[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]




                 STATE AND LOCAL PANDEMIC PREPAREDNESS

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

                                HEARING

                               before the

                         COMMITTEE ON OVERSIGHT
                         AND GOVERNMENT REFORM

                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED ELEVENTH CONGRESS

                             FIRST SESSION

                               __________

                              MAY 20, 2009

                               __________

                           Serial No. 111-33

                               __________

Printed for the use of the Committee on Oversight and Government Reform


  Available via the World Wide Web: http://www.gpoaccess.gov/congress/
                               index.html
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              COMMITTEE ON OVERSIGHT AND GOVERNMENT REFORM

                   EDOLPHUS TOWNS, New York, Chairman
PAUL E. KANJORSKI, Pennsylvania      DARRELL E. ISSA, California
CAROLYN B. MALONEY, New York         DAN BURTON, Indiana
ELIJAH E. CUMMINGS, Maryland         JOHN M. McHUGH, New York
DENNIS J. KUCINICH, Ohio             JOHN L. MICA, Florida
JOHN F. TIERNEY, Massachusetts       MARK E. SOUDER, Indiana
WM. LACY CLAY, Missouri              TODD RUSSELL PLATTS, Pennsylvania
DIANE E. WATSON, California          JOHN J. DUNCAN, Jr., Tennessee
STEPHEN F. LYNCH, Massachusetts      MICHAEL R. TURNER, Ohio
JIM COOPER, Tennessee                LYNN A. WESTMORELAND, Georgia
GERALD E. CONNOLLY, Virginia         PATRICK T. McHENRY, North Carolina
MIKE QUIGLEY, Illinois               BRIAN P. BILBRAY, California
MARCY KAPTUR, Ohio                   JIM JORDAN, Ohio
ELEANOR HOLMES NORTON, District of   JEFF FLAKE, Arizona
    Columbia                         JEFF FORTENBERRY, Nebraska
PATRICK J. KENNEDY, Rhode Island     JASON CHAFFETZ, Utah
DANNY K. DAVIS, Illinois             AARON SCHOCK, Illinois
CHRIS VAN HOLLEN, Maryland
HENRY CUELLAR, Texas
PAUL W. HODES, New Hampshire
CHRISTOPHER S. MURPHY, Connecticut
PETER WELCH, Vermont
BILL FOSTER, Illinois
JACKIE SPEIER, California
STEVE DRIEHAUS, Ohio
------ ------

                      Ron Stroman, Staff Director
                Michael McCarthy, Deputy Staff Director
                      Carla Hultberg, Chief Clerk
                  Larry Brady, Minority Staff Director

















                            C O N T E N T S

                              ----------                              
                                                                   Page
Hearing held on May 20, 2009.....................................     1
Statement of:
    Sosin, Daniel M., Director, Coordinating Office for Terrorism 
      Preparedness and Emergency Response, Centers for Disease 
      Control and Prevention, U.S. Department of Health and Human 
      Services; Guthrie Birkhead, deputy commissioner for public 
      health, New YorK State Department of Health; Rex Archer, 
      director of health, Kansas City Health Department; Terry 
      Allan, health commissioner, county of Cuyahoga, OH; and 
      Paul Jarris, executive director, Association of State and 
      Territorial Health Officials...............................    12
        Allan, Terry.............................................    52
        Archer, Rex..............................................    36
        Birkhead, Guthrie........................................    25
        Jarris, Paul.............................................    58
        Sosin, Daniel M..........................................    12
Letters, statements, etc., submitted for the record by:
    Allan, Terry, health commissioner, county of Cuyahoga, OH, 
      prepared statement of......................................    54
    Archer, Rex, director of health, Kansas City Health 
      Department, prepared statement of..........................    38
    Birkhead, Guthrie, deputy commissioner for public health, New 
      YorK State Department of Health, prepared statement of.....    27
    Issa, Hon. Darrell E., a Representative in Congress from the 
      State of California, prepared statement of.................     9
    Jarris, Paul, executive director, Association of State and 
      Territorial Health Officials, prepared statement of........    60
    Sosin, Daniel M., Director, Coordinating Office for Terrorism 
      Preparedness and Emergency Response, Centers for Disease 
      Control and Prevention, U.S. Department of Health and Human 
      Services, prepared statement of............................    14
    Towns, Chairman Edolphus, a Representative in Congress from 
      the State of New York, prepared statement of...............     3

 
                 STATE AND LOCAL PANDEMIC PREPAREDNESS

                              ----------                              


                        WEDNESDAY, MAY 20, 2009

                          House of Representatives,
              Committee on Oversight and Government Reform,
                                                    Washington, DC.
    The committee met, pursuant to notice, at 2:43 p.m., in 
room 2154, Rayburn House Office Building, Hon. Edolphus Towns 
(chairman of the committee) presiding.
    Present: Representatives Towns, Cummings, Kucinich, Clay, 
Lynch, Kennedy, Van Hollen, Cuellar, Foster, Issa, Platts, and 
Bilbray.
    Staff present: Jason Powell, counsel and special policy 
advisor; Kwane Drabo and Katherine Graham, investigators; Peter 
Fise, staff assistant; Linda Good, deputy chief clerk; Jean 
Gosa, clerk; Adam Hodge, deputy press secretary; Carla 
Hultberg, chief clerk; Marc Johnson and Ophelia Rivas, 
assistant clerks; Jesse McCollum, senior advisor; Jenny 
Rosenberg, director of communications; Shrita Sterlin, deputy 
director of communications; Ron Stroman, staff director; 
Lawrence Brady, minority staff director; Jennifer Safavian, 
minority chief counsel for oversight and investigations; Dan 
Blankenburg, minority director of outreach and senior advisor; 
Adam Fromm, minority chief clerk and Member liaison; Kurt 
Bardella, minority press secretary; and Ashley Callen, minority 
counsel.
    Chairman Towns. The meeting will come to order. Good 
afternoon and thank you for being here.
    This hearing comes as a dozen schools in New York City are 
closed due to the H1N1 influenza outbreaks. This hearing also 
comes as New York City, my hometown, suffers the first H1N1 
fatality. I would like to begin this hearing by offering my 
sincere condolences to the family of Assistant Principal Mitch 
Wiener and also to the students, faculty, and staff of 
Intermediate School 238.
    With adequate preparation, our Nation responds better to 
natural emergencies than any other country. However, the 9/11 
terror attack and Hurricane Katrina demonstrated the 
consequences of inadequate planning and preparation. These 
events have also taught us that while national planning is 
required, it is the State and local public health departments, 
safety professionals, and first responders who are the most 
critical to get help to those in immediate need.
    Today's hearing will look at the ability of States and 
local communities to maintain an appropriate level of readiness 
to respond to a pandemic flu, and how Federal authorities can 
assist them in mounting a sustained and effective response to a 
pandemic striking the United States.
    Unlike a typical natural disaster such as a hurricane or a 
wildfire, outbreaks of pandemic flu affect all regions of the 
country virtually at the same time, making regional cooperation 
impossible. Also with a pandemic, it is necessary for public 
health teams to function 24/7 in a three shift pattern for a 
period of several months. These public health workers must 
conduct surveillance, lab tests, and treatments while 
coordinating school closings, surges at hospitals, and the 
storage and distribution of treatments and vaccines.
    Shifting national priorities and the impact of the current 
economic downturn have led to budget cuts in health departments 
across the country. According to the National Association of 
County and City Health Officials, 53 percent of local health 
departments in the State of New York lost staff in 2008 and 40 
percent expect to make more layoffs this year.
    While dealing with budget and work force challenges, New 
York has become a focal point of the current H1N1 outbreak. 
Nationally, the public health work force has been recently 
reduced by over 7,000 workers with more reductions expected. 
Over 85 percent of local health departments reduced their staff 
in 2008 and 46 percent are expected to lay off more workers in 
2009.
    A recent and seemingly prophetic GAO report published on 
February 26, 2009 warns of the continued threat of a pandemic 
as our national priorities move from pandemic preparedness to 
the economy and other issues. Current events remind us that 
pandemics can strike at any time and with little warning. Our 
communities need to stay ready to respond to such a threat.
    I am hopeful that this hearing will shed light on exactly 
how prepared we are to respond to a pandemic at the State and 
local level. I am also hopeful that our witnesses will help us 
discover what we all can do, not just in the Federal 
Government, to make sure our communities are ready to handle 
what Mother Nature dishes out. I want to thank all of our 
witnesses for appearing here today. I look forward to your 
testimony as well.
    At this time, I would like to yield to the ranking member 
from California, Congressman Issa.
    [The prepared statement of Chairman Edolphus Towns 
follows:]



[GRAPHIC(S) NOT AVAILABLE TIFF FORMAT]


    Mr. Issa. Thank you, Mr. Chairman. Thank you for holding 
this important hearing on State and local pandemic 
preparedness. I also want to thank our witnesses for taking 
time out of their busy schedules to testify before the 
committee. We recognize that in order to prepare for a hearing 
like this it isn't just the work of those who will prepare, but 
in fact is of some of the most important people in our local 
and State response units.
    In the event of an outbreak of pandemic flu, a coordinated 
response between the Federal, State, and local authorities from 
the Departments of Homeland Security and Health and Human 
Services to public health departments, hospitals, and emergency 
response teams in the smallest of American towns will be key to 
ensuring the health and safety of all Americans.
    The question of whether there will be an outbreak of 
pandemic flu somewhere in the world of a proportion similar to 
that of the early 1900's is not an if but a when. To address 
threats from SARS and avian influenza, the Bush administration 
created the National Strategy for Pandemic Influenza in 2005, a 
comprehensive approach for preparing for, detecting, and 
responding to a potential pandemic. The Strategy established 
guidance for Federal, State, and local preparedness and 
response. Additionally, since 2002 over $9 billion in grants 
have gone out to the States to strengthen hospital and public 
health preparedness. This coordinated response strategy is in 
the midst of having its first test, the outbreak of the H1N1 or 
swine flu.
    As comprehensive as our plans at the Federal level might 
be, absent proper coordination with State and local 
governments, any type of emergency response will be lacking. 
Less than 2 months before the H1N1 outbreak first appeared, GAO 
reported that more could be done to facilitate coordination 
between Federal, State, and local governments and the private 
sector to prepare for a pandemic. Questions also remain about 
the adequacy of the strategic national stockpile, and how 
assets such as antivirals and respirators in the stockpile are 
distributed to the States during an emergency. Today we have an 
opportunity to learn more about the gaps that may exist and 
what we can do to address them should this epidemic worsen or 
before any health emergency.
    Additionally, it is clear that we now have a number of 
financial problems at the Federal, State, and local level. It 
is inevitable that without an immediate requirement for 
pandemic flu preparation, States and localities would begin 
trying to divert funds to other areas. This would be done at 
perhaps the worst possible time. Even as we speak, the national 
stockpiles in some areas are being depleted simply because they 
have reached their expiration.
    Only a week ago, I had individuals involved in our anthrax 
preparedness in my office showing me a table of the expiration 
of anthrax. In fact, this material is being destroyed. A small 
amount of it is going to our troops in Iraq and we are thankful 
for that. But the majority of it in all likelihood will not be 
used unless health officials begin to find either ways to 
certify a longer time before expiration or to disburse it to 
first responders who could, in fact, take advantage today of 
preparation for a possible anthrax outbreak.
    This and many other areas are of importance to this 
committee. Although there has been good work done since 9/11 to 
help America be the best it can be in the case of any kind of 
an emergency--including a man-made one--budget cuts at the 
Federal, State, and local level are in fact of great concern to 
us. We have to know if we will maintain our preparedness and 
even improve it, particularly with regard to our coordination. 
Or are we saving pennies now to not be able to save lives 
later?
    Thank you, Mr. Chairman, for holding this hearing. I yield 
back.
    [The prepared statement of Hon. Darrell E. Issa follows:]

[GRAPHIC(S) NOT AVAILABLE TIFF FORMAT]

    Chairman Towns. Thank you very much for your statement. I 
yield 5 minutes to the gentleman from Rhode Island, Patrick 
Kennedy.
    Mr. Kennedy. Thank you, Mr. Chairman. Welcome all of you.
    I would like to get into the response to potential pandemic 
and the necessity to address the psychological response. 
Obviously, back in the 1940's, 1950's, 1960's there was that 
civil preparedness. Everybody got under their desks; everyone 
had a bomb shelter. There was a sense that we needed to get 
people prepared in the event of war, of World War III. One 
thing that it did for people is it gave them a sense that they 
had some control over their situation. In light of these 
announcements from the 24 hour barrage of the media, a lot of 
people get anxious and nervous because they don't know what 
they are supposed to do.
    Do you not think that it is necessary for us to--even in 
light of the fact that now we have terrorism--to have people 
prepared in this country and to have a plan of action in 
advance at their workplaces, at their schools, when they are 
traveling to work, when they are at home, or whatever the 
situation may be as to how to do, what to do, and things they 
need to follow in order to respond to a given scenario? Isn't 
it important that they practice that scenario? Shouldn't we, as 
a society, encourage that kind of civil preparedness so that 
there isn't a mass deluge of people to the emergency rooms in 
this country, which is exactly the opposite of what you want in 
a kind of situation like this? Would you all comment on that?
    Chairman Towns. Would the gentleman yield? We have not 
sworn them in yet, so hold the question. You have made a note. 
Then after I swear them in, they will give you an answer. All 
right?
    The gentleman from Texas, Mr. Cuellar.
    Mr. Cuellar. Mr. Chairman, I have some questions but I will 
reserve them so we can get started with the testimony. Thank 
you.
    Chairman Towns. The gentleman from Illinois, Mr. Foster.
    Mr. Foster. I thank the chairman for having this. I yield 
back.
    Chairman Towns. Thank you very much.
    Now will you please stand. I will swear you in so you can 
get to Patrick's question.
    [Witnesses sworn.]
    Chairman Towns. Let the record reflect that all of the 
witnesses answered in the affirmative. You may be seated.
    Why don't we just go right down the line starting with you, 
Dr. Sosin? We will just come right down the line.

 STATEMENTS OF DANIEL M. SOSIN, DIRECTOR, COORDINATING OFFICE 
FOR TERRORISM PREPAREDNESS AND EMERGENCY RESPONSE, CENTERS FOR 
 DISEASE CONTROL AND PREVENTION, U.S. DEPARTMENT OF HEALTH AND 
   HUMAN SERVICES; GUTHRIE BIRKHEAD, DEPUTY COMMISSIONER FOR 
PUBLIC HEALTH, NEW YORK STATE DEPARTMENT OF HEALTH; REX ARCHER, 
DIRECTOR OF HEALTH, KANSAS CITY HEALTH DEPARTMENT; TERRY ALLAN, 
 HEALTH COMMISSIONER, COUNTY OF CUYAHOGA, OH; AND PAUL JARRIS, 
EXECUTIVE DIRECTOR, ASSOCIATION OF STATE AND TERRITORIAL HEALTH 
                           OFFICIALS

                  STATEMENT OF DANIEL M. SOSIN

    Dr. Sosin. Good afternoon, Chairman Towns, Ranking Member 
Issa, and distinguished members of the committee. I am Dan 
Sosin, Acting Director of the Coordinating Office for Terrorism 
Preparedness and Emergency Response from the Centers for 
Disease Control and Prevention. Thank you for the opportunity 
to discuss the importance of State and local public health 
preparedness and response efforts and how we can further our 
response to public health emergencies in the United States.
    Our Nation's current response to the 2009 novel H1N1 
influenza is a direct result of the investments and support 
from the Congress for State and local public health 
preparedness and the hard work of Federal, State, and local 
public health officials across the country. This outbreak has 
placed huge demands on State and local public health 
departments to rapidly expand on the ground investigations and 
response activities, and has highlighted how necessary it is to 
have a trained work force at the ready.
    State and local public health departments are first 
responders to a wide variety of health threats, many of which 
never make the evening news. The many duties of public health 
departments include tracking the source, spread, and severity 
of health threats; educating the public on how to safeguard 
their health; and delivering medicines, guidance, and community 
interventions to lessen disease. Public health departments must 
have flexible and scalable capacity to respond to all hazards, 
both to major events such as influenza pandemics and terrorist 
attacks, and also to more routine events including community 
outbreaks of infectious diseases, chemical spills, and natural 
disasters.
    The primary Federal support for emergency preparedness and 
response at the State and local public health department level 
is CDC's Public Health Emergency Preparedness Cooperative 
Agreement. This Cooperative Agreement provides funding and 
scientific expertise in areas such as surveillance and health 
monitoring, epidemiology, laboratory testing, countermeasure 
delivery, incident management, and emergency communications.
    In addition, public health departments received 
supplemental funding for pandemic influenza preparedness from 
2006 to 2008 to support practical, community-based approaches 
to prevent or delay the spread of an influenza pandemic. 
Activities related to this supplemental funding include 
planning; community summits to facilitate engagement across 
Government agencies, business, and nonprofit organizations; and 
exercises to test response capabilities such as providing 
antiviral drugs and vaccinating broad segments of the 
community.
    These efforts paid off. During the response to 2009 H1N1 
influenza, public health departments at the State and local 
levels have been working around the clock. Emergency operation 
centers have been activated and emergency plans put into place 
across the country. Public health officials started tracking 
possible cases of H1N1 influenza, tested a large number of 
samples for the presence of the virus, provided information to 
communities about how to slow the spread of the virus, and 
educated the public about precautionary measures they could 
take.
    This education worked. A national survey conducted by the 
Harvard School of Public Health earlier this month found that 
two thirds of respondents report that they or someone in their 
household washed their hands or used hand sanitizer more 
frequently in response to reports about H1N1 flu. Over half say 
that they made preparations to stay at home if they or a family 
member became sick.
    Despite the great strides in preparedness and response for 
pandemic influenza, work remains to be done. More can be done 
to bolster the public health work force, which is the 
foundation of effective preparedness and response. Ongoing 
shortages exist in key occupations such as epidemiology, 
laboratory science, and public health nursing. It is also a 
challenge to have enough public health workers at the ready to 
deliver medicines and medical supplies during an emergency. The 
Nation's systems for tracking disease can also be improved. For 
example, we do not have nationwide electronic systems to 
automatically manage and share data such as laboratory results 
that are vital for response efforts.
    The path of the 2009 H1N1 outbreak may change. We need to 
be prepared for possible resurgence of this virus in the fall, 
potentially in a more virulent form. Complicating matters, 
other public health incidents that need our attention continue 
to arise such as food-borne disease outbreaks, floods, 
wildfires, and soon the hurricane season will be here. We must 
remain vigilant throughout this and subsequent outbreaks.
    At no time in our Nation's history have we been more 
prepared to face this kind of challenge. Nevertheless, more 
work remains to be done. We look forward to working closely 
with you to continue to prepare the Nation for evolving health 
threats.
    Thank you for the honor to speak before you today. I am 
happy to answer questions.
    [The prepared statement of Dr. Sosin follows:]

[GRAPHIC(S) NOT AVAILABLE TIFF FORMAT]

    Chairman Towns. Thank you very much, Dr. Sosin.
    Dr. Birkhead, let me just say a few words about you. He is 
the deputy commissioner for public health for the State of New 
York, and is an associate professor of epidemiology at the 
University of Albany School of Public Health. Dr. Birkhead.

                 STATEMENT OF GUTHRIE BIRKHEAD

    Dr. Birkhead. Thank you very much, Chairman Towns, 
Congressman Issa, and distinguished committee members. Thank 
you for the opportunity to testify today.
    The events of the last month with the dramatic emergence of 
the H1N1 swine influenza and the equally rapid public health 
response have proven the value of the investment we have made 
as a Nation in health emergency preparedness planning in recent 
years. In a short time we have learned a lot about H1N1, but we 
still have a lot to learn. Last week it appeared that things 
were getting back to normal, but the virus has continued to 
circulate in many communities. A number of schools, as the 
chairman noted, have been closed in New York City this week due 
to high rates of absenteeism from H1N1. In my testimony today I 
will provide a little background about New York's response and 
address the committee's questions.
    On April 25th, the New York Governor David Patterson 
directed the State Health Department to activate its emergency 
preparedness plan in response to the H1N1 cases in New York 
State. This plan was developed over a number of years of 
pandemic planning and involves the collaboration of programs 
across the Health Department, other State governmental 
agencies, and local public health departments including the New 
York City Department of Health.
    In terms of the committee's question on the need for 
resources and the impact of the economic downturn, two Federal 
funds sources have played a critical role to the State in 
developing its current preparedness: the CDC Public Health 
Preparedness Cooperative Agreement, which Dr. Sosin mentioned, 
and the DHHS Hospital Preparedness Cooperative Agreement. These 
funds, I would point out, have been reduced by 40 percent and 
24 percent respectively in the last 5 years. In addition, the 
State did receive pandemic influenza supplemental funds, as Dr. 
Sosin noted, from 2005 to 2008, but those funds have now also 
ceased. New York City also receives this same direct funding.
    New York State has provided $60 million in the State budget 
to support State preparedness programming. These funds have 
been used to purchase supplies and medications for the State's 
emergency stockpile, including the supply for New York City. We 
have purchased the maximum number of antiviral treatment 
courses allowed under the Federal program and now have 3.1 
million treatment courses of antivirals on hand. We also 
purchased other supplies such as 17,000 ventilators for 
patients with respiratory failure during a pandemic.
    New York has made it a priority to fund local health 
departments which are key to the local response, the boots on 
the ground if you will, for local response. We have provided 
$96 million in State and Federal funds over the last 7 years to 
our local health departments. Funding to locals was viewed as 
so important that the State Health Department absorbed the 
entire cut in the CDC preparedness grant in recent years in 
order to keep the county funding whole. However, due to the 
current fiscal crisis, county funding finally was reduced by 
almost 40 percent for the remainder of the current contract 
cycle. Ironically, this occurred on April 1st, just before the 
H1N1 hit. Many local health departments had to lay off 
preparedness staff at that point.
    In this context, the current discussion of the additional 
$350 million in one-time Federal funding to State health 
departments and locals to deal with H1N1 is welcome news, 
although the exact number should be examined to be sure it is 
enough when we are clear on what we are being asked to do with 
it. Such funding will be critical for States to maintain and 
strengthen their public health response capabilities in the 
face of what will likely be an ongoing threat. In particular, 
State and local health departments are likely to play a key 
role in any mass vaccination efforts should an H1N1 influenza 
vaccine be made. Such a vaccination program would be 
unprecedented in scope given the size of the population to be 
vaccinated. Federal funds will be critical to these efforts, 
but it is also critical for Congress to look to restoration of 
the cuts I mentioned in the base public health and hospital 
preparedness programs, respectively, that States have sustained 
over the last 5 years. One-time funding cannot provide for 
ongoing infrastructure needed to address H1N1 and future public 
health emergencies.
    In conclusion, some have suggested that public health may 
have overreacted to these events because a severe pandemic has 
not yet materialized. I want to assure you that at each step of 
the way, prudent steps were taken to prepare and protect the 
population in the face of uncertainty about the virus. State 
Health Department scientists who have spent their careers 
working on influenza have commented to me that this H1N1 virus 
represents the biggest shift in influenza viruses in their 
professional lifetimes.
    While initial guidance, for example, to close schools 
following a single case may seem in retrospect to have been 
overkill, I would make the analogy to hurricane preparedness. 
When a hurricane is bearing down on you, you don't take the 
view that we can relax because it might veer off. You have to 
assume the worst and prepare for it. That is what the public 
health community has done in the past month with H1N1 
influenza.
    We are much better prepared than we were even a few years 
ago. However, there are gaps in health preparedness 
infrastructure that can only be addressed by stable base 
funding to maintain that infrastructure. I urge Congress to 
consider restoring those funds.
    Thank you, Mr. Chairman. I look forward to answering your 
questions.
    [The prepared statement of Dr. Birkhead follows:]

[GRAPHIC(S) NOT AVAILABLE TIFF FORMAT]

    Chairman Towns. Thank you very much, Dr. Birkhead.
    Dr. Rex Archer is the director of health for Kansas City, 
MO and is a past president of the National Association of 
County and City Health Officials. Welcome, Dr. Archer.

                    STATEMENT OF REX ARCHER

    Dr. Archer. Good afternoon. Protecting and serving a 
population of 475,000 in Kansas City, MO is a challenge. We 
have a 143-year history and tradition of protecting against 
contagious and communicable diseases.
    Approximately 10 years ago in the spring of 1999, I started 
asking where we were as a Nation at the local public health 
department level in preparing for bioterrorism or various 
emerging infectious disease threats. As often happens when you 
ask those questions, they put you as Chair of a committee. So 
we have had a committee in NACCHO for 10 years that has been 
working on these issues. We have made a lot of progress but 
there is the old saying, the only thing harder than preparing 
for a disaster is answering the question of why you didn't. So 
with that, I believe that our charge is in looking at how we 
may need to reform some aspects of public health.
    Actually, we can borrow a model from fire departments. If 
you think about a fire and influenza, a fire burns through 
buildings and influenza burns through people. Fire departments 
don't respond with the minimum they need to put out a fire. 
They come in with extra trucks in our urban areas to put out 
that fire because you don't want to chase a fire. They have 
surge capacity to respond to those types of events.
    Ninety-nine percent of the time there aren't fires going on 
in our urban fire departments, but 99 percent of the time our 
local health departments are being challenged with covering all 
their mandates right now. So we don't have that surge capacity 
that we need to be able to respond. As an example, I really 
believe that if I think about our health department and where 
we were back in 1999, we were less than 5 percent prepared to 
manage a Category III pandemic from influenza. We have made 
tremendous progress, but I think we peaked back in about 2006.
    In a sense, we have a perfect storm going on with Federal, 
State, and local funds being cut. We don't have the people 
there to maintain our plans that were developed. The pandemic 
flu funding was critical for us to develop relationships with 
our churches and our faith community in general, with our 
schools, and with our business community. But this exercise 
that we have been going through recently with this H1N1 has 
really pointed out that the things that we put in place a few 
years ago, those communities are now asking us to respond, but 
the people aren't there anymore because the funding went away.
    As an example, I have 186 staff for serving that almost 
half a million people, but only 20 of them are really available 
for this kind of event. They are often funded out of grants, 
and that is an issue I think we need to look at. We could 
change the Federal guidance so that people under grants are 
expected to be cross-trained and prepared for these kinds of 
issues, whatever the funding source coming down, so that we 
would have them and be able to deploy them in these kinds of 
incidents.
    Basically, if we had had to go any longer with this event, 
we were at the point where we had prepared to stop and reduce 
our number of restaurant inspections, and to stop some of our 
contact tracing for sexually transmitted diseases. We were 
running our staff at 12 to 14 hours a day with half that time 
even over the weekend. And that was all really voluntary 
because we don't pay them overtime. So it really makes it very 
difficult to manage.
    Our response, though, was extremely effective. We activated 
and CDC was very helpful in communicating with us; the National 
Public Health Information Coalition was useful. The things that 
we had were in place. My fear is, though, that we are losing 
ground.
    If I had to really sum up, I want to thank the other local 
health departments, the State Health Department, and CDC for 
all of their work. But we really need the staff to keep the 
relationships. When you develop relationships with school 
systems, with faith communities, and with businesses but then 
those people go away, the plan can be there on the shelf but 
you can't exercise the plan in an emergency.
    Thank you.
    [The prepared statement of Dr. Archer follows:]

[GRAPHIC(S) NOT AVAILABLE TIFF FORMAT]

    Chairman Towns. Thank you very much.
    I would like to yield to the gentleman from Ohio, Mr. 
Kucinich, to introduce the next witness.
    Mr. Kucinich. Thank you very much, Mr. Chairman. It is my 
pleasure to introduce Mr. Terry Allan. Mr. Allan is the health 
commissioner for Cuyahoga County, in which my constituency of 
the 10th district is included. He is the commissioner for the 
Cuyahoga County Board of Health. The Cuyahoga County Board of 
Health is the local public health authority for over 886,000 
citizens and 57 greater Cleveland communities. So he has a lot 
of responsibilities. Mr. Allan is also president-elect of the 
Association of Ohio Health Commissioners and the former 
regional coordinator for Public Health Preparedness in the 
northeast region of Ohio.
    Thank you very much, Mr. Chairman. It is a pleasure to have 
you here, Mr. Allan, for your testimony to our committee.
    Chairman Towns. Thank you very much. We yield him 5 
minutes.

                    STATEMENT OF TERRY ALLAN

    Mr. Allan. Mr. Chairman, Ranking Member Issa, and 
Congressman Kucinich, thank you for the introduction, and 
members of the committee, we appreciate the time to talk to you 
today.
    I want to give you my perspective from greater Cleveland on 
what we know and what we still need to do from our experience 
over the last several weeks. The H1N1 response really has been 
a live exercise testing our capabilities and illuminating our 
gaps and challenges that we still have ahead of us as we really 
prepare for what is to come, the unknowns for the coming flu 
season this fall.
    Funding cuts have been mentioned. Close to 40 percent have 
effected Ohio as well as local health departments. Certainly, 
as we look at the State and local funding challenges that 
everyone is facing, we expect those further cuts to be on the 
horizon. That is very concerning to us just as we acknowledge 
our capabilities, which I will talk a little bit about, but 
also illuminate our challenges.
    In greater Cleveland, we have been working hard for many 
years, working with our partners throughout the region on our 
24/7 response capability and our comprehensive planning; 
establishing strong relationships with the first responder 
community, a regional cooperation with mutual aid to assist 
across that five county region that Congressman Kucinich 
mentioned; improving our ability to determine the distribution 
and determinants of disease, our epidemiology capacity; 
improving the ability to communicate with the public, which was 
very critical so that they had a trusted communication point 
during this event; and developing a working knowledge of 
incident command structure that police and fire have been 
working with for many years.
    In terms of our gaps, we still have a lot of work to do 
around volunteer recruitment, training, and retention. Right 
now in the greater Cleveland area, we have about 5,000 
volunteers. We need closer to 8,500. In our five county region, 
we need about 15,000 volunteers. They need to be trained; they 
need to be oriented; and they need to be made available very 
quickly to assist us if we need to ramp up.
    Our regional distributions of antivirals--which very much 
came to point here in recent weeks to distribute those to our 
community partners, to hospitals, and to perhaps the indigent 
folks who have nowhere else to receive these services--are 
critical. So are alternate care site planning when hospitals 
are full, surge capacity in terms of staffing that Dr. Archer 
mentioned, and social distancing plans.
    We may need to be telling folks if things were to get very 
severe, in the worst of circumstances, to stay home from 
school, to stay home from work, to telecommute. The kids would 
then need to stay away from the mall so we are not in a 
position of passing the virus around. Vulnerable populations, 
the poor and disabled, are particularly at risk. We need local 
surveillance capacity to be able to identify early on when an 
outbreak may hit your community.
    In my view, public health is an essential partner and must 
be viewed as part of the national defense system. Acquiring 
stable and adequate funding for public health is absolutely 
critical if we are going to be available and reliable for the 
public in a way that they have a right to expect. Because of 
the budget cuts, we are particularly concerned and hopeful at 
the same time about the $350 million that was talked about in 
supplemental money that the House was gracious enough to put 
into the budget. We are hopeful that it will be part of a 
conference discussion.
    In terms of personal preparedness that Congressman Kennedy 
spoke of, we have suffered nationally, we believe, from pan-flu 
paralysis with the general public becoming fatigued from our 
calls. They have an emergency plan for your community. Our H1N1 
response is an opportunity to develop a culture of 
preparedness. Folks are paying attention right now, so every 
family knows what to do.
    We need resources now, because as of August 2009, our 
pandemic flu funding will be zeroed out. So, it is our hope 
that we will have the opportunity to continue these efforts. It 
really is about people. It is people on the ground that are 
there to respond day in and day out to assure the public and to 
limit the scope and magnitude of an outbreak.
    Thank you, Mr. Chairman.
    [The prepared statement of Mr. Allan follows:]

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    Chairman Towns. Thank you very much.
    Dr. Paul Jarris is a family physician currently serving as 
the executive director of the Association of State and 
Territorial Health Officials. He is also the former 
commissioner of health for the State of Vermont. Doctor, you 
have 5 minutes.

                    STATEMENT OF PAUL JARRIS

    Dr. Jarris. Thank you, Mr. Chairman, Ranking Member Issa, 
and other Congressmen for this opportunity to speak before you. 
I have submitted written testimony to you, but rather than 
repeating some of what has been said before, I think I will try 
to emphasize some points.
    Chairman Towns. Your entire statement will be included in 
the record.
    Dr. Jarris. Thank you. There are a couple of points that I 
think are worth stressing. As much as we would like to believe 
that this episode is over, this episode is not over in the 
United States. We still face a novel influenza that is 
spreading rapidly in this country. It is in 48 States as well 
as the District of Columbia. We have confirmed in the 
laboratory 5,700 ill individuals but there are probably more 
along the order of 100,000 Americans who have been made ill so 
far.
    We frequently hear the comment that this is just like 
another seasonal influenza. It simply is not. The average age 
of the ill individual with this outbreak right now is 19. The 
average age of an individual in the intensive care unit with 
this illness is 23. That is not a seasonal influenza. Seasonal 
influenzas also do not occur this time of year. So this is a 
novel and new virus. We simply do not understand it yet.
    We do not know what is going to happen in the fall. I would 
argue that if we are lucky, this will come back in the fall, if 
it goes away in the summer, at the same level of virulence. But 
it would not be responsible for us to not keep history in mind 
and recognize that in 1918 that second wave was far more 
severe. In 1957 in Japan, that influenza came back with a 
second wave that was much more severe. So history would mandate 
that we are prepared in the fall for what comes at us.
    I do believe that we can be very proud and your committee 
can be very proud of the performance of the Government. Dr. 
Sosin, Dr. Besser, and all of Health and Human Services in the 
Federal Government should be commended on the way this was 
organized so that the Federal Government, State governments, 
and local governments came together as a single public health 
entity to respond to the American people. The Harvard survey is 
testament to that when 80 percent of the public reports that 
they are satisfied with the governmental response and 88 
percent say that they are satisfied with the information they 
have gotten.
    I think we all wish we could go home. It is not going to 
get any better than that. But we still have many challenges yet 
to face. Now we did, based on the investments Congress made, 
plan and exercise these plans over the past number of years. 
Our response to date has been quite good.
    But as we all know, plans do not survive the first contact. 
Many assumptions in our plans were incorrect. We assumed that 
this virus would start overseas, that we would have a month to 
2 months to figure out how transmissible this virus was and how 
severe it was. Well, it didn't. It began in North America so we 
had to activate plans without really understanding the virus 
and how transmissible and how severe it was. We don't fully 
understand that right now. But we were able to adopt and modify 
what we were doing and I think provide a very good response.
    As you have heard the other witnesses testify, there is a 
big difference between a 3-week response, which we have just 
gone through, and a full epidemic or pandemic response which 
may be 6 months or more. We simply cannot sustain the level of 
response we have had in this Nation to date. As was mentioned, 
we do not have the work force. We don't have the depth on the 
bench. It is only humanly possible to work two to three shifts 
for so long with a work force that has been cut by 11,000 in 
the past year and likely will be cut by 11,000 more at the 
local and State level. It is not humanly possible to maintain 
this response. That is why we need your help.
    As was mentioned before, we have seen significant cuts in 
State and local preparedness funding that comes through the 
CDC. We have seen significant cuts in the hospital preparedness 
money which comes out of ASPER in HHS. In addition, we have had 
no pandemic planning funding at the State and local levels 
since August 2008. So what you are seeing is a response but 
there is no fuel in the tank. We are asking you please to 
assist the States and the locals to mount a response for what 
may come at us in the fall.
    Very quickly, I will give you one example of what we have 
to prepare for. We are likely to develop a pandemic influenza 
vaccine. This novel H1N1 vaccine for the fall, it likely will 
require two doses. That is 600 million vaccinations we may have 
to give in the fall on top of the usual 80 to 100 million doses 
we give for seasonal influenza. So we are talking about 
potentially 700 million vaccinations to give in the fall with a 
work force that is diminished. The complexity of that, not only 
the cost of it but the complexity of administering that to 
Americans in a timely fashion, is tremendous.
    The vaccine will roll off the production line at 15,000 to 
20,000 doses a week. It will be distributed by the Federal 
Government to the States on a per capita basis. So it will be 
dribbling in over a number of months and we have to go down a 
priority list to protect the first responders, the health care 
providers, and others. So as one example, that is the level of 
complexity we face and that is the need. We need resources for 
the fall.
    I would be happy to answer questions. I apologize for going 
over time.
    [The prepared statement of Dr. Jarris follows:]

[GRAPHIC(S) NOT AVAILABLE TIFF FORMAT]

    Chairman Towns. Thank you. Let me thank all of you for your 
testimony.
    Let me say that is sort of frightening when you think about 
it in those terms and then with you saying that you are losing 
staff. It seems to me that you should be adding staff at this 
time.
    Dr. Birkhead, Dr. Archer, Mr. Allan, your States have 
created a preparedness plan and you submitted it to CDC. Are 
your States currently able to carry out those plans as 
submitted? Dr. Birkhead.
    Dr. Birkhead. Yes. I think, as Dr. Jarris said, we have 
been carrying them out for the last 3 weeks. It is fortunate 
that we had gone through that planning process. We have 
actually implemented the plans that we developed. But I think 
the point is how long it is sustainable.
    We at the State level have had to pull staff from many 
different areas of the Health Department off of their regular 
duties. For a couple weeks there we were working 7 days a week 
in 18 hour shifts. The sustainability of that is hard to 
imagine for much longer. Then, adding on to that the 
vaccination program which may come about this fall, I think 
there is a huge need. So we are able to maintain what has 
happened so far but I think, as Dr. Jarris aptly said, the tank 
is empty at this point. We need to refuel.
    Chairman Towns. Thank you, Dr. Birkhead. Dr. Archer.
    Dr. Archer. In 2006 we were better able to. We had more 
staffing and had funding for some of the relationships on the 
plan. It is one thing to say you are going to interact with 
your business community because of these social distancing and 
other issues--and we had done training--but it is another thing 
then to support that if you don't have the people there 
anymore.
    So I would say that I am afraid that many local health 
departments across the country have lost ground in the last few 
years. Yes, we can do almost anything for 2 or 3 weeks but we 
got to the point of exhaustion just during this incident.
    Chairman Towns. Yes, OK. Mr. Allan.
    Mr. Allan. Mr. Chairman, I think that we know what to do. 
To reiterate what has just been said, we just don't have the 
horses to do it over an extended period of time. If we had a 
higher severity situation where we had a lot more cases, a more 
severe disease, more contact tracing, and were dealing with a 
lot more fear--which was already substantial even in this 
circumstance--compounded by the confluence of things that Dr. 
Birkhead mentioned around a fall vaccination campaign, we are 
going to be severely strapped. We won't be able to do it.
    Chairman Towns. Right. You know, it is not really making a 
lot of sense to have a plan if you can't implement it, is it?
    Dr. Archer. Well, just think about regular seasonal 
influenza. We can't vaccinate one third of our population in a 
regular year when we have a year to prepare and plan for it.
    Chairman Towns. Let me ask you this: Are you asking for 
money? Quite often people will need it but they won't ask for 
it. Are you asking for additional money?
    Dr. Birkhead. Well, in my testimony I asked for two things. 
I supported the idea of the one-time $350 million. That is 
going to be desperately needed if we are going to vaccinate 
this fall. But I also asked for restoration of the cuts that 
have occurred in the CDC and HHS hospital funding programs over 
the last 5 years. That is partly why we are at reduced levels 
at this point.
    Chairman Towns. Dr. Archer.
    Dr. Archer. Sometimes public health is not very good at 
asking for funds. We try to do what we can, and you are 
correct. We made a mistake, I believe, when we asked originally 
after 9/11 in the anthrax attacks for just under $1 billion. 
The country deserves a level of protection much more than that 
to truly have the infrastructure to not only protect against 
these things but also when our health care costs are going out 
of sight.
    Our population in this country is down; 30 or 40 nations 
are above us in regard to life expectancy because we are not 
investing in prevention. So if we put the systems in place to 
truly work with our communities to prevent illness on a day-to-
day basis, that we should be investing in. We could also turn 
that structure in these kinds of emergencies and we would have 
those relationships. So I actually would go out on a limb and 
say we need 5 to 10 times what we are currently getting to 
really make a big difference in the population's health.
    Chairman Towns. Thank you. Mr. Allan.
    Mr. Allan. Thank you, Mr. Chairman. I think that as Dr. 
Archer said, public health isn't very good at asking. Often we 
just we are out there trying to help the least among us. 
Certainly I am concerned about these vulnerable populations, 
the disabled and the poor, that are most susceptible often to 
disease.
    I think that the stability of funding is important. We see 
sort of a seesaw effect and it is difficult to maintain staff 
to do whatever it is that needs to be done. It is not really 
about building widgets or counting widgets, as has been said. 
It is about having staff in place to surge, to respond during 
these events. There is lots of work in public health to do but 
to be able to put all hands on deck for this response is 
critical. Right now, the resources aren't there, particularly 
for the folks least able to fight off disease.
    Chairman Towns. Thank you very much. I yield to the ranking 
member, Congressman Issa from California.
    Mr. Issa. Thank you very much, Chairman. Dr. Jarris, I 
didn't intend to ask this question but I just want to followup 
on something you said in your opening statement. You said 
150,000 units a week. I am just trying to do the math. That 
doesn't get you to 300 million in a year. I am assuming that 
whatever you can't make in the 1-year, you are not going to 
make the others. So there is no plan based on that volume to 
achieve 600 million doses, right?
    Dr. Jarris. If I mis-spoke, I apologize. Initially, there 
will likely be volume that comes off of the vaccine that is 
being produced. We are not quite sure how large that will be. 
After that, 15 to 20 million doses a week should be coming out 
and being distributed. So if we take the 600 million----
    Mr. Issa. 15 million?
    Dr. Jarris. Yes. I apologize if I mis-spoke.
    Mr. Issa. OK, that is a different number. The record may be 
more accurate than my hearing. I just wanted to followup on 
that. Dr. Sosin, pronounce it for me so I get it right.
    Dr. Sosin. It is Sosin, sir.
    Mr. Issa. Sosin. Thank you. I apologize. With my name I 
should be more sensitive to everyone's name. Doctor, 
realistically, historically, in an outbreak, once we get past 
the first responders, don't we always allocate our resources to 
less than the entire population, including the plan you have 
for smallpox? And I guess I am leading up to the point that we 
do not have enough smallpox vaccine to begin to do the entire 
population. That is not even in the plan, is it?
    Dr. Sosin. Actually stockpiled, we do have sufficient 
smallpox vaccine for the entire population. The challenges of 
administering that vaccine are really where the bottleneck and 
the most difficult challenges will lie. But your broader point, 
which is planning for catastrophic events----
    Mr. Issa. OK. Let us take anthrax, for example. How many 
doses do you have today in a stockpile? And more importantly, 
how many will you have 5 years from now with the current no 
orders?
    Dr. Sosin. I will have to get back to you on the specific 
numbers. We have both antibiotic treatments for anthrax as well 
as vaccine for anthrax and a strategy for increasing vaccine as 
well as development of a new generation vaccine for anthrax. So 
there is a lot of work in progress. And I will get you the 
specific numbers. The broader question you raise of planning 
for catastrophic events, which means the system fails 
inevitably runs into limitations of resources, and therefore 
prioritization and strategy to do the best we can and address 
the best we can within the limitations of resources.
    Mr. Issa. And back to the resources for just a second, Dr. 
Sosin. Since we spend about twice as much as the Europeans do 
on health care, I am going to assume that money alone does not 
fix the problem based on how we spend money on health care in 
America, just the fact that we already spend more than the 
nations we are being compared to. Is not the most important 
thing for us to have is a plan to ensure that our first 
responders, including all the health care professionals that 
will receive people, are able to be continuously inoculated, 
prepared, or, if we do not have something, the first to 
receive? Is that not sort of the crux, the most important crux 
of the plan is that we not lose those people which Dr. Jarris 
and others have said are already in short supply.
    Dr. Sosin. Clearly, there are a number of priorities for 
how we respond most effectively. First line responders are one 
of those priority groups, whether that is in the health care 
system, whether that is in emergency response and emergency 
management system. I think the comments made earlier about 
vulnerable populations, however, reflect also Government 
responsibility to assure that there is a safety net for those 
with the least access and the greatest need. So planning really 
has to be in the broadest sense. But there are strategic 
priorities set for early stages versus later stages of 
response.
    Mr. Issa. OK. And one followup to something I said in my 
opening comment. Since the anthrax stockpile is expiring and it 
has never been offered broadly to first responders, do you have 
a plan to deal with making that available to first responders 
around the country, including our health professionals, rather 
than destroy the stockpile which is currently in the plan?
    Dr. Sosin. There is ongoing discussions amongst the 
emergency responder community with the Department of Homeland 
Security, Department of Health and Human Services about the 
appropriateness, suitability of this vaccine in that setting. 
There have been advisory committees for immunization practices 
looking at and providing permissive guidance that without 
sufficient understanding of risk there may be a point in time 
where risk is sufficient to warrant pre-vaccination of those 
populations. So there is discussion about that. There is the 
ability to make that vaccine available before it expires. But 
that is active discussions going on right now.
    Mr. Issa. Let me just ask one final followup question, Mr. 
Chairman, if I may.
    Chairman Towns. You may.
    Mr. Issa. Are our health care professionals, specifically 
doctors and nurses at our community centers around the country, 
are they not the most informed consent individuals? And if you 
have a distribution request and it is a voluntary taking by 
those individuals--remembering that our military is not 
voluntary, they get the shots whether they like it or not; they 
go to combat, they are going to have it--would that not be a 
group that by definition, the safeguards you are talking about 
protecting them from not having enough informed consent, is 
this not a group of people that we normally rely on to advise 
people and, therefore, if a doctor at the Cleveland Clinic or 
Cuyahoga Community Hospital wants that medicine and has the 
normal informed consent, are they not by definition the people 
who should be allowed to make that decision, not have it 
micromanaged in Washington?
    Dr. Sosin. Thank you, sir.
    Mr. Issa. You are most welcome.
    Dr. Sosin. My understanding is that the licensed vaccine is 
actually potentially commercially available. The company has 
indicated that they have capacity to produce and sell the 
vaccine additionally. These questions are really about the 
purchases that the Federal Government has made and is there a 
strategy for making that available to populations in need. I am 
not aware that the health care community, in the similar way as 
they were not terribly interested in smallpox vaccine, has 
indicated an interest in anthrax vaccine at the same time.
    The emergency responder community, we hear, is mixed in 
terms of their perspective on whether that should be required 
or made available to them. And the Department of Homeland 
Security is establishing whether this is appropriate for their 
approved equipment list and therefore the funds can be used 
from Homeland Security to do it. So there is complexity there. 
But your broader question of whether the medical community 
should be in a position to utilize a licensed product, 
absolutely. That is the way our health system works.
    Mr. Issa. Mr. Chairman, that was not my question. The 
question is, before we throw this material away or actually 
spend money destroying it, will we make it available with 
ordinary, if you will, informed consent so that it not be 
literally thrown away while the alternative to go buy, is what 
the hospitals, including the first responders in Cleveland, who 
asked me about this when I was there.
    Chairman Towns. Right. And that is an excellent question.
    Let me just say before I yield to the gentleman from Rhode 
Island, you have a plan, but without the resources you do not 
have a plan. You cannot carry it out. And I think that you need 
to be honest about it and just sort of point it out and let us 
see if we can get some help for you. It does not make you a bad 
commissioner, a bad administrator because you do not have the 
resources. I think you have to fight to get the resources 
because this is serious. If you have a plan and you cannot 
implement it, it is no plan.
    Dr. Archer. And one of those resources is the challenge, 
and the failed challenge I think, in this country in regards to 
vaccine production. We have problems with standard vaccines not 
always being there when we need them. We have to change our 
message to the public. There are ways to fix it if we actually 
sat down and talked about it. Having worked in Ford Motor Co., 
I could use the analogy that if we had to make cars, decide how 
many were made today 9 months ago, if you had to change the 
model every year, if you had to throw every car away that was 
not sold within 3 months, and if you had to share the keys with 
others. Because half the benefit of vaccines is not the 
individual but the herd immunity effect, if you looked at all 
those dynamics, no wonder we are having trouble producing 
vaccine at the level that we should be in this country. We need 
to address that and fix that.
    Talking about who is going to be a priority whether it is 
first responders or whatever, the real problem is we have not 
fixed a production issue of vaccines in this country so that we 
can get them to everybody. Yes, there are challenges with 
smallpox, there are challenges with anthrax, but that does not 
spread like wildfire or like influenza. So it is a little 
different animal. We really do need to be able to vaccinate 
every American for normal seasonal influenza.
    Chairman Towns. I agree. I agree with you.
    Dr. Jarris. Mr. Chairman, may I comment?
    Chairman Towns. Yes.
    Dr. Jarris. I think you are right and the comments have 
been made appropriately that where we can mount a response, we 
cannot maintain it. So our plan is not adequate because the 
resources are not there.
    At the time we testified before the committees a couple of 
weeks ago and we said we were requesting $350 million for State 
and local preparedness, that was a figure that is a very low 
figure. That figure would be equivalent to what we have gotten. 
We have had a single $600 million appropriation in the past. We 
got $250 million and $350 million to support State and local 
preparedness. So all we asked for was basically another sum of 
money to continue the level of planning and preparedness we 
did.
    Frankly, we made a mistake because that was before we knew 
how serious this was and how serious the fall may be. So the 
$350 million in the House right now is probably not nearly 
enough and it is a start to get us to revise our plans.
    We also asked for some money to purchase antivirals, to get 
to Mr. Issa's point, for healthcare workers and critical 
responders. Our strategic national stockpile right now only has 
countermeasures, masks and antivirals, for treatment, it does 
not have masks and antivirals for prophylaxis for healthcare 
workers, public health workers, and ambulance. So we asked for 
money for that also.
    So, clearly, we need more money. As you say, it is not 
appropriate to put first responders, whether it be public 
health, fire, ambulance squads, in harm's way without 
protecting them. And yet our current strategic national 
stockpile does not have antivirals for that prophylaxis. So we 
really do need more money and I am sorry we under-asked.
    Chairman Towns. Right. Thank you very much.
    I yield to the gentleman from Rhode Island who had asked 
this question. He might want to rephrase it now.
    Mr. Kennedy. No. I would really like, just as the chairman 
asked, to get some real numbers in terms of what would be ideal 
budgets. I serve on the Appropriations Health and Human 
Services Committee for HHS. We are going to be going into 
markup in the next couple of weeks. This is frightening.
    All I know is that I would be derelict in my job as a 
Member of Congress, as a member of that committee if next fall 
I am sitting here in Congress and we have this flu, and by all 
accounts this flu is coming back, and this scenario that you 
are painting for us is happening, and I am sitting there after 
having sat in this hearing and someone said weren't you in that 
hearing, didn't you hear what they told you, and I did nothing 
about it.
    For one thing, we have been told there are not going to be 
any more supplementals. So this has to be part of this year's 
budget. It has to be part of this year's appropriations. So we 
had better get to it. And knowing the glazed-over look in 
appropriators' eyes when you talk about more money for this and 
that, if something is not burning up, things are not going to 
get funded. We have to really, as you all have said, seize the 
opportunity that we have right now in terms of the public's 
attention on this and really make the most of it because we are 
not going to have this opportunity until next fall and that may 
be too late.
    So we had better move now. And I just want to underscore 
your urgency about this and say, do not hold back. OK? You are 
not stepping on anybody's toes. OK? You are going to be 
derelict in your own responsibilities to the administration 
which you work for and to your own obligation to public health 
if you do not make some really aggressive and ambitious budgets 
and put them forward in spite of whatever your higher-ups say. 
Frankly, I am going to demand it, I am going to push for it, as 
I know the chairman will, to get these answers.
    The fact that you cannot even vaccinate one-third of your 
current population when you had a year to prepare for it 
terrifies me. We have just a few months to prepare for the H1N1 
this fall and we cannot even prepare to get a third of the 
yearly, which is only a million and change, and we are talking 
about 600 million doses.
    The scale of this thing is enormous and I do not think we 
have even wrapped our heads around how big a challenge this is. 
So we need to know the ratio of public health personnel to the 
population that is needed. We need to know the ratio of 
volunteers that we need, backup personnel that we need versus 
population. That is going to be needed. We need to have the 
numbers of prophylactic equipment and the like. All of those 
things need to be sized up.
    And again I would ask you, what do we have in terms of 
plans for the faith community, for the private sector, for the 
public sector and the like that they can exercise? Are we using 
technology for the cell phones, for twitter, for email? What 
are we doing to be able to message people when it comes to this 
modern society, to be able to communicate with them so they are 
not just getting messages from these 24-hour news that often 
are inflammatory and full of misrepresentations in terms of 
news? How do we get facts out there and real information in 
terms of what to do and where to go so people feel empowered 
and not fearful? That is the key. That is what I want to ask 
you guys. How do we make people feel empowered here?
    Dr. Sosin. Thank you, sir. Getting to your first points 
about having confidence in your Government, having confidence 
that you know what to do and therefore responding more 
effectively, that is absolutely critical. The numbers that Dr. 
Jarris shared about this event where we approached it very 
aggressively, we did use twitter and widgets and other kinds of 
tools to reach the broadest population we could, distributed 
from the Federal level, State and local levels through 
practitioners as well as directly to the public, communications 
just in time about what you can do and what you can expect, and 
what we know and what we do not know has been one of the 
successes of our response so far. Maintaining the pace, 
addressing the complexity, those will be challenges in a larger 
scale event for sure.
    So, yes, we are responding to some of those communication 
challenges that empower the public, empower business, etc. We 
have definitely come a long way with respect to engaging 
business, engaging the faith community, engaging the public and 
we have a lot more work to do. I will point out that those 
plans discussed here have been evaluated in quite a lot of 
detail. Twelve departments and two offices of the White House 
participated in a joint review of the pandemic influenza plans 
and there is a volume of information on the pandemicflu.gov Web 
site on those evaluations.
    Importantly, the kinds of activities that we have been 
talking about here that lie in the lane of public health were 
the strongest parts of those plans. The weakest parts of those 
plans were the broader interagency, intergovernmental 
coordination, interdisciplinary coordination with the emergency 
response community at-large, with the service sectors, etc.
    So even the plans that we have reflect gaps and needs for 
more effort, not just sustainment of where we were 6 years ago.
    Dr. Birkhead. I would just like to add that I agree 
completely. Public communication is critical. We cannot respond 
to a pandemic in this country without people understanding what 
their role is, what they need to do. We have invested a lot of 
effort in New York and I know in the other States in trying to 
do that. We have also worked with our business and faith 
communities. We have worked with businesses to develop 
continuity of operations plans so they can continue to operate 
in a pandemic, particularly if people can work from home, that 
kind of thing.
    That does not always work but to try and think through. In 
a normal flu season we only vaccinate 100 million people 
because there is not a demand out there for it. I think we have 
gotten their attention, as others have said, with this H1N1 and 
the challenge will be how to meet the demand that I suspect we 
will see if we did really roll out a vaccine and try to offer 
it to everybody. That will be the real challenge.
    And you are right, we need to have the detailed plan of how 
many people we need to do that. We partly need to see when it 
is going to happen, how quickly it will roll out, will we 
really see 15 million doses a week coming out. There is a lot 
of detail there to give you a precise answer. But we need a lot 
more than we have right now.
    Mr. Allan. Congressman Kennedy, I think the whole issue of 
this culture of preparedness, getting folks to think about 
this, Red Cross has worked on this for some time. There is 
fatigue when people have a sense that nothing happens. They 
think that public health is Chicken Little, you know. And I 
think from our end this is a wake up call and we are hoping to 
now capitalize. CDC has some great educational information that 
talks about, you know, clean hands save lives. Just a basic 
message is critical.
    But there is lots of fear and there is a tremendous amount 
of rumors that occur in the middle of this that everyone here 
has dealt with that need to be dispelled as quickly as 
possible. And that individual preparedness and planning for 
families and understanding messaging are, I think, essential. 
It is nice that there is attention now being paid to public 
health and an understanding of the critical nature of what we 
do. So I am glad that this discussion is being held.
    Dr. Jarris. Congressman Kennedy, you are bringing up a very 
important point about communication and maintaining the 
credibility of Government. And what we saw in 1918, because of 
a lack of transparency, is people did lose faith in the 
Government. We saw some of the social fabric in this country, 
neighbor caring for neighbor, breaking down. So that is 
something that we very deliberately have to pursue.
    One thing I would ask you all to keep in mind is that we do 
not have a separate work force in public health that we pull 
out of the closet for a pandemic or a hurricane. These are our 
every day work force and that is why we need to have that bench 
strength and those professionals, those nurses, laboratory 
staff, and epidemiologists on board every day so we can surge 
with them. Part of that system of public health that we so 
clearly need are experts in communication.
    You mentioned that you are on the HHS Subcommittee. Very 
importantly, the communication was done so well because we had 
experts working on how to communicate with the public, who were 
monitoring the twitters, the blogs, the Webs, the newspaper 
articles, the television media to see where the direction was, 
what are people thinking, what are they reporting, so we could 
on a daily basis adjust our messaging, and on a daily basis the 
CDC's Director's talking points were sent to the State health 
officials, were sent to the local health officials who were on 
message.
    One of the reasons I bring that up is that messaging is 
coordinated within the CDC and the National Center for Health 
Marketing, a terrible name and a very unfortunate name. But 
they are undergoing significant cuts in the budget. I believe 
it is $9 million in the fiscal year 2009 budget and $3 million 
in the 2010 budget. It has a terrible name, marketing. We say 
what is that doing in public health. But what they are doing is 
understanding how to communicate expertly with the public. And 
much of our success was due to that Center's work. So I would 
ask you to take a hard look at that. And maybe they can change 
their name. Thank you.
    Dr. Archer. We will get back to you with the challenge you 
put out to us on the ratios in regards to public health folks 
and volunteers, etc. And I think that is critical. To give you 
an example, we have a full-time public information officer that 
is paid out of the CDC funds for preparedness. That person does 
not just serve our Kansas City but serves the whole region in 
regards to preparedness. Now they carry a 24/7 media pager. 
They will respond 90 percent of the time within 5 minutes.
    If we do not get a call from the media in 2 days, we check 
the battery or try to figure out what is going on because they 
are constantly having interaction with the media. That allows 
us to change that message. When the message is wrong at the 6 
o'clock news, we can usually get it changed by the 10 o'clock 
news because we have the interactions with the media. That is 
not present in all of our communities and we need that support. 
But that person burned out in this event and we had to send 
them home just to get some rest.
    Mr. Kennedy. Well, I hate to bring up burned out, but 
National Guard is already burned out. But I imagine you 
mentioned national security when you mention this. I imagine 
national security would be invoked in favor of bringing in 
National Guard to help you in some way. Maybe you could give us 
a response at some later date about what you think of deploying 
National Guard, proper training included.
    Dr. Archer. We have the Medical Reserve Corps but that is 
done on a shoe string. We really need some of those protections 
the National Guard have in regards to actually paying people 
for training and those things. We could create a model that 
would really work and we would love to work with you on that.
    Chairman Towns. Right. The gentleman's time has expired. 
Let me recognize the Women's Caucus and we have a lot of health 
care people involved. We just want to thank you very much for 
your attendance. Thank you very much Women's Caucus.
    At this time I yield to Congressman Bilbray.
    Mr. Bilbray. Thank you very much, Mr. Chairman. Coming from 
southern California, burned out takes on a different concept, 
especially after the couple of years that we have had.
    What is the population of Vermont?
    Dr. Jarris. It is about 620,000 people, not including the 
cows.
    Mr. Bilbray. Wow. OK. I supervise the disaster preparedness 
system and the health care system for the county of San Diego, 
which is 3 million. I assume your disaster preparedness 
structure is probably State-wide and not regional.
    Dr. Jarris. Well, I am no longer with the State of Vermont. 
But yes, Vermont had a single structure for the whole State.
    Mr. Bilbray. Single structure. I figured so for that size. 
And Mr. Archer, you pointed out on this, and this is where how 
this all works in, the network of how well integrated, you are 
all integrated into the disaster preparedness structure, right?
    Dr. Archer. Yes.
    Mr. Bilbray. Doctor, if you were going to be somebody who 
wanted to plant a virus in 500 people that would have the most 
impact on this country, if you were going to figure out a 
profession, 500 people, maybe two or three professions, have 
you guys looked at exactly what group of people have the 
potential to spread the problem fastest and easiest?
    Dr. Sosin. Sir, with respect to terrorism and biological 
terrorism, there is a governmental process of establishing risk 
and conducting a risk assessment that includes understanding of 
impact, of capabilities, of those who might attempt to do such 
things. That is not what I am here prepared to speak about 
today. But I will acknowledge that nature as a terrorist here 
with influenza, it is about the best reassorting virus to be 
able to pick up antiviral resistance and modify during the 
course of a season that you could ever devise in a laboratory. 
So we are up against something that is really quite daunting.
    Mr. Bilbray. I am just thinking about what we can do as an 
oversight committee rather than just complain about what the 
executive branch is not doing enough of, what we can do to be 
proactive on this. And last October it became obvious to me as 
somebody who had worked with public health that if there was 
ever 500 people who could come in close proximity to a lot of 
people all over this country, that all meet at one location and 
go out into the country, it would be the Members of Congress. I 
mean you talk about the vectors, paid for with taxpayer's 
money, get out there and kiss as many babies as you can, shake 
as many hands as you can.
    And frankly, Mr. Chairman, this is one of the concerns that 
I have. There was a lot of discussion about the Members of 
Congress getting inoculation. Frankly, I think it should be a 
requirement that the Senators and House Members are required to 
be inoculated. Unless there is a medical reason for them not to 
be, with how much exposure we constitute to the general public, 
that is one of those things.
    The other group that is probably the only group that is 
more than your duly elected Representatives of the House and 
Senate would be flight attendants and pilots. I do not know, 
there may be other professions. But boy, I think history has 
proven the flight attendant potential for spreading disease. 
But I think we need to talk about this in frank and open ways, 
back and forth, of what are we not doing, are we requiring 
those involved with commercial aviation to be inoculated, and 
are we talking about ourselves, making sure that we are not 
part of the problem.
    But I want you to know that I listened to the Vice 
President. I did not fly last week. I was very concerned about 
that and made sure I stayed put.
    Let us go on. Notifying the public. Mr. Kennedy raised this 
issue. What is the potential in your city, in St. Louis? Do you 
have reverse 911 now?
    Dr. Archer. I am in Kansas City, MO.
    Mr. Bilbray. Kansas City. I am sorry.
    Dr. Archer. We do not have reverse 911. We do have 
tremendous cooperation with all of our TV stations. So as long 
as they have power and can broadcast, we have that mechanism to 
get information out.
    Mr. Bilbray. When you were in Vermont did they have reverse 
911?
    Dr. Jarris. No.
    Mr. Bilbray. Anybody?
    Mr. Allan. The city of Cleveland has a warning system 
within the city boundaries and some select, more financially 
well off suburbs have some capacity. But it is not uniform 
outside of the city.
    Mr. Bilbray. But the city has the ability to call people's 
homes with a message telling them, being able to call into 
them?
    Mr. Allan. Yes. With a message, it is a one-way type, 
right.
    Mr. Bilbray. OK. Just explaining it, because we developed 
that because of our fires. We can actually tell street by 
street, neighborhood by neighborhood what the conditions were, 
be informed. I am sorry that Mr. Kennedy is not here because 
there is a place of being able to empower and the locals being 
able to be that bridge.
    There is a very real possibility with this new strain that 
we will not see the drop off during the summer. Has anybody 
even discussed that, that we may have this right through the 
summer?
    Dr. Sosin. There is a lot of attention to the virus 
domestically as well as abroad, and in particular in the 
Southern Hemisphere which is entering its typical seasonal 
influenza season. So we are not standing down and I do not 
believe any of the folks at this table are really returning to 
business as usual. We do not typically see much virus activity. 
But as Dr. Jarris pointed out, this has not been a typical 
virus. So we are watching very carefully. This is still very 
early on in this outbreak and anything is possible with this 
virus.
    Mr. Bilbray. Mr. Chairman, one last question. We are 
talking about what we can do. If you had FDA approve a post-
exposure treatment that was genetically engineered to address 
11 out of 16 different strains, if you had the ability to have 
an effective post-exposure treatment or had a vaccine that was 
multi-strain, if you had that lined up and ready in time for 
the next cycle, would that not be a major plus for you to be 
able to start tooling up? And this gets down to your issue of 
us changing our operations and getting the stuff available. 
Just comment on that.
    Dr. Birkhead. Well I think we are not talking about post-
exposure, but the vaccine we are talking about would be exactly 
what you are saying. And yes, that is what we need.
    Mr. Bilbray. OK. I just want you guys to keep raising the 
issue that we have to also put pressure on FDA. When we talk 
about crisis alarm, they need to change their procedures and we 
need to change our procedures to make sure that we don't, like 
the British when they are fighting the Zulus, have everybody 
lined up in straight little rows while they are being wiped out 
because the regulations say that is what you have to do to get 
ammo. We need to change our procedures to make sure you have 
the assets that could be available to you, not just because of 
monetary but because of regulatory obstructions. Doctor, do you 
want to comment on that?
    Dr. Jarris. Yes. I think there is a very good example of 
where we could use assistance in this regard. There is a shelf 
life extension program currently that the Department of 
Defense, VA, the SNS--I think those are the organizations--use. 
In that program, the Tamiflu has been extended now for up to 10 
years, the shelf life. The Tamiflu in the State stockpiles is 
not under a shelf life extension program. We worked very hard 
with the FDA and the manufacturers so that it went from 5 years 
to 7 years. That saved us $200 million in the States.
    If we could develop a shelf life extension program so that 
we aren't discarding hundreds of millions of dollars worth of 
antivirals, that would be extremely valuable. It would be 
minimal cost for huge savings. That is clearly an 
intergovernmental affair.
    Chairman Towns. The gentleman's time has expired. I will 
allow you to answer. Go ahead.
    Dr. Sosin. I just want to correct one issue. The issue with 
Tamiflu is the manufacturer went to FDA and said, look, our 
product actually can last 7 years, not 5 years, allowing for a 
process of relabeling and extending the expiration date. So 
that process actually is available to States who have received 
Tamiflu from the Federal supply. There is a process that has to 
be gone through. But the shelf life extension program is a 
broader issue about all expiring products.
    Mr. Bilbray. Thank you, Mr. Chairman. I just think that we 
need to be more proactive in looking at this and have as much 
passion about changing our regulations to make the resources as 
we are about spending money and throwing money at the problem. 
Here is one of those items that Mr. Issa was pointing out. 
Thank you.
    Chairman Towns. Thank you very much. The gentleman's time 
is expired. The Congressman from Texas, Congressman Cuellar?
    Mr. Cuellar. Mr. Chairman, thank you very much for having 
this meeting. I want to thank the witnesses for being here. I 
chair the Subcommittee on Response and Preparedness of the 
Homeland Security Committee so I value what you all have been 
saying. I appreciate it. I will start off with my first 
question to Dr. Sosin.
    Again, thank you for the work that you do there at CDC. My 
question refers to the time that you were dealing with bio-
surveillance. I am from Laredo, TX, right at the U.S.-Mexico 
border. As you know, we have been hit pretty hard by the H1N1 
cases that we have had. I know that the surveillance 
information is critical for those in leadership positions to 
make the best decisions regarding resource allocation, school 
closures, those types of decisions.
    Can you tell me how the information being put out by CDC by 
its various biosurveillance efforts is helping the States, 
territories, tribes, and localities to make those decisions? 
Then what sorts of lessons have we learned so far from the H1N1 
situation? How do you see those being incorporated into the 
current system so that we are better prepared as a Nation if 
the disease gets worse, particularly this coming winter?
    Dr. Sosin. Thank you, sir. One thing I would like to start 
off by acknowledging is that surveillance and biosurveillance 
begins at the local and State level. What we are able to 
provide back to State and locals to help inform them is a 
broader, bigger national picture that crosses jurisdictional 
boundaries. So it is a partnership from the ground up.
    Biosurveillance, some of the efforts to get earlier cues of 
events that might be happening, to detect them and respond to 
them more quickly, that narrower piece really had a relatively 
smaller role to play in the early development of this outbreak. 
It was laboratory-detected very early on and a major focus at 
the public health level was to go out and investigate 
laboratory confirmed cases to better understand this outbreak. 
As the outbreak spread, our ability to understand what is going 
on broadly in communities where the laboratory was only one 
small piece of the broader outbreak, that information is 
becoming more valuable.
    Certainly, probably the most useful piece of focus that we 
have made in biosurveillance in the past few years is how we 
integrate information from multiple different types of 
information streams and then present that to decisionmakers on 
a daily basis in briefings, in slide sets, and whatever else 
that we share broadly. We have had some success there as well.
    So I think that the feedback on biosurveillance efforts is 
too early in this outbreak to tell you entirely. I think the 
focus on biosurveillance as syndromic influenza-like illness is 
too narrow. The focus on health information technology and 
electronic laboratory information, death certificate 
information and hospital or medical information, is a place 
where at the State, local, and Federal levels we need to 
continue to advance those developments.
    Mr. Cuellar. How are we doing on the transition, doctor, 
from developing vaccines in eggs--as you know, they are 
developed in eggs--to a cell-based solution? Where are we on 
that? We need a lot of eggs to develop vaccines, Mr. Chairman.
    Dr. Sosin. It is a process of development. There are new 
platforms for vaccine development. They are pretty early. They 
are not replacing egg development at this point in time. I 
can't give you particulars as it relates to the H1N1 vaccine 
development, how much would be egg and how much in cellular 
techniques. If that is something that you would like more 
information on, we can provide that to you.
    Mr. Cuellar. I would like to get that. Real quick because I 
am out of time, I have just a quick question to one of the 
other four gentlemen. Again, understanding the strains--I think 
you articulated that pretty well--how much more do you think 
public health departments can handle right now with the H1N1 
outbreaks occurring? You have those strains.
    I guess whoever provided the pictorial here, I guess this 
is pretty much what we are looking at where we have that up. We 
are down here in this current situation and I guess to get up 
here it is going to take a lot of effort. I assume there is a 
lot of strain in what you all do. I think that is the message 
that we are getting loud and clear. Dr. Birkhead or anybody who 
wants to answer?
    Dr. Birkhead. No, that is right. I think public health 
departments across the country at the State and local level 
have been operating almost 24/7 now for the last month. It has 
eased up a little bit but it is not going away. We need to 
arrive at a new normal for going forward. But if this gears up 
at all in the fall and we are having to do vaccination at the 
same time, it is not going to be sustainable without more 
resources.
    Mr. Cuellar. I think the chairman was correct. I think we 
are trying to get some input from you all. We might not grant 
all the wishes but we certainly want to know what you think we 
ought to be addressing.
    Thank you to all of you. I appreciate your time and effort 
for being here. Thank you, Mr. Chairman.
    Chairman Towns. Thank you very much. I thank the gentleman 
for his questions. Congressman Kucinich.
    Mr. Kucinich. Thank you very much, Mr. Chairman. Mr. Allan, 
does Cuyahoga County currently have the ability to handle a 
pandemic? Do we have the health infrastructure to be able to do 
that?
    Mr. Allan. I think, Congressman Kucinich, that Cuyahoga 
County has a wealth of certainly health care capacity. I think 
that in the H1N1 response, it is important to note that the 
current activity relative to this virus is sort of uneven 
around the country right now. Certainly in New York there is a 
lot of activity, as Dr. Birkhead pointed out, and we have been 
reading in the newspapers.
    I think if we start to move forward on a pandemic of higher 
severity, we are going to be stressing the system. The current 
level of severity that we are dealing with was sporadic 
activity in Ohio and in the greater Cleveland area is something 
that we think we can maintain activity on in terms of control.
    Mr. Kucinich. You are saying we have the health 
infrastructure to maintain public health support for a 
pandemic?
    Mr. Allan. I am saying that in terms of a pandemic of this 
low severity that we are seeing, we can deal with it locally. 
If it begins to become more severe, we are going to have some 
serious problems.
    Mr. Kucinich. Well, you have said in your testimony that 
not knowing if the virus will shift or drift, we are looking 
into the fall of 2009 and beyond, you have a To Do list. Your 
To Do list notes that if funding levels continue to drop as 
anticipated, we will be unable to advance our detection, 
preparedness, and response. Now detection is an essential part 
of being able to get ahead of a pandemic, right?
    Mr. Allan. Right.
    Mr. Kucinich. Can you put a dollar figure on what Cuyahoga 
County needs in order to adequately advance detection 
preparedness and response capacity to a level that would be 
necessary if a more severe virus were to emerge?
    Mr. Allan. Well, we were back in 2005 somewhere around $2.2 
to $2.5 million in terms of our funding level for the county. 
That involved both the city and the county. That allowed us to 
advance our plans, I think substantially. We have seen cuts, 
which means now we are losing people. That means the To Do list 
is still sitting there. In fact, as people step away, the To Do 
list may get longer for us to accomplish.
    So from our end, we think a relatively modest investment 
nationally in public health relative to other national issues 
can go a long way. If we look at a situation where we are going 
to be having to vaccinate folks to a new virus, also dealing 
with seasonal flu vaccination, dealing with a potential 
escalation of severity in the fall, that confluence of things 
right now we are not prepared to address.
    Mr. Kucinich. What about if there were an increase in 
incidents? Would you have the infrastructure at this moment to 
be able to keep up with testing suspected carriers of a virus?
    Mr. Allan. Well, that testing in Ohio specifically ties 
back into some rapid detection work that is being done in the 
hospitals. Then the activity all flows through the State health 
department. So it is a question of capacity of the State health 
department. If we saw a significant increase, I know that there 
were some early delays as people were dealing with the volume. 
But it is a question of State level capacity. We have one lab 
in Ohio and it all goes through Columbus.
    Mr. Kucinich. One lab?
    Mr. Allan. One lab to handle this incident, yes.
    Mr. Kucinich. Do you have direct contact with the CDC?
    Mr. Allan. Our contact occurs through the State health 
department.
    Mr. Kucinich. I think, Mr. Chairman, it would be 
interesting to canvass the State health departments to see 
about their contact with the CDC. Because if something is 
getting out of control in an area, in a county as large as 
Cuyahoga, it seems to me that the large counties, which in some 
cases are bigger than some States, should have a quicker 
connection to CDC since we are talking about the fact that a 
virus by its very nature can spread in any direction at any 
time.
    Did you want to say something, Dr. Birkhead?
    Dr. Birkhead. Yes. Let me just comment from New York State 
and New York City's point of view. We do have direct access to 
the scientists at CDC. With the school situations going on and 
now looking also at more hospitalized cases, we have been able 
to have conference calls directly with the folks at CDC.
    Mr. Kucinich. You know, Mr. Chairman, I think one of the 
things that we might want to do is to ask the CDC about these 
large metropolitan areas. Instead of going through States, 
large metropolitan areas should have the ability to contact the 
CDC directly. My time has run out, but I want to make sure 
metropolitan areas will have the ability to respond 
appropriately to any threat of a pandemic.
    Chairman Towns. Thank you very much. Congressman Lynch.
    Mr. Lynch. Thank you, Mr. Chairman. Thank you for holding 
this hearing along with the ranking member. I want to thank the 
witnesses for their willingness to help the committee with its 
work. Dr. Sosin, thank you for your service to our country. I 
appreciate that.
    We had a hearing here last week centrally dealing with the 
vulnerability of some of our employees. I happen to chair that 
subcommittee. Right now, we have a situation where we have a 
lot of our folks on the borders--Customs and Border Patrol 
folks, ICE, Transportation Security officers--and they are on 
our country's borders as well as at our major ports of entry. I 
would say on average many of these officers probably screen and 
some of them come in direct physical contact with 3,000 
passengers or travelers per shift.
    Up until recently, even through this crisis, H1N1 pandemic, 
they were instructed by their supervisors at the Department of 
Homeland Security and other agencies that they were not to wear 
masks. They basically had these masks, not very threatening, 
but apparently the Department of Homeland Security felt that 
the public might be overly alarmed if the border patrol 
officers and transit security officers wore something like 
this. These are N95 masks, just for the record. They were told, 
as a matter of fact, to take off these masks when a few of them 
took the initiative to protect themselves. And this is where 
the CDC comes in.
    The Department of Homeland Security said they were relying 
on a determination by CDC that masks like this and repeated 
applications of Purell were medically unnecessary for our 
border security folks and transportation security officers even 
though they are in physical contact--they are wanding, checking 
passports, and coming into physical contact--on a regular basis 
with these folks. Again, they use the term ``medically 
unnecessary.'' Meanwhile, we have instructions from CDC saying 
folks should cover their mouths, wash their hands, and avoid 
unnecessary travel to Mexico.
    So now I have hundreds, actually thousands of border folks, 
security officers--and the Laredo facility is part of this, the 
busiest checkpoint in our country--and even though we have that 
concern out there, meanwhile our people, the U.S. transit 
security officers and border patrol people, are looking across 
the Laredo checkpoint and the Mexican folks on the other side, 
the Mexican security officers all have these masks on. But we 
are being told that it is medically unnecessary.
    The World Health Organization has already taken it to a 
Level V, which means a global pandemic is imminent. I just find 
it mystifying why we have the World Health Organization saying 
we are at Level V going to Level VI on a global pandemic, we 
have schools shutting down all over the place, and in the 
meantime we have these officers who are actually screening 
3,000 travelers a day. The epicenter of this thing was in 
Mexico City. Infection counts in Texas, California, and Arizona 
are off the charts. They are something like 400 percent of the 
national average.
    And here we are not letting our folks wear these masks 
because it might alarm the public. I am just wondering, where 
is the sense of that policy?
    Dr. Sosin. Thank you, sir. This is challenging 
decisionmaking. It is not strictly a science-based decision.
    Mr. Lynch. Apparently.
    Dr. Sosin. The specifics of the Department's of Homeland 
Security decisions and the interactions with CDC are ongoing 
and evolving. So that is one piece. The challenge here is 
establishing level of risk versus level of response that is 
feasible and appropriate. Whether it is ever appropriate to 
forbid people to use protective equipment or not is an issue 
that I do not want to touch on. But whether it should be 
required or recommended is the challenge that CDC has been 
trying to produce in its guidance.
    Let me say that the crux of the CDC position, as reflected 
in the National Institute for Occupational Safety and Health, 
which is a part of CDC, is that when in doubt, we offer 
guidance which protects the worker. When in doubt whether 
influenza can spread through airborne mechanisms and we have a 
severe situation, we err on the side of protecting the worker. 
The challenge here--the WHO phases are not severity based--and 
the challenge in this entire outbreak has been whether this is 
more severe than what we see in seasonal flu and therefore 
whether we should take more extreme measures than we typically 
take in seasonal flu.
    As you know, the Border Patrol or border agents do not wear 
masks during flu season. So that question of, are they at risk 
of more severe illness than they would be under comparable 
circumstances, has been the most challenging part of this. We 
continue to watch for evidence of severity, for evidence of 
uniqueness and needs for protection. We continue to offer 
guidance which is at minimum permissive of that type of 
protection and, when felt to be appropriate, specific guidance 
to use.
    All I can say is that this continues to be a discussion. I 
know over the last 2 days decision briefs about health care 
workers, which is another work force of great concern, and the 
use of respirators like those in 1995 continue to be worked 
through so that we have practical, feasible, manageable 
guidance which also protects the worker.
    Mr. Lynch. OK. I appreciate your attempt to answer that 
question. I really do. And it is not your decision so I am not 
laying it on you.
    Mr. Chairman, could I ask Dr. Jarris to take a crack at 
that?
    It seems that I have a Level V pandemic which, according to 
the World Health Organization, is a strong signal that a 
pandemic is imminent and that the time to finalize the 
organization, communication, and implementation of plan 
mitigation measures is very short. OK, so I have the World 
Health Organization telling me this. We have people sick all 
over the place. I would hate to be the 3,000th person that this 
security officer frisks and wands because he is likely to be 
contaminated at this point and he is contaminating all the way 
down the line. This is Government bureaucracy at its worst. We 
just need to move the ball forward here and inject a little bit 
of common sense into the situation.
    Dr. Jarris. Congressman, I think your question is a very 
valid one. It is an example of the types of things we have been 
wrestling with for the last 3 weeks and why we have not gotten 
sleep in the last 3 weeks. There are many, many examples of 
issues like this where we, as Dr. Sosin said, because it 
started in North America we did not have the 2-months to figure 
out how this transmitted from one person to another. Was it 
aerosol? Was it a droplet? We simply did not know that. We did 
not know how transmissible it was. Was the border guard at risk 
or not at risk? What did it take to actually transmit this? We 
did not know that. How severe was it?
    Initially, given what was going on in Mexico, we weren't 
very concerned. It looked as if it was not that severe. But we 
still do not quite know that. So we were in a situation of 
trying to make decisions in the face of tremendous uncertainty, 
always balancing what is the prudent thing to do against what 
is the disruption to society.
    Two weeks ago I was in a committee in which we were being 
encouraged to close the border. In retrospect, I think we would 
have said that probably was not the right thing to do. But 
there certainly were people feeling strongly that, well, why 
wouldn't we do that. So this is what we are struggling with.
    This is an indication of why we now need to go back, given 
that we have had these plans which have been obviously 
imperfect, and we can give you many other examples of imperfect 
situations, and dedicate the time and the resources this summer 
to figure out what are we going to do in the fall if this comes 
back bigger, what are we going to do in the fall if this comes 
back more serious, and we need to be prepared. We need to 
address some of the issues of: How do we look at CDC guidance, 
OSHA guidance, and NIOSH guidance, and which one actually 
applies in a given situation because they may be different.
    Mr. Lynch. Right. I appreciate your remarks and I 
appreciate the perspective that you provide. You do say, 
properly I think, that we have to figure this out by the fall. 
I think everybody on the panel has said we could have a 
situation in the fall. Meanwhile, our Border Patrol people and 
transit security officers cannot use masks. It seems rather 
silly to me. But we will see how that goes.
    Mr. Chairman, I have abused my time and I want to yield at 
this point. Thank you very much.
    Chairman Towns. Thank you very much. Let me thank all of 
you for your testimony. I appreciate your thoughts and insight, 
and I appreciate the interest of all the Members who attended 
today.
    Before we adjourn, I would like to emphasize the continuing 
need for attention to be given to the issue of State and local 
pandemic readiness. As we have seen in recent weeks, an 
outbreak can strike at any time and potentially take a heavy 
toll. We must be prepared in order to protect the lives of our 
citizens. We do not wait for a house fire before we make sure 
that our fire department has fire engines and water hoses. 
Likewise, we cannot wait for a pandemic before we make sure our 
public health departments have trained responders and a 
mechanism in place to provide vaccines and treatments.
    The question becomes one of the next steps. The House 
passed funding for State and local pandemic preparedness in the 
fiscal year 2009 Supplemental Appropriation Act just last week. 
Congresswoman Tammy Baldwin has recently introduced a bill, 
House of Representatives 805, of which I am a proud cosponsor. 
This bill, Strengthening of America's Public Health System, 
would provide Federal support for improving public health 
agencies' infectious disease surveillance and reporting.
    What kind of sustained support can the Federal Government 
provide given today's harsh economic circumstances? How can 
States, localities, the Federal Government, and other entities 
leverage the resources that we already have in order to 
increase our public response capabilities?
    Please, please let the record demonstrate my submission of 
a binder with documents relating to this hearing. Without 
objection, I enter this binder into the committee record.
    The record will remain open for 5 days for any additional 
comments. Thank you very much.
    Without objection, the committee stands adjourned.
    [Whereupon, at 4:30 p.m., the committee was adjourned.]
    [Additional information submitted for the hearing record 
follows:]

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