess part of the planning, I hope, would be figuring out 
other arrangements to take care of people outside of a hospital 
context, but also to bring in more medical professionals into 
that area. How is the planning going there? What are the 
recommendations there?
    Admiral Vanderwagen. I think that States using the Hospital 
Preparedness Grants and their own funds--States have been 
increasing their fiscal commitment to these activities as much 
as the Federal Government have--are investing in expanded bed 
capacity in the form of stand-up portable hospitals so that 
they have that mobility for a variety of events, but they can 
certainly use them within a pan flu environment. The limiting 
step in many of these things is going to be the number of 
people who are ill or not ill and are available in the 
community. If you have a 40 percent absentee rate, for 
instance, in health care workers, it is going to be tough for 
them to provide the care. That is where the volunteer workforce 
is being pre-identified.
    Yes, where we see the cases coming early in the 
environment, and this is where many of these exercises are 
targeted, we are seeing it emerge in Location X. What can we 
bring to that particular fight? That is a high priority. Once 
it goes to a half-dozen or so communities, then we would 
probably back off with some of that extra push because then we 
are going to be looking at a broader-based problem. If we can 
slow it down in L.A., better for us. But if it is in 20 cities, 
well, it is already on the spread. Then we need to go to Plan 
B, which is the local capacity plan.
    Dr. Jolly. And I would add the key in this is really up 
front trying to reduce the burden on the health care system. 
The health care system is under stress now and would be under 
more stress, and the more we can employ community mitigation 
strategies broadly across the community very early, and the 
modeling shows that the key is doing it early when you can 
really make a difference to really reduce the load and spread 
out the load on the health care system to improve everyone's 
outcome.
    Senator Pryor. Does that also include the economic load? 
Have you thought about these hospitals, because they are going 
to treat people and if they are totally overwhelmed, and given 
the percentage of uninsured, etc., just special circumstances, 
is this going to financially, not ruin, but greatly burden our 
health care system?
    Dr. Jolly. I think there are a number of potential effects, 
economic being one, and supplies and others that are all part 
of the mix and they are part of the modeling and part of the 
exercises.
    Admiral Vanderwagen. And this goes to how we work in sync. 
What Secretary Leavitt can do is declare a public health 
emergency behind Secretary Chertoff's leadership on the 
Incident of National Significance. If we declare a public 
health emergency, that sets in effect many waivers. That gives 
the hospitals many opportunities to take care of people and be 
reimbursed in ways they might not otherwise be reimbursed.
    Second, hospitals that are part of the National Disaster 
Management System in disasters, if they are taking additional 
patient burdens, can get paid at about 115 percent of the 
existing Medicare rate. So that helps to over-compensate. And 
then there are always supplemental requests. In Hurricane 
Katrina, for instance, we had some additional funds identified 
to support the facilities in Louisiana and Mississippi that 
were under dire economic stress.
    Senator Pryor. Senator Akaka.

               OPENING STATEMENT OF SENATOR AKAKA

    Senator Akaka. Thank you very much, Mr. Chairman. I am glad 
to be here with you and with our witnesses. You know that I 
share your concerns about the possibility of pandemic influenza 
outbreak not only in our country but around the world, and also 
because of the prediction that was made by WHO in 2004 about 
the concern about A H5N1 outbreak and how deadly it would be 
and what a disaster that would be.
    So I was glad to note that last month, the Department of 
Homeland Security conducted a National Preparedness Month 
campaign and 1,700 State and local-level organizations 
participated in that, and this week, Senator Pryor and I have 
had respective hearings in our Subcommittees on pandemic flu. 
So I am glad that we are giving it that kind of focus.
    Admiral it is good to see you.
    Admiral Vanderwagen. [In Hawaiian.]
    Senator Akaka. Aloha. According to the CDC, Admiral, among 
the three flu strains it is preparing for in the 2007 and 2008 
season, one is type AH3N2. This strain is linked to the 1968 
Hong Kong pandemic flu, noted as the deadliest flu in the past 
30 years, which killed two million people worldwide. What is 
the outlook for this upcoming season, and are we prepared for 
this type of influenza?
    Admiral Vanderwagen. Well, as you know, vaccines are 
produced, or they have to begin production about 6 months 
before the season actually arrives, and so the folks who are 
prognosticating these things, looking at the epidemiology, try 
and pick those virus strains that are most likely to appear. 
Sometimes you don't get absolutely the right one. One of the 
things that we are seeing in the Southern Hemisphere right now 
is a virus that we may not have full protection from. We think 
that the influenza viruses that we have will provide pretty 
good coverage for it, but we are seeing in the Southern 
Hemisphere a pretty tough influenza season.
    As you know, in a routine year, 36,000 people die in the 
United States from this seasonal influenza. So while we worry 
about pandemics, seasonal influenza is not a white event, 
either.
    Dr. Jolly. If I could, I would add that some years are more 
closely matched than others, as a physician, in the influenza 
vaccine, but I think our major issue is to really get the word 
out and get people vaccinated who need to be vaccinated and 
have them--I believe we have 130 million doses available for 
this coming year, so our supply is good and our challenge is to 
get the public vaccinated early and aggressively.
    Senator Akaka. There is a big concern about whether we will 
be able to have the vaccine. Is there any concern that as avian 
flu attacks chickens and eggs, and I understand that the eggs 
play a part in this vaccine or are used to produce this 
vaccine, that these may be problems producing enough vaccine? 
Is that true?
    Admiral Vanderwagen. Well, as you know, sir, we received in 
the supplemental about $5.6 billion. We have invested about 
$3.2 billion of that already and much of that has gone into 
helping companies convert from egg-based to cell-based 
technologies. I think we have five or so manufacturers now that 
are converting over to cell-based production capability, and 
that would be useful both for seasonal flu, but also in a 
pandemic event. That is one of the major investments. Our next 
investment, we are trying to target a recombinant vaccine that 
will shorten the production time by half, at least it appears 
that it will do that based on European studies. So we are 
trying to get around this egg-based older approach to vaccine 
production.
    Dr. Jolly. I would add that our poultry industry has taken 
great strides toward biosecurity in general and this subset of 
the industry that produces these eggs is a very secure subset 
and that is a key part of keeping that supply open.
    Senator Akaka. Admiral and Dr. Jolly, HHS and DHS are the 
Federal leaders in pandemic emergency response, but GAO 
recently testified that their respective roles haven't been 
clarified. Have HHS and DHS communicated to the State and local 
jurisdictions around the country the roles and responsibilities 
of each agency?
    Dr. Jolly. As we have stated in the prior hearing, I think, 
when GAO was there and also in our statements, there is a 
fairly clear--a very clear delineation of roles of HHS as the 
manager of the overall incident, and that is being manifested 
in all of our interactions with the States and also through the 
work of our Principal Federal Official group and their support 
group as they move throughout the States and regions. That 
leaves HHS with a large role of managing emergency support 
function, the public health and medical.
    Senator Akaka. Admiral, do you want to comment?
    Admiral Vanderwagen. I fully agree. I think we have worked 
very closely with Admiral Crea as she has tried to develop the 
DHS overarching response capability and we nestle into that 
with our health piece. But she has got a broader 
responsibility--public safety, transportation, energy, etc. 
Our's is the health link.
    Senator Akaka. Admiral, you mentioned that the current flu 
vaccine may not give us sufficient protection this season. If 
this is the case, have you made any new predictions about the 
number of possible fatalities this season?
    Admiral Vanderwagen. I don't have any epidemiologic 
projections of any change in our seasonal usual. We have seen 
some different behavior, some increased infectivity in the 
Southern Hemisphere and we will just kind of have to see how 
that projects into our population.
    Senator Akaka. Admiral, HHS has responsibility for 
overseeing and administering the Strategic National Stockpile 
of anti-viral drugs and vaccines. Congress appropriated $6.1 
billion over 3 years for HHS to work with States on building a 
stockpile of Tamiflu, Relenza, and available vaccines. Can you 
give us a status update of the stockpile for Hawaii?
    Admiral Vanderwagen. [In Hawaiian.] I couldn't answer 
specifically with Hawaii. I can get that for the record for 
you, sir. I didn't do my full homework, I guess.
    I think that where we are--you may recall that the 
acquisition of anti-virals, the strategy was to purchase enough 
anti-virals, and at the time that the strategy was marked out 
they were only producing 15 million regimens a year, so the 
notion was, let us buy enough to treat the percentage of people 
we think may get infected, not prophylaxis, treatment. We have 
purchased on plan in 2007 about 37 million treatment courses 
and the States have purchased about 15 million. We were on plan 
to purchase the balance up to a total of 81 million treatment 
courses by the end of 2008, and we are on plan to get that 
done. I think we are making good progress.
    Our other investments, as I spoke to you, are about 
increasing our vaccine production capability, looking for 
alternatives to the existing anti-virals so that if we develop 
resistance, we have another drug to work with, diagnostics so 
that we can determine is it just seasonal flu or is it an avian 
flu. Those investments have gone a long way to building an 
infrastructural base that gives us more options in the future.
    Senator Akaka. Thank you so much for your responses.
    Senator Pryor. Thank you, Senator Akaka. We appreciate your 
time on this.
    Let me follow up, if I may, with you, Admiral, about 
something we got into just a few minutes ago and that is the 
vaccine. I would like your comments on the World Health 
Organization report that says that worldwide production 
capability for pandemic flu vaccine would be 1.2 million doses 
total. I am wondering if that is consistent with your 
understanding or if you think that there is more worldwide 
capacity than that.
    Admiral Vanderwagen. I think there is much more capacity 
than that. We have taken delivery this year alone into the 
stockpile something on the order of magnitude of about 15 
million doses of vaccine. So just for our purchases alone, we 
are purchasing a lot more than that.
    Senator Pryor. I was going to ask you that, because you 
mentioned the stockpile a few moments ago and I think you 
mentioned that you had some stockpile of the flu that you have 
seen mostly in Asia that you are already stockpiling. Tell me 
about our stockpiles. What is the shelf life of the vaccine? 
How long can we stockpile them before we have to replenish? If 
you don't mind, give us the status of our stockpile.
    Admiral Vanderwagen. Sure. With regards to vaccines, and 
now I am talking about a pre-pandemic vaccine, H5N1----
    Senator Pryor. Right.
    Admiral Vanderwagen [continuing.] There are two or three 
different varieties of that that have been identified in South 
Asia, Indonesia and Vietnam. We have about 26 million doses. By 
the end of this calendar year, we will have 26 million doses of 
vaccine based on those viruses. They have about a 3-year shelf 
life to them. It is just biologicals. They only last for a 
fixed period of time, which leads to the question about 
sustainability that I think, over time, this is going to be the 
issue that we are all going to have to confront, State, local, 
Federal, is how will we sustain some of these investments that 
we have made when they run out of shelf life or the equipment 
becomes obsolete, etc.
    I have mentioned to you the 37.5 million doses of anti-
virals that we have. We will purchase another 13 million or so 
up to 50 million on the Federal side. The States have 15 
million. They will purchase another 3 to 4 million to meet that 
treatment goal. Right now, we are entertaining, with the 
production capability that the anti-viral manufacturers have 
for Relenza and Tamiflu, should we consider the use of these in 
a prophylactic way, that is for people who are in high-risk 
work environments--hospital workers. We know from seasonal flu 
that 15 to 30 percent of health care workers in hospitals that 
have influenza load will get sick.
    Should we be using anti-virals for prophylaxis for those 
kind of folks, people who are home taking care of somebody with 
pan flu? Should we recommend using the anti-virals in a 
prophylactic mode there? That will have implications for 
acquisition, purchasing, and is that a local responsibility? Is 
it an individual responsibility? Is it a business 
responsibility? These are some of the issues that we are 
working through right now with our stakeholders.
    Senator Pryor. And you also hinted--maybe I misunderstood 
what you said earlier, but maybe hinted that you were looking 
at ways to have a larger capacity. I read something recently 
about maybe retrofitting some domestic production plants. Could 
you give us a status report----
    Admiral Vanderwagen. Production capacity, I spoke to 
adjuvants, and I will come back to that in just a minute, but 
production capacity has expanded significantly with the 
investments we have been able to make with the $6 billion that 
Congress gave us. That has been a major part of our investment. 
We have put about $133 million into facilities retrofitting. We 
have put about $10 million into international vaccine 
production.
    Antigen spearing, which is what I mentioned earlier, 
antigen is the part of the virus that is in the vaccine that 
stimulates your immune system. These antigen spearing agents, 
when added to the vaccine, may make that vaccine more potent, 
in effect reducing. Right now, it takes 90 micrograms to get a 
good response when we give the vaccine, but these adjuvants, 
some of them have demonstrated efficacy down to three 
micrograms. We are not betting on three micrograms, but if it 
gets us a 10- or a 20-fold increase, down to 15, 20 micrograms, 
or below that, we are going to have a lot more vaccine 
available to us fairly quickly just by adding these adjuvants. 
Those are in clinical trials right now to establish their 
safety and their efficacy.
    Senator Pryor. On the vaccines, what is the criteria that 
HHS uses to decide which producers receive vaccine production 
contracts? Are you limited based on patents and brand names, 
what is out there, or are these more like generics that it is a 
competitive bid? How does that process work?
    Admiral Vanderwagen. Our basic criterion is very simple. We 
want U.S.-licensed manufacturers because we want domestic 
production capability. We have five or six firms in the hunt. 
They have different approaches and so on, but we believe that 
by building the infrastructural base across the market base, we 
are doing a better job of assuring that we have the domestic 
production capability that we may need in this event rather 
than relying on international suppliers.
    Senator Pryor. And the last thing on that is we have a 
certain stockpile. Are we planning on, assuming we have a 
pandemic like the chart shows there, being able to go out and 
get quite a bit more in a very rapid fashion, and if that is 
the plan, are we doing advance pricing contracts or are we 
working with the manufacturers to be ready in the event that 
terrible day comes?
    Admiral Vanderwagen. Well, the material is plentiful and we 
have recently conducted some gap analysis and we don't believe 
that--some of the industries don't have any further production 
capacity available to them and we are going to have to work out 
how we could expand their production capacity if they are going 
to provide a surge product in high demand. That would include 
such things as M-95 respirators. Other products rely heavily on 
offshore raw materials. They may have production capacity 
domestically, but they have offshore materials supplies. This 
gets to be a pretty complex market analysis and will take 
continued dialogue with our industry partners to achieve 
reasonable solutions. We are trying to prioritize it against 
the highest priority demands, such as ventilators and other 
respiratory care materials.
    Senator Pryor. Senator Sununu, did you have any questions 
of this panel?

              OPENING STATEMENT OF SENATOR SUNUNU

    Senator Sununu. No, I don't. I just appreciate the 
testimony. Sorry to have arrived a little bit late. I will 
submit a written introductory statement for the record, but I 
want to give an opportunity for all the panelists to have some 
time, so I thank you, Mr. Chairman, and thank both of our 
witnesses on the first panel.
    [The prepared statement of Senator Sununu follows:]

                  PREPARED STATEMENT OF SENATOR SUNUNU

    Good afternoon. I would like to thank all of the witnesses who have 
agreed to testify before today's hearing, and would especially like to 
thank Homeland Security and Emergency Management Director Christopher 
Pope from my home State of New Hampshire who will provide testimony on 
our second panel.
    Director Pope came up through the ranks in the Concord, NH fire 
department having served as a Firefighter, Paramedic, Lieutenant, 
Acting Captain, Battalion Chief, and Division Commander before becoming 
Chief. As Chief, Director Pope was responsible for 117 employees and a 
regional dispatch enter that handled 20,000 emergency calls per year. 
Additionally, he developed the Emergency Management Master Plan for 
Concord. Director Pope's strong background in public safety 
administration and emergency management is an asset to New Hampshire 
and I am pleased that he could be with us today.
    This afternoon, this Subcommittee looks into the issue of Pandemic 
Influenza Preparedness at the State and Local level. While we know that 
we can never be truly prepared for a pandemic outbreak, it is important 
that our State and local partners have the resources they need from the 
Federal Government to be ready. This hearing is an important step in 
opening those lines of communication. I look forward to hearing from 
both our Federal and State partners.

    Senator Pryor. I want to thank both of you for being here. 
We may submit some written questions and we will leave our 
record open for a little while in order to do that back and 
forth. Thank you.
    Admiral Vanderwagen. The dialogue is absolutely necessary, 
Mr. Chairman. We have a challenge together to meet the Nation's 
needs. Thank you for your interest.
    Senator Pryor. Thank you.
    As the first panel is leaving, I will ask the second panel 
to come forward. Let me go ahead and introduce them. First, we 
will hear from Dr. Paul Halverson, Director of Health for the 
Arkansas Department of Health and State Health Officer. Dr. 
Halverson has an extensive background in public health, having 
served as a member of the Senior Biomedical Research Service at 
the Centers for Disease Control and also as the Director of the 
Division of Public Health Systems Development and Research.
    Next, we will have Christopher Pope, the Director of 
Homeland Security and Emergency Management for the New 
Hampshire Department of Safety. He has a solid background in 
public safety administration and emergency management. He 
served as the fire chief there in Concord and he has developed 
an emergency management master plan. As a former fire chief, he 
brings a unique perspective on the role of first responders in 
a health crisis.
    And our third panelist will be Yvonne Madlock, Director of 
the Memphis and Shelby County Health Department and a Board 
member of the National Association for County and City Health 
Officials. She has a strong background in public health, 
particularly in dealing with issues at the local and county 
level.
    Dr. Halverson, welcome, and if you want to give your 
opening statement. Thank you.

TESTIMONY OF PAUL K. HALVERSON, DrPH, MHSA, FACHE,\1\ DIRECTOR 
    AND STATE HEALTH OFFICER, ARKANSAS DEPARTMENT OF HEALTH

    Dr. Halverson. Thank you, Senator, and thank you, Senator 
Pryor and Senator Sununu for the invitation to appear today. 
This is a very important time, I think, for our State and also 
our Nation as we work together in putting together a plan and 
to exercise that plan in preparation for a pandemic.
---------------------------------------------------------------------------
    \1\ The prepared statement of Mr. Halverson appears in the Appendix 
on page 56.
---------------------------------------------------------------------------
    As Senator Pryor mentioned, I serve as a member of Governor 
Beebe's cabinet and am responsible for public health in 
Arkansas. We have nearly 5,000 employees and contractors in 95 
local offices and in 75 counties in Arkansas. The Arkansas 
Department of Emergency Management has the primary 
responsibility for emergency response generally, but the 
governor has designated the Arkansas Department of Health to 
have lead responsibility for pandemic influenza preparedness 
and response.
    Arkansas is a great small State with approximately 2.8 
million people. We have six metropolitan areas with a 
population of over 55,000, but the majority of our State is a 
collection of small towns and villages. Although we are home to 
Wal-Mart, the largest retailer in the world, approximately one-
third of our workforce is employed by small business. Most 
small businesses cannot withstand the impact of lost workers 
and the workers cannot afford to miss work. We have 84 
hospitals that are part of our Hospital Preparedness Program 
and 10,897 licensed beds and approximately 2,000 active 
physicians. According to the CDC-anticipated attack rate of 
around 35 percent, we would have over 500,000 people clinically 
ill, over 11,000 hospitalized, and over 3,500 people would die 
in the event of a pandemic that is being forecasted.
    One of the biggest challenges facing our State is the 
ability to sustain basic needs, such as electricity, food, 
water, and other services during an emergency because many of 
our smaller communities lack the resources and manpower to 
support these services. Federal funding and guidance have 
provided our State with the ability to provide critical 
infrastructure and make extensive progress in preparedness 
efforts in our State. We have taken an early proactive position 
in regard to pandemic preparedness, enacting planning 
strategies designed to protect Arkansans from any threats to 
public health, really an all-hazards approach from the public 
health perspective.
    Hurricane Katrina was an example of our ability to respond 
to over 75,000 evacuees that came to our State, and we believe 
because of our preparedness, we were able to meet the challenge 
of that great influx of individuals.
    We have conducted 233 pandemic briefings and over 97 
exercises, working with over 9,000 people in Arkansas, 
including county, State, and our work with CDC. We are working 
closely with State and county government organizations, first 
responders, police, sheriffs, hospitals, and a variety of 
private sector partners. Partnership really is the key. It will 
allow us to be successful as we work together to make the most 
of our resources.
    With the support of our legislature, we have been able to 
purchase our maximum allotment of anti-virals and personal 
protective equipment. We convened an expert panel on 
recommendations regarding priority use of anti-virals and 
vaccine when it becomes available. We have worked to develop a 
medical reserve corps with volunteer physicians and nurses and 
other health professionals and our state-of-the-art laboratory 
has been designated by CDC for testing avian flu.
    Surveillance really is very critical in our State and every 
State and we work very closely with the CDC as well as sentinel 
sites and physicians in the monitoring of Medicaid claims data 
as a part of our approach towards surveillance.
    There are a number of things that we have done to respond, 
including mass flu vaccination campaigns, and we will again 
this year be working to try to exercise those plans and believe 
that the whole idea of exercising is critical to our success.
    We have also focused on special populations with physical 
disabilities and partnered with the Governor's Commission on 
People with Disabilities and the Arkansas Association of the 
Deaf, and we are developing a List Serve for our deaf 
population, 60 to 80 percent of whom use Blackberries and 
cellular telephones to communicate.
    There are a number of issues, and I will talk about those 
briefly. Our hospitals in Arkansas have worked carefully with 
the Department to address issues around capacity, but we really 
do need to focus on our ability to be prepared in terms of not 
just the materials, but the people necessary to achieve that. 
In our urban areas in particular, we have shared staffing that 
really needs to be sorted out because people who will work in 
multiple facilities will only be able to work in one generally 
and we need to work in terms of that.
    Funding is also very important to us. In a small State like 
Arkansas, it is critical to have stable and sustainable 
funding.
    And last, let me just mention that, again, our working 
together in partnership with State, Federal, and county 
governments is really crucial to our continued success.
    Thank you so much and I appreciate the opportunity to be 
here this morning.
    Senator Pryor. Thank you. Mr. Pope.

    TESTIMONY OF CHRISTOPHER M. POPE,\1\ DIRECTOR, HOMELAND 
   SECURITY AND EMERGENCY MANAGEMENT, STATE OF NEW HAMPSHIRE

    Mr. Pope. Good afternoon, Mr. Chairman, Senator Sununu. My 
name is Christopher Pope and I do serve as the Director of 
Homeland Security and Emergency Management in the State of New 
Hampshire. I was appointed by Governor Lynch just over a year 
ago following a 30-year career in the fire service, functioning 
as a local responder both in EMS and fire and hazardous 
materials response.
---------------------------------------------------------------------------
    \1\ The prepared statement of Mr. Pope appears in the Appendix on 
page 66.
---------------------------------------------------------------------------
    Each State has characteristics which make it unique in 
terms of pandemic planning. I wish to point out a few of these 
unique factors about New Hampshire which impact our public 
health and our all-hazard planning efforts.
    First, while New Hampshire is small geographically, it sits 
in a compact region of States in the Northeast. The cities of 
New York, Boston, Hartford, Providence, Portland, Albany, and 
Montreal all exist within a shorter driving distance from New 
Hampshire's Emergency Operations Center than the distance 
separating Los Angeles from San Francisco. This means that 
evacuation surge secondary to any natural or human-caused 
disaster in this densely-populated region will significantly 
impact our State.
    Second, we share a border with Canada, which is important 
both due to the potential of the illegal entry of those intent 
on committing harm, but also because local citizens routinely 
cross the border every day to conduct business. As we all know, 
State and foreign borders do not stop floods, terrorist events, 
or pandemics.
    Third, Portsmouth, New Hampshire is an active seaport with 
significant critical infrastructure that supports not just the 
economy of the State, but that of the entire region.
    Fourth, New Hampshire is a major tourist destination in all 
four seasons of the year.
    And finally, New Hampshire has a very small county 
government presence within the State. There are no county 
emergency management directors. There are no county public 
health officials or county emergency operations centers. Prior 
to recent pandemic planning initiatives, all 234 communities 
within our State reported to one central government agency on 
all matters related to natural disasters and public health 
crises.
    These unique factors have caused New Hampshire to take a 
slightly different approach to public health planning and 
response. For example, a Memorandum of Understanding was signed 
between the New Hampshire Department of Safety and the New 
Hampshire Department of Health and Human Services to allow 
collaboration in the area of emergency preparedness by actually 
embedding Department of Health and Human Services staff in the 
Division of Homeland Security and Emergency Management. Our 
bioterrorism unit exists within the Department of Safety rather 
than within our Department of Health and Human Services. This 
forces these two key State agencies to work closely together, 
thus building a strong partnership.
    The Director of Public Health, the State epidemiologist, 
the chief of our public health lab, our grants manager, our 
bioterrorism chief, and I, along with several other staff, meet 
twice per month to review public health planning efforts and 
further our strategic planning.
    Because of the lack of a county public health structure, it 
became evident for the need to develop a regional approach to 
respond to a pandemic. Thus, New Hampshire developed 19 what we 
refer to as All-Health Hazard Regions (AHHR) covering all 234 
of our communities. As of late summer, 14 AHHRs had completed a 
pandemic influenza annex to their all-hazard public health 
plan, with the remaining five nearing completion. The AHHRs 
have identified acute care centers, neighborhood emergency 
health centers, point of dispensing distribution centers, and 
mass quarantine centers, and they have already developed or are 
in the process of developing plans on how these would be 
operationalized.
    All 19 AHHRs have conducted tabletop exercises of their 
all-health hazards plan for public health response. Pandemic 
Phase 1 and 2 funds were distributed to AHHRs to support 
enhanced regional response plans, including community medical 
surge. These efforts have increased the capability and capacity 
of the health care system with these regions. Several of these 
regions have purchased medical supplies to support acute care 
centers to reduce the likelihood that hospitals will be 
expected to provide them. Because of the number of exercises 
that have occurred, community-based partners and health care 
system partners have demonstrated they have a better 
understanding of the real capacity of hospitals.
    My submitted written testimony details a list of cross-
cutting lessons learned from the many exercises conducted in 
New Hampshire. It further lists a large number of 
accomplishments subsequent to these exercises. It also delves 
into details related to our building of interstate and 
international regionalization initiatives. Two I will mention 
quickly.
    The Northeast States Emergency Consortium (NESEC), is a 
group of the six New England emergency management directors and 
those from New York and New Jersey cooperatively working to 
deal with emergency management issues and now public health-
related issues, as well.
    The second group, International Emergency Management Group 
(IEMG), exists with those same States and our friends in the 
Eastern Provinces, including Quebec, New Brunswick, Nova 
Scotia, Prince Edward Island, Labrador, and Newfoundland.
    I would like to briefly relate to you some feedback that we 
have received from our State partners and our local communities 
in terms of what the Federal Government, and State Government, 
for that matter, working together can do to improve our 
efforts.
    One, the need to support for small towns to update and 
develop their local emergency operations plan, either directly 
to the community for hiring of a consultant or other staff 
member, and to require the plans be all-hazard.
    Earmarked funding for disability agencies and organizations 
to participate in planning and exercises. For example, 
interpreters for the deaf and hard of hearing individuals to 
participate in a 90-minute planning meeting can cost between 
$200 and $250.
    Cooperative funding between DHHS and Homeland Security to 
fund Points of Distribution where communities share a border 
with other States or Canada. It is difficult to prepare a plan 
and fund for POD activations without these cross-border 
fundings.
    These are but four of many recommendations that we have and 
many I have submitted as part of my written testimony.
    Finally, I would say that local government, States, and the 
private sector have made great strides in their preparedness 
and response capabilities in public health crises. However, we 
are still not at the acceptable level of readiness that our 
citizens expect and deserve. States and local governments 
continue to need funding and leadership from the Federal 
Government as we continue to build these capabilities.
    I wish to thank the Members of this Committee for inviting 
me here today to report these findings and I also wish to 
publicly thank the many local public health and emergency 
management officials who provided me with input for this 
report. Together, we commit to you to continue to knock down 
the stovepipes and continue to foster a cooperative environment 
between the myriad public and private entities that will be 
called upon to serve our citizens in times of disaster. Thank 
you very much.
    Senator Pryor. Thank you. Ms. Madlock.

 TESTIMONY OF YVONNE S. MADLOCK, MAT,\1\ DIRECTOR, MEMPHIS AND 
SHELBY COUNTY HEALTH DEPARTMENT, MEMPHIS, TENNESSEE, ON BEHALF 
    OF THE NATIONAL ASSOCIATION FOR COUNTY AND CITY HEALTH 
                           OFFICIALS

    Ms. Madlock. Good afternoon, Senator Pryor and Senator 
Sununu. On behalf of the citizens of Memphis and Shelby County 
and on behalf of local public health agencies across the United 
States, I appreciate the opportunity to come and share with you 
some comments on the state of pan flu preparedness at the 
public health level, local level, across the Nation.
---------------------------------------------------------------------------
    \1\ The prepared statement of Ms. Madlock appears in the Appendix 
on page 75.
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    My name is Yvonne Madlock. I am Director of Memphis and 
Shelby County Health Department and I have worked there for the 
last 12 years. Along with my staff, I have been deeply engaged 
in pandemic flu preparedness planning activities.
    As a part of our work, we have had an increasing number of 
opportunities over the last several years to work closely with 
our colleagues throughout the Mid-South Region and particularly 
with our colleagues in Arkansas. I would like to tell you about 
the successes we have had as we have prepared our community and 
our region for what we perceive to be the inevitability of 
pandemic influenza.
    We believe we have done a good job in coordinating with 
Federal, State, and community entities in developing a strong 
and comprehensive local plan for pandemic response, and I would 
believe that most local public health departments have had 
similar experiences. Key to our success in coordinating has 
been our ability to bring elected officials, key community 
leaders, and stakeholders together to learn and engage in 
pandemic flu planning.
    More specifically, we have established 20 Points of 
Distribution, what we call PODs, and the mechanisms for 
distributing and administering vaccines and medications to a 
large population, in our case, an MSA of more than 1.2 million 
people in just a few days. This spring, we had a great turnout 
in learning from our pan flu exercise, where more than 86 
persons from across the region representing public health, 
local elected officials, police and fire and emergency medical 
services, public schools and college, the airport authority, 
and community organizations and businesses.
    The following is a list of some of the things that we 
learned as a result of those experiences. First, we learned 
there is still work to be done in the area of public education. 
As Senator Pryor referenced earlier, many people are either 
under-informed or misinformed about the reality and the threat 
of flu and the need to plan for self-sufficiency. Delivering 
this message is challenging, particularly in this age of short 
attention spans when headlines compete for our attention moment 
by moment.
    Second, we are very concerned about business continuity 
planning. Pandemics are not like hurricanes or tornadoes. They 
are not a single incident that happens over the course of a few 
hours or even a few days. Sustaining life as we know it and its 
necessary business processes over weeks, months, and maybe even 
years with a shrunken workforce is one of the major challenges 
and consequences of pandemic flu that we all face and that I 
believe has not yet been adequately addressed.
    Third, the exercise emphasized for us the distinct role of 
local responders. For instance, the Strategic National 
Stockpile is a Federal and State resource, but its deployment 
will be a local responsibility. Memphis and Shelby County 
residents will look to the local health department and to local 
government to distribute vaccines and medications in a quick 
and efficient manner. They will look to us for specifics on the 
epidemic in our community, where to go for assistance, and how 
to protect themselves and their families.
    All disasters are local and response is dependent upon the 
knowledge, the skills, the resources of local responders 
representing multiple disciplines. But local does not mean 
isolated. Regionalism in planning is critical. Disasters, 
whether manmade or naturally occurring, do not respect 
political or geographic boundaries. National policies and 
guidance, written into funding opportunities that encourages 
and supports multi-State planning, minimalizing credentialing 
challenges, encouraging inter-governmental agreements, would be 
very helpful.
    For example, Memphis is located in the extreme Southwest 
corner of Tennessee and really serves as the metropolitan hub 
of a three-State region, a mostly rural set of counties that 
surround us for almost 120 miles in either direction. So in 
terms of disaster planning, as Memphis goes, so goes the multi-
State region that surrounds us. Adequate cross-jurisdictional 
planning can mean the difference in our ability to immunize our 
MSA in 48 hours or not.
    At the local level, our uniform public safety partners have 
learned the value of public health in protecting communities in 
emergencies. We need to translate those lessons learned locally 
to the Federal level. The Federal Government can help by 
insisting that local public health be at the table at the 
local, State, and Federal levels as planning is done and 
funding allocations are made.
    Again, I thank you very much for the opportunity to come 
before you today and for your interest in this very important 
issue to the health of all of our Nation.
    Senator Pryor. Thank you. What I would like to do is go 
ahead and lead off with a few questions, then turn it over to 
Senator Sununu. It looks like we may have a vote here in the 
next 10 or 15 minutes, but we will just play it by ear and see 
how it goes.
    The first thing I have for all three of you is just a 
general statement on the working relationship that you all have 
with the Federal Government. Is there sufficient two-way 
communication between your offices and the Federal Government? 
Is the Federal Government providing resources and accessibility 
on a variety of fronts? Dr. Halverson.
    Dr. Halverson. I appreciate the question because I think it 
really is important. As we talked about earlier, this is about 
a partnership and if the partnership is not effective, our 
response will not be, either. And I think, at least from 
Arkansas's perspective, we have a very positive relationship 
between the Department of Health and the Department of Health 
and Human Services and CDC in particular.
    One of the things that CDC has done specifically to address 
this issue is the development of what is called the Senior 
Management Official. That is an individual from the Director's 
Office at CDC who works in Arkansas on our executive staff and 
provides a responsibility as a liaison. That has been 
incredibly important to us as we have been able to use that 
individual to work with us to address issues that we have from 
time to time.
    The issue of Homeland Security, I think, and the Department 
of Homeland Security is a relatively new partner for us. We did 
attend a briefing recently that described the partnership 
between the Department of Homeland Security and HHS and the 
State and local health departments and how it will work. 
Frankly, it is too early to tell. This is really about 
relationships and I think that our strong working relationship 
and history with HHS has been very positive. I have a lot of 
hope for what could be a strong partnership with the Department 
of Homeland Security, but we really need to work that out and 
develop those relationships, as well.
    Senator Pryor. Mr. Pope.
    Mr. Pope. I would certainly echo Dr. Halverson's comment. 
And frankly, it is refreshing to see people at the Federal 
level who work as hard and just are as dedicated as we sense 
these folks are, and there is nothing that if you could not in 
some way add an additional 10 or 20 hours to each day, I don't 
think there are any problems we couldn't overcome.
    One other comment that I would make is that States and 
local governments tend to get a little bit frustrated with 
short deadlines, quick turnaround times that are imposed upon 
us by the Federal Government in order to comply with certain 
grant requirements. That is a controversial issue at times, but 
I will say that it is my opinion that it is those deadlines 
which will--it needs to be a balance, but it is those deadlines 
that keeps us making progress.
    Senator Pryor. Good.
    Ms. Madlock. Thank you. I would say that the relationship 
as I perceive it between the Tennessee Department of Health and 
the Federal level in the health sector is a very strong one. 
Ours at the local level is a bit more by proxy and a bit more 
indirect. But we do have a growing strength in that 
relationship, and I think overtures and recognition of the 
importance of direct communication between the Federal level 
and the local level is absolutely growing.
    On the flip side, when we go to Homeland Security, that 
represents for us a new construct also and we really are 
working in two different organizational constructs. While we 
have a very well developed, historically developed State 
structure for public health, the emerging structure for 
Homeland Security is a new one and we are working with 
different regions, different counties comprising those regions, 
and beginning to learn one another, so that the opportunities, 
I think, ultimately will be there for us to communicate a lot 
more with Homeland Security at the local level than has emerged 
or has grown or evolved to exist thus far directly with the 
Department of Health and Human Services.
    So it is a set of relationships that are different 
depending upon the office we are working with and they are in 
different States of evolution. But again, I think meetings like 
this and other opportunities we have had bode well for the 
potential for us to strengthen those relationships. I think 
everyone wants that to happen and I think we all recognize that 
is a critical element of success of planning.
    Senator Pryor. Well, thank you for those answers. One of 
the reasons I asked is because the two witnesses from the 
previous panel stayed here to listen to what you all had to 
say, and that is a good indicator to me that they are listening 
and they are working with you. As Senator Sununu will tell you, 
that is not always the case. A lot of times, the one panel will 
just leave the room, but I am so pleased that the previous 
panel stayed here to listen to what our local people have to 
say.
    At this point, I am going to turn it over to Senator Sununu 
for his questions and I will have a few follow-ups. Thank you.
    Senator Sununu. It is possible, Mr. Chairman, that they saw 
your question and super simply were well prepared, but somehow, 
I think that is probably not the case, having spent time with 
Chris Pope and others who have been working on these issues. I 
do get the sense that, partly because of the priority Congress 
has made, but I think because of the dedication of people at 
the local level, there is a good channel of communication.
    I want to begin by asking Chris Pope about that regional 
communication and regional coordination. You mentioned New 
Hampshire's involvement with the Northeastern States Consortium 
to help facilitate a better regional approach. Can you give 
some specific examples of how that regional approach has had an 
impact on New Hampshire?
    Mr. Pope. Sure. Well, a practical example that I can give 
you is in a non-public health scenario where we had an ice 
storm, a severe ice storm in the Northeast that affected New 
Hampshire, Vermont, Maine. I had tens of thousands of citizens 
without power for more than a week, and there is a very 
specific need to get a very basic line, electric company line 
truck from the Eastern Canadian Provinces into New Hampshire, 
Vermont, and Maine to help local utility crews restore power. 
It is part of a mutual aid agreement, and without agreements 
and conversation and planning ahead of time, those line trucks 
will sit at a border because of credible homeland security 
concerns and not get into the country as quickly as they are 
needed.
    So you meet ahead of time, you identify issues, you conduct 
tabletop exercises, and you exchange business cards before a 
disaster occurs, and this has been incredibly valuable.
    Senator Sununu. Why is it important to be part of that 
Northeastern Consortium even as you have the FEMA Region 1 
structure in place on top of it?
    Mr. Pope. Well, simply because we as the regional, either 
the directors of the Eastern Canadian Provinces or the 
directors in the New England Northeast States, we are driving 
our agenda. FEMA is not driving our agenda. And by the way, we 
attend meetings called by FEMA Region 1. We have got a terrific 
working relationship with FEMA Region 1.
    But there are times when we need to meet where we are in 
control of our own agenda, we are talking about the issues that 
are germane to us, and I think--and FEMA attends our meetings, 
as well, as does DHS. So this has been a positive, very 
positive thing. And by the way, we have had visitors from the 
Southern U.S. border attend these meetings and interest from, 
for example, Guam, who wants to build a similar relationship 
with Japan, who would be their primary help in a disaster.
    Senator Sununu. Dr. Halverson, you mentioned 96 exercises 
that you have participated in. Have any of those extended into 
a regional approach, and what are some of the key findings or 
experiences that have come out of those exercises for you?
    Dr. Halverson. Well, we do an awful lot on a regional 
basis, and in particular as we think about some of our border 
States between Tennessee and Texas. We have taken a little bit 
different approach in the issues related to pandemic, however, 
with guidance from CDC and the Department of Homeland Security 
and Health. The issue here is that in the event of pandemic, we 
really need to be planning what we can do as a State and not--
and frankly, it is a very difficult thing for us because it is 
our standard operating procedure to work together on a regional 
basis to create and share resources.
    In this instance, we certainly are aware of what is 
occurring, particularly in Texarkana, Texas, and Texas, and in 
Memphis, West Memphis, and in those areas. We do the planning, 
but we also are very deliberate in some of our work with 
pandemic to be thinking about what are we going to be doing 
collectively within the State. So our emphasis really has been 
on a State level.
    Now, from the perspective of counties, we are working 
together, and we do an awful lot of work sharing between 
counties within the State of Arkansas and we have a very 
established regional approach within our State, sharing 
resources, both people and material, to be able to work 
together in that regard.
    So again, for us, we do both regional approach but also be 
thinking about what we have to do on our own.
    Senator Sununu. Ms. Madlock, I have heard a lot of concerns 
about a lack of surge capacity within our health care system. 
Is this an issue in Memphis and Shelby, and what is being done 
or what might be done to deal with a lack of surge capacity in 
the event of a pandemic?
    Ms. Madlock. I would say I think the information you have 
heard, sir, is absolutely correct. I think the reality for most 
health care systems across the United States, and it is 
certainly true in Memphis and Shelby County, is that it is 
working at capacity right now. We have limited bed capacity in 
our community.
    One of the things we realize is that we probably could 
never build and create the full amount of beds and support 
services that would be available to medically respond to a 
pandemic as you see depicted here. And so one of the things we 
obviously try to do is to create strategies that will provide 
us distance of time and the luxury of time so that we can 
minimize that medical impact as much as possible.
    But in addition, we are working--we have a Medical Reserve 
Corps in Memphis and Shelby County. I know that they exist 
throughout the United States and I think they create great 
opportunities for bringing in folks to work in non-traditional 
roles that they may not assume on a regular day-to-day basis so 
that they can aid the effort as much as possible.
    So I think there are different approaches to responding to 
that, whether it is to build capacity through the use of 
volunteers, whether it is work to maximize the relationships of 
hospitals and health care systems across regions, and we are 
working to do that also, working with 19 hospitals in our 
region to try and identify capacities of both equipment, beds, 
workforce, etc., or to develop strategies of intervention so 
that we can minimize the demand to the extent that we possibly 
can.
    Senator Sununu. Director Pope, have New Hampshire hospitals 
taken a similar approach, a slightly different approach to 
dealing with the question of surge capacity?
    Mr. Pope. Our plan for the most part, and I am going to 
over-simplify it, but it is essentially not to rely on the 
hospitals for any kind of surge capacity for the same reasons 
that were very well enunciated by Ms. Madlock. We have asked 
our 19 AHHRs to go out, identify facilities in their 
communities that meet certain requirements, characteristics, 
that could function in an infrastructure capacity as an acute 
care center, as a help center, or any of the other, a POD, and 
we have actually started to exercise these locations as the 
operational plans are being built out.
    Senator Sununu. One of the things you mentioned in your 
testimony that would be of value that the Federal Government 
could provide is cooperative funding between DHS and DHHS to 
support Point of Distribution centers for communities that 
border other States, or in the case of New Hampshire, other 
countries like Canada. Has the Northern States Consortium or 
the International Emergency Management Group reached out to DHS 
and DHHS and how have they responded?
    Mr. Pope. That is the direction we have taken, and more 
specifically the issue becomes, and I will give you a very 
quick specific example. On the Western border of New Hampshire, 
where we border Vermont, we have major medical centers, 
including Dartmouth-Hitchcock on the Western part of the State. 
So you will see people from Vermont coming in on an every day 
basis to seek medical care, doctors' offices, into New 
Hampshire. And that is unique compared to what might happen on 
the Eastern border of our State with Maine, where we may 
actually have people from New Hampshire going into Maine to 
normally seek medical care.
    So the issues are a little bit different, but the problem 
we run into is we can't take Federal--we have had difficulty in 
trying to fund exercises where it appears in any way, shape, or 
form that the funds are going towards some activity or benefit 
in another State. So we have had some challenges there and we 
have asked NESEC to look into that with FEMA and DHHS/CDC.
    Senator Sununu. Thank you. Thank you, Mr. Chairman.
    Senator Pryor. Thank you. Dr. Halverson, you mentioned in 
your opening statement about non-medical containment exercise. 
Could you tell me what that is, why you did it, and what were 
some of the lessons?
    Dr. Halverson. Well, again, our issue, Senator, is that, as 
Dr. Vanderwagen testified earlier, the issue early on is to 
slow down the spread of this disease, and frankly, issues 
around social distancing, the limiting of large crowds, the 
early use of social distancing and limited quarantine, we think 
are really important. They relate to our ability to more 
effectively manage the spread of disease. So it really has been 
our focus to try to create an interest not just in the use of 
the anti-virals or the vaccine, but practical issues that 
individuals could take to try to minimize their risk and 
contain the exposure.
    Senator Pryor. Let me ask you, Ms. Madlock, about Memphis. 
We have seen this chart here with the map of the United States 
where hypothetically something starts in Los Angeles, and we 
appreciate that, but we also need to recognize that Memphis has 
one of the busiest airports in the United States.\1\ Is it the 
largest freight----
---------------------------------------------------------------------------
    \1\ The chart referred to appears in the Appendix on page 90.
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    Ms. Madlock. It is the largest cargo airport in the world, 
Senator.
    Senator Pryor. There you go, the largest cargo airport in 
the world. When I hear a statistic like that, I think it is 
just as likely that something like this could start in the mid-
section of the country, in Memphis, Tennessee.
    Memphis is such a regional city because it is right on the 
Mississippi River and Arkansas is across the river. If you draw 
a little circle around it, you are touching Mississippi, the 
very Southern part of Illinois and Missouri. It has always been 
that way. In Memphis, they call it the Mid-South, right?
    Ms. Madlock. Yes.
    Senator Pryor. I am curious about your sense about your 
capability for early monitoring and detection of a flu problem. 
In other words, theoretically, it could be some airport workers 
or some pilots or whatever it may be. I know you have a lot of 
people coming in from overseas because you are an international 
airport, as well. Do you feel like your city and your State has 
the tools necessary to do that early monitoring, to maybe try 
to contain it there before it really becomes a pandemic?
    Ms. Madlock. We are working on several fronts, and I think 
you have highlighted both our pride and our great challenge in 
the event a pandemic comes into the United States. We are 
working on several fronts. One of those is to develop very 
strong surveillance. We have recently been able to further the 
development on three different levels and on three different 
approaches.
    One is the Syndromic Surveillance System, using the early 
aberrant reporting system that was developed by CDC, which 
allows us to receive electronically information from emergency 
rooms throughout our region so that we can monitor and see if 
we have unexpected rates or incidences of infections or 
diseases that we would not otherwise expect.
    In addition to that, we have a system in place utilizing a 
surveillance system that provides us data from our public 
school system, where we get reports from 49 different schools 
to measure and monitor absenteeism rates.
    We are also working with a program that I believe is a 
national program also, but in the Mid-South region is looking 
at the retail pharmaceutical sales of drug stores, pharmacies 
throughout the Mid-South, so that we can see if we have had an 
exceptional spike in sales of anti-diarrheals or cold and flu 
medication.
    Those are kinds of early warning signals that will allow us 
to, as Dr. Halverson has mentioned and Dr. Vanderwagen 
mentioned earlier, provide us with an opportunity for early 
detection to slow down the spread. It is classic public health. 
It is the attempt to identify a risk early enough so that 
preventive interventions can be effective.
    So those are some of the major thrusts that we have, and I 
had another response, and as I went down that path I lost it, 
but I will be happy to respond further to that question.
    Senator Pryor. Great.
    Ms. Madlock. I can submit you something in writing along 
those lines.
    Senator Pryor. That would be great. Let me ask the whole 
panel about a patient care question, and that is, as I 
understand it, in most day-to-day practices, doctors naturally 
tend to treat the sickest people first, but with flu and when 
you have a pandemic situation, there is at least one school of 
thought that says you should treat those who are the most 
likely to survive. Who makes that kind of decision? Do we have 
a protocol? Is it a national protocol or a State-by-State 
protocol, or city-by-city, hospital-by-hospital? How will that 
be done? That is kind of a micro question, but I am curious 
about how that works. Who wants to take that?
    Dr. Halverson. I would be happy to start. Senator, I think 
you have identified one of the most difficult questions that I 
believe our physicians and health officials will face in the 
event of a pandemic. In Arkansas, one of the ways in which we 
have addressed this is by working very collaboratively with the 
Arkansas Medical Society and ethicists and we have created the 
opportunity to provide a consultation team to hospital ethics 
committees to begin working now to begin to address those kinds 
of questions that you have mentioned.
    Whether it is the priority of treatment is a major issue. 
The other issue relates to, for example, patients who are 
currently on a ventilator and the ability at some point in time 
to say that this person who has been on a ventilator for the 
last 6 months or 8 months or more may not necessarily be able 
to be sustained on a ventilator because there are other 
patients that might benefit more.
    These are difficult questions and ones in which we have 
asked our hospitals to begin to address now prospectively. 
Obviously, it is easier to face these issues today than it is 
to deal with them in the heat of the moment. So again, it is 
not going to make it a whole lot easier, but it will hopefully 
begin to address those issues now.
    Senator Pryor. Did either of you want to take that, as 
well?
    Mr. Pope. Well, I would certainly echo, and my background 
is not epidemiology or medical ethics for sure, but we will, 
from the State perspective, look for some guidance from the 
Federal Government, broad guidelines. Absent those, we will 
build our own protocols. We do have a group that we can pull 
together, an ethics group. It may or may not be practical to do 
that. It is best done ahead of time, obviously, and not after 
the incident occurs.
    Ms. Madlock. I certainly would agree with both gentlemen 
who have spoken thus far on that issue. The other piece would 
be that I think that is only one of the ethical issues that, 
again, we at the local level will be looking for support from 
our partners in the medical community as well as our partners 
at the Federal level. I know that the Centers for Disease 
Control is grappling with issues as to, for example, how do we 
prioritize the distribution of a relatively scarce commodity, 
such as the vaccine maybe in the early stages. So we have many 
issues as to how do we utilize scarce resources in a time of 
medical and public health crisis.
    If I might, Senator, just as a point of privilege--not any 
privilege, but a point of response to your earlier question in 
regard to Memphis serving as a transportation hub for the 
Nation, indeed the world, one of the things we are also working 
on is the development of guidelines and protocols as to how do 
we isolate, quarantine, or control the potential for an 
infection to be introduced through that international travel, 
and so we have convened the airport authority, our medical 
community, our public health community, and local officials to 
begin to talk about that very issue and to begin to develop 
some really strong plans in that regard. We do recognize that 
is a major point of vulnerability.
    Senator Pryor. Let me ask one more question, and Senator 
Sununu may have some more, as well, but on the issue of 
quarantine, I think all the witnesses have mentioned 
quarantine, all five of you, in different contexts. I know the 
University of Michigan did a study looking at 43 of the cities 
who were impacted by the 1918 pandemic and St. Louis, Missouri, 
had the fewest deaths. One of the reasons they did is because 
they closed schools, churches, and other community gatherings 
for 10 weeks to 2\1/2\ months.
    My question for the panel generally is do we have plans on 
the shelf that we can pull out to do that and take such drastic 
steps if we need to? I mean, have you all gone through the 
planning of all the things that need to be done in order to do 
that type of quarantine?
    Dr. Halverson. Senator, I think that is an excellent 
example of the reason why we need to work together in 
partnership. As we speak, actually, we have a very strong 
relationship with our Department of Education and the over 200 
school districts in the State of Arkansas. One of the issues 
that we are addressing is the authority to actually close 
schools, and not close schools for a couple of weeks but 
potentially for several months or maybe the entire term. As you 
pointed out very correctly, it is really about being able to 
move quickly and take decisive action to limit public 
gatherings. Schools are one example. Churches are another. 
There are a lot of factors relating to--and consequences of 
taking that action.
    So we are working with our Department of Education and 
school superintendents. We have actually conducted a State-wide 
planning meeting with our education leaders, and this is one of 
the issues that we are addressing right now. We are in the 
process of finalizing a draft on indicators for when we would 
take action, who would do it, how we would notify people.
    But there are a lot of other downstream issues, also, 
Senator, relating to the credit for children, how the teachers 
are going to be paid, who would pay the teachers, how to deal 
with a lot of downstream effects of making that kind of a 
decision. It is a very big decision, but we think it is 
important to address it early on.
    Senator Pryor. Let me ask this. Who makes that decision? Is 
that made on the local school board level or is that made city, 
county, or State?
    Dr. Halverson. In Arkansas, and I guess each State may be a 
little bit different, but as the State Health Officer, I would 
have the authority to make that decision generally in 
collaboration with the Director of the Department of Education 
and with the governor. But we clearly have the legal authority 
to actually close schools, and that would then be communicated 
to the local school superintendents and principals. But we 
really do want to see this as a collaborative decision, but we 
are in the process right now of delineating roles and 
responsibilities and action steps to make that very clear with 
everyone.
    Senator Pryor. Do you have any comments on that?
    Mr. Pope. I would just add that the problem is highly 
complex because in the case of private schools, for example, 
you have students who may be coming from overseas. You may have 
students coming from an area where there are already test-
positive cases. But I would also say that schools throughout 
the Nation, especially in the Northern climates, close due to 
weather events and other events, so they are fully aware of 
what the consequences are as enunciated by Dr. Halverson when 
you do close a school.
    That said, we have exercised this particular issue. There 
is a clear delineation as to who makes the call in our State, 
and that doesn't mean it is an easy call, but we have an 
educational annex to our State pandemic flu protocol.
    Senator Pryor. Senator Sununu.
    Senator Sununu. I have one last question for all of you to 
address. You have all participated in different simulations, 
tabletop exercises, also live exercises, drills, some on a 
small scale, I know some on a very significant large scale 
involving movement of materials and people to try to work 
through all the issues associated with pandemic response. I 
would like each of you to name the exercise or the program that 
you have found to be the most helpful in revealing steps that 
need to be taken, assessments that need to be made to improve 
your level of preparedness. Why don't we start with you, Ms. 
Madlock.
    Ms. Madlock. Yes, happy to. We conducted a drill, an 
exercise in late June of this year. It was an exercise of our 
POD administration system. We tested our ability to convene all 
of our partners and stand a POD up in a very brief period of 
time and be able to work patients through the system and have 
them immunized and back out again.
    I found it to be incredibly valuable for a number of 
reasons. One, it gave us an opportunity to work with all of 
those partners that came from all different disciplines 
throughout the community and the region.
    Second, I think the thing that was particularly valuable is 
that it gave our lay, not our lay, but our professional public 
health employees across the board, a cross-section of those 
employees, an opportunity to experience emergency response 
activities. It is one thing to read about it. It is another 
thing to learn about it. It is another thing to learn the 
language of NIMS and be able to talk the talk. But to be 
actually able to work in a different capacity and see the 
importance, the critical importance that your role and your 
showing up, your presence in an emergency situation can make 
and be is vitally important. We also then gave those same 
employees an opportunity to participate in the after-action 
report development so that they gave input into what worked for 
them, what else they needed to learn and know, and how it 
changed their perspective of their roles.
    So from the standpoint of interagency coordination and 
internal organizational staff development, to be really ready 
to respond, I found it to be incredibly valuable----
    Senator Sununu. Roughly how many people participated?
    Ms. Madlock. Oh, I would say probably about 100 of about 
500 to 600 people on our staff.
    Senator Sununu. Thank you. Director Pope.
    Mr. Pope. I would point to two things quickly. One is, and 
some of my peers may not agree with me, but the HSC compliance, 
Homeland Security Exercise and Evaluation Compliance--these are 
standards that exercises should follow when they are being 
conducted and I think they force you to really look at your 
weaknesses and what you need to do to improve.
    The second thing is just exercising, getting to your full-
scale exercises where you are exercising various pieces. We had 
a large 5-day pandemic exercise in New Hampshire this past 
spring. We relocated SNS assets from Georgia to New Hampshire, 
distributed them. We had hundreds of volunteers in five 
different cities, communities, or three different communities 
in New Hampshire actually going through and receiving a 
theoretic anti-viral or whatever it happened to be.
    First of all, it is very heartwarming to see the number of 
volunteers and people that are actually doing this. This is the 
battlefield, as far as I am concerned, and the work that is 
being done is just--I can't say enough about it. But the 
rewards will be there. Will it be perfect when it happens? No, 
but if we continue to do this, we are going to see, I hope, a 
much better outcome than we did back in the early part of the 
20 Century, the last time this happened.
    Senator Sununu. Dr. Halverson.
    Dr. Halverson. Probably the most significant exercise for 
us occurred mid-summer this year. We actually participated with 
the CDC and created--we were corresponding with CDC in real 
time using our videoconferencing equipment, stood up our 
Emergency Operations Center for a couple of days, worked with 
our hospitals and local health departments. So it really was 
for us a test of our Federal, State, and local response. It 
allowed us to deploy equipment that we don't normally use on a 
day-to-day basis. It allowed us to test things. We found things 
that didn't work. We found things that we needed to improve on. 
And frankly, that was a great exercise for us.
    Probably one of the most important things, though, that we 
have identified is now working with our local communities and 
having them have that same kind of experience. And so we work 
very collaboratively standing up our EOC as necessary, then 
working with the local community to test communications 
systems, work with hospitals, and again, all coordination with 
our Arkansas Department of Emergency Management, that is a 
partnership for us, as well, and we communicate very frequently 
in much the same way that Director Pope has mentioned that they 
coordinate their efforts. We do in Arkansas, as well, and that 
has been a good relationship.
    But that Federal, State, local exercise, I thought was very 
revealing, very helpful, and we did a full after-action review, 
as well.
    Senator Sununu. Thank you. Thank you all.
    Senator Pryor. Senator Sununu, thank you for your 
participation here today, and Senator Akaka, as well.
    I want to say that we will leave the record open for 2 
weeks. I know that some Senators will want to submit questions 
to the panel. We appreciate you all getting those answers back 
to us as quickly as possible.
    I want to thank both panels, and again give a special thank 
you to the first panel, who stuck around to hear the testimony 
of the second panel and to continue the dialogue. It is very 
helpful.
    So I want to thank everybody for participating and this 
hearing is adjourned.
    [Whereupon, at 4:27 p.m., the Subcommittee was adjourned.]

                            A P P E N D I X

                              ----------                              


                  PREPARED STATEMENT OF SENATOR OBAMA

    I would like to thank the Chairman and Ranking Member for their 
leadership on what continues to be an important health issue in our 
country--pandemic flu.
    As all of you know, we are facing the start of flu season here in 
the United States, and by many indicators, our public health officials 
and the medical community are better prepared than in previous years. 
Recent reports from the Centers for Disease Control and Prevention 
indicate that a shortage of flu vaccine is not expected, as production 
has reached an unprecedented 132 million doses. This preparedness is 
particularly good news, because improving our ability to respond to 
seasonal flu will certainly enhance our ability to respond to other 
natural and manmade disasters, including a top concern of mine--
pandemic flu.
    The Centers for Disease Control has described pandemic flu as 
inevitable and the biggest threat to public health in this Nation. And 
we know that much work remains to be done with regards to pandemic 
preparedness and response. The recent incident involving tuberculosis-
infected Andrew Speaker is one stark reminder. As serious as XDR 
tuberculosis has been to contain and control, dealing with pandemic flu 
will be many times more difficult.
    We need only look back over the last hundred years to remind 
ourselves of the speed and devastation caused by this potentially fatal 
virus. The Spanish flu pandemic in 1918, the Asian flu pandemic in 
1957, and the Hong Kong flu pandemic in 1968 are all harrowing 
reminders. The Spanish flu pandemic was the most severe, causing over 
500,000 deaths in the United States and more than 20 million deaths 
worldwide. Obviously, with our global trade and travel, the United 
States remains highly vulnerable to any pandemic; the recent 
tuberculosis incident involving Andrew Speaker clearly indicates that 
much work needs to be done in the area of surveillance and tracking the 
whereabouts of infected citizens, especially those leaving and entering 
our country.
    Congress has a responsibility to be proactive in building this 
Nation's defenses against all public health disasters. During my time 
in the U.S. Senate, I have introduced two bills specific to this 
challenge--one that speaks directly to the threat of avian flu and 
another that speaks more broadly at improving our emergency response. 
Briefly, the AVIAN Act of 2005 focused on pandemic preparedness and 
response in the areas of surveillance, preventive and medical care, 
core public health functions, information, and communication, with 
emphasis on collaboration and cooperation at the State, national and 
international level. More recently, I introduced the Improving 
Emergency Medical Care and Response Act of 2007 which will improve the 
coordination of emergency medical services, expand communication and 
patient-tracking systems, and implement a regionalized data management 
system.
    Even though the last flu pandemic occurred almost 40 years ago, we 
need only look as far back as 2005 to the events of Hurricane Katrina 
to be reminded of our poor response to a large-scale emergency. 
Preparing for flu outbreaks goes beyond just vaccine production, and we 
must remain vigilant in our efforts towards refining and implementing 
an effective and comprehensive preparedness strategy. I commend you for 
holding this hearing today and I look forward to working with my 
colleagues on this issue moving forward.

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