[Senate Hearing 111-154]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 111-154
 
                     PANDEMIC FLU: CLOSING THE GAPS

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

                                HEARING

                               before the

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

                                 of the

                              COMMITTEE ON
                         HOMELAND SECURITY AND
                          GOVERNMENTAL AFFAIRS
                          UNITED STATES SENATE


                     ONE HUNDRED ELEVENTH CONGRESS

                             FIRST SESSION

                               __________

                              JUNE 3, 2009

                               __________

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

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



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        COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS

               JOSEPH I. LIEBERMAN, Connecticut, Chairman
CARL LEVIN, Michigan                 SUSAN M. COLLINS, Maine
DANIEL K. AKAKA, Hawaii              TOM COBURN, Oklahoma
THOMAS R. CARPER, Delaware           JOHN McCAIN, Arizona
MARK L. PRYOR, Arkansas              GEORGE V. VOINOVICH, Ohio
MARY L. LANDRIEU, Louisiana          JOHN ENSIGN, Nevada
CLAIRE McCASKILL, Missouri           LINDSEY GRAHAM, South Carolina
JON TESTER, Montana
ROLAND W. BURRIS, Illinois
MICHAEL F. BENNET, Colorado

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


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

                   MARK L. PRYOR, Arkansas, Chairman
DANIEL K. AKAKA, Hawaii              JOHN ENSIGN, Nevada
MARY L. LANDRIEU, Louisiana          GEORGE V. VOINOVICH, Ohio
JON TESTER, Montana                  LINDSEY GRAHAM, South Carolina
MICHAEL F. BENNET, Colorado
                     Kristen Sharp, Staff Director
                 Mike McBride, Minority Staff Director
                       Kelsey Stroud, Chief Clerk
                            C O N T E N T S

                                 ------                                
Opening statement:
                                                                   Page
    Senator Pryor................................................     1
Prepared statement:
    Senator Ensign...............................................    23

                               WITNESSES
                        Wednesday, June 3, 2009

Bernice Steinhardt, Director, Strategic Issues, U.S. Government 
  Accountability Office..........................................     2
John Thomasian, Director, National Governors Association Center 
  for Best Practices.............................................     4
Paul E. Jarris, M.D., MBA, Executive Director, Association of 
  State and Territorial Health Officials.........................     6
Stephen M. Ostroff, M.D., Director, Bureau of Epidemiology and 
  Acting Physician General, Pennsylvania Department of Health....     8

                     Alphabetical List of Witnesses

Jarris, Paul E., M.D., MBA:
    Testimony....................................................     6
    Prepared statement...........................................    62
Ostroff, Stephen, M.D.:
    Testimony....................................................     8
    Prepared statement...........................................    69
Steinhardt, Bernice:
    Testimony....................................................     2
    Prepared statement...........................................    24
Thomasian, John:
    Testimony....................................................     4
    Prepared statement...........................................    48

                                APPENDIX

Questions and responses submitted for the Record from:
    Mr. Thomasian................................................    76
    Dr. Jarris...................................................    83
    Dr. Ostroff..................................................    86
Map of ``Confirmed Cases Of Swine Flu Across The Globe,'' 
  submitted by Senator Pryor.....................................    93


                    PANDEMIC FLU: CLOSING THE GAPS

                              ----------                              


                        WEDNESDAY, JUNE 3, 2009

                                 U.S. Senate,      
             Ad Hoc Subcommittee on State, Local, and      
           Private Sector Preparedness and Integration,    
                    of the Committee on Homeland Security  
                                  and Governmental Affairs,
                                                    Washington, DC.
    The Subcommittee met, pursuant to notice, at 2:05 p.m., in 
room SD-342, Dirksen Senate Office Building, Hon. Mark L. 
Pryor, Chairman of the Subcommittee, presiding.
    Present: Senator Pryor.

               OPENING STATEMENT OF SENATOR PRYOR

    Senator Pryor. I will go ahead and call our meeting to 
order. I want to thank everyone for being here today. This is 
the Subcommittee on State, Local, and Private Sector 
Preparedness and Integration and it is time for us to update 
our efforts on pandemic influenza.
    The Centers for Disease Control (CDC) has described 
pandemic flu as both inevitable and as one of the biggest 
threats to public health in the Nation. In October 2007, I 
chaired a hearing entitled, ``Pandemic Influenza: State and 
Local Efforts to Prepare.'' At that hearing, HHS, DHS, and 
State and local health officials testified. The witnesses cited 
efforts underway that included national strategies, plans, and 
exercises. Now less than 2 years later, we are faced with the 
reality of a pandemic threat.
    In late March and early April 2009, the first cases of a 
new flu virus, the H1N1, were reported in Southern California 
and San Antonio, Texas. So far, the CDC has confirmed 10,053 
cases in 50 States and in the District of Columbia. This 
includes seven cases in my home State of Arkansas according to 
the CDC. The CDC reports that most of the influenza viruses 
being detected now in the United States are of the strain. 
Further, CDC's Dr. Anne Schuchat has said this will be a 
marathon and not a sprint, and even if this outbreak is a small 
one, we can anticipate that we may have a subsequent or follow-
up outbreak several months later and we need to stay ready.
    One of the things we have talked about in this Subcommittee 
before is hurricane preparedness. Years ago, there was an 
exercise authorized and then for whatever reason, the money 
wasn't available to conduct the Hurricane Pam exercise, which 
was almost identical to the scenario we saw when Hurricane 
Katrina struck.
    We find ourselves today in somewhat of a similar situation 
in that we have had this flu scare already this spring and now 
it looks like, if flu behaves like it normally does, we will 
have a few months where it won't be that active, and then I 
hope I am wrong, but it looks like it may come back in the 
fall. We just need to make sure that we are ready, that we are 
doing everything that we can do, and that the State, local, and 
private sector are working together on this.
    So what I would like to do is introduce the panel and ask 
each of you to make a 5-minute statement. We may be joined by 
some other Senators. I know Senator Ensign has been trying to 
change his schedule to get here. We will keep the record open 
after the conclusion of the hearing for a couple of weeks and 
let Senators submit questions, and if there are follow-ups that 
we need to work with you on, we will do that.
    Let me introduce the panel. First, we have Bernice 
Steinhardt. She is Director of the Government Accountability 
Office's Governmentwide Management Issues. She has led the 
preparation of 11 GAO reports, the most recent, ``Sustaining 
Focus on the Nation's Planning and Preparedness Efforts.'' It 
synthesizes 23 recommendations that we should be working on 
now. Ten of them have yet to be acted on.
    Our second panelist will be John Thomasian. He is the 
Director of the National Governors Association's Center for 
Best Practices.
    Next, we will have Dr. Paul Jarris. Dr. Jarris is the 
Executive Director of the Association of State and Territorial 
Health Officials (ASTHO).
    Finally, we will have Dr. Ostroff. Dr. Ostroff is the 
Acting Physician General and Director of the Bureau of 
Epidemiology for the Pennsylvania Department of Health.
    What I would like to do is open it up, 5 minutes each, and 
then we will ask questions. Go ahead.

TESTIMONY OF BERNICE STEINHARDT,\1\ DIRECTOR, STRATEGIC ISSUES, 
             U.S. GOVERNMENT ACCOUNTABILITY OFFICE

    Ms. Steinhardt. Thank you very much, Senator Pryor. I 
really appreciate the chance to be here today. I wanted to talk 
to you about the report that you mentioned a moment ago that we 
issued this past February which synthesized the results of 
close to a dozen reports that we have issued since 2006. In 
that February report, we pointed out that despite the economic 
crisis and other national priorities that had become top 
priorities for the country, a pandemic influenza is still a 
very real threat and requires continued leadership attention. 
When the H1N1 virus emerged 2 months later, that warning was 
dramatically underscored.
---------------------------------------------------------------------------
    \1\ The prepared statement of Ms. Steinhardt appears in the 
Appendix on page 24.
---------------------------------------------------------------------------
    Before I go into the findings of our reports, I want first 
just to acknowledge the important progress that we have made in 
the last few years. In addition to the National Pandemic 
Strategy and Implementation Plan that was developed by the 
Federal Government, all 50 States and the District of Columbia 
now have pandemic plans, as do many local governments and 
private companies, and we have clearly benefited from all of 
this planning.
    But that said, there are still some significant gaps in our 
planning and preparedness. For one thing, the leadership roles 
in a pandemic, the ``Who is in charge?'' question, have not 
been clearly worked out and tested. Under the National Pandemic 
Plan, the Secretaries of Health and Human Services and the 
Secretary of Homeland Security are supposed to share leadership 
responsibilities along with a system of Federal Coordinating 
Officials and also Principal Federal Officials and the FEMA 
Administrator. And all of these positions may be vital in a 
pandemic, but how they will work together has not been tested 
yet.
    So in 2007, we recommended that HHS and DHS work together 
to develop and conduct national tests and exercises, and the 
Departments agreed with our recommendation, but since that 
time, there still has not been a national exercise for this 
purpose. Now that we have new people filling some of these 
leadership positions, the need to clarify these relationships 
in practice is only heightened.
    Beyond the lack of clarity on leadership roles, the 
National Strategy and Plan have a number of other missing 
pieces, and I will mention just a couple. First of all, key 
stakeholders, like State and local and tribal governments, were 
not directly involved in developing the plan, even though the 
plan relies on them in a number of instances to carry out some 
key elements of the plan.
    Second, there were no mechanisms described in the plan for 
updating the plan and reporting on its progress, and this issue 
of updating the plan is particularly timely since this is a 3-
year plan and it was developed in May 2006.
    To fill these gaps, we recommended that the Homeland 
Security Council establish a process for updating the plan that 
would, first of all, involve key stakeholders and incorporate 
lessons learned from exercises and other sources. We made that 
recommendation in 2007, but the Homeland Security Council 
didn't comment on it, nor did they indicate whether they would 
act on it. But I would say that it is especially pertinent 
today as we try to learn from the experiences of the H1N1 
outbreak.
    As we go forward, it is also essential for the Federal 
Government to share its expertise and coordinate its decisions 
with other levels of government and the private sector. A 
number of mechanisms were developed for these purposes, but 
they could be used even more, and I will mention one example.
    In a 2008 report that we did on State and local pandemic 
planning, we pointed out that an HHS-led assessment of State 
plans found many major gaps in 16 of 22 priority areas that 
included policies related to school closures and community 
containment. At that same time, a number of the State and local 
officials that we were talking to told us that they would 
welcome additional guidance from the Federal Government in 
these same areas, and I know the National Governors Association 
found many of the same kinds of issues.
    DHS and HHS at that time had earlier convened a series of 
regional workshops with State officials to help them with their 
planning efforts and we thought that the two Departments could 
use additional workshops to help States address the gaps in 
their pandemic plans. The two Departments, HHS and DHS, agreed 
with our recommendation, but they haven't held any additional 
meetings since then.
    In closing, I just want to point out that it's important to 
bear in mind that while the current H1N1 outbreaks seem to have 
been relatively mild, the virus could return, as you pointed 
out, Senator. It could return in a second wave this fall or 
winter in a more virulent form. So given this risk, the 
Administration and Federal agencies should be turning their 
attention to filling some of the gaps that our work has pointed 
out, while time is still on our side.
    Thanks very much.
    Senator Pryor. Thank you. Mr. Thomasian.

 TESTIMONY OF JOHN THOMASIAN,\1\ DIRECTOR, NATIONAL GOVERNORS 
             ASSOCIATION CENTER FOR BEST PRACTICES

    Mr. Thomasian. Thank you, Mr. Chairman. As you pointed out, 
my name is John Thomasian and I direct the National Governors 
Association Center for Best Practices and I appreciate the 
opportunity to testify before you today on pandemic influenza 
and how we can close potential gaps in our capacity to respond. 
My comments today are based on the work we have done over the 
past several years with the States on pandemic planning that 
began in 2006 with a Governor's Guide. It included training 
workshops, nine regional training workshops for all 50 States 
and four territories in 2007 and 2008, and our work continues 
today as we assist the Governors' Homeland Security Advisors in 
responding to the recent outbreak.
---------------------------------------------------------------------------
    \1\ The prepared statement of Mr. Thomasian appears in the Appendix 
on page 48.
---------------------------------------------------------------------------
    I am going to focus on five key areas very quickly: 
Information sharing, interagency coordination, school closings, 
continuity of government and coordination with the private 
sector, and communication with the public. Each of these were 
identified as problems in our previous work and I will discuss 
how each of them were handled in the current outbreak.
    Information sharing--information sharing during the recent 
flu event demonstrated that systems worked much better than we 
anticipated. The flow of information between the Federal 
Government and the States was nearly constant during the 
initial weeks of the outbreak and case counts were updated 
daily. Morbidity and mortality figures were readily available. 
And the Federal Government did a good job pushing information 
down to State and local government.
    That being said, there is room for improvement. Both CDC 
and DHS began to hold independent daily briefings for State 
officials in the early weeks. These briefings often contained 
the same information and often contained the same Federal 
officials. But States were never sure if all the information 
was new, so they put time aside for all the briefings. As a 
result, State officials spent several hours each day monitoring 
conference calls instead of response activities. In the future, 
DHS and CDC should hold a single daily briefing with States on 
all essential information.
    Interagency coordination--when we held our workshops in 
2007 and 2008, many State teams were meeting for the first 
time. They were not clear on their own responsibilities, much 
less those of their Federal counterparts. Three years later, 
with additional planning and exercises, the situation has 
improved. I think the Centers for Disease Control and 
Department of Homeland Security worked well together during the 
recent outbreak and provided a relatively seamless portal to 
Federal resources and technical assistance. At the State level, 
homeland security agencies began coordinating immediately with 
their health departments and many States enacted emergency 
declarations and other orders to begin mobilizing broader State 
resources, if needed.
    Looking ahead, we must recognize that good interagency 
coordination deteriorates without practice. To maintain 
performance, States must be given encouragement and resources 
to conduct preparedness exercises with multiple agencies and 
levels of government. This is a capacity that will go away over 
time.
    School closures--school closure policy was a topic of 
intense discussion at each of our national workshops with 
little consistency in approach. It was not a surprise, 
therefore, when the recent outbreak led to a patchwork of 
school closure decisions. One issue was that the Centers for 
Disease Control's written guidance suggested that closures 
should be based on laboratory-confirmed cases, while public 
comments by some Federal officials suggested decisions should 
be based on suspected or probable cases or even when students 
had a family member with the disease.
    Also missing was advice to parents and students on actions 
to be taken outside of the classroom to limit the spread of the 
disease. In many cases, dismissed students simply recongregated 
at shopping malls or other venues to share potential 
infections. More precise advice will be needed from CDC in the 
future to help States and districts implement a more consistent 
approach to school closure. Guidance should also address 
prevention actions beyond school grounds.
    Continuity of government and coordination with the private 
sector on critical services--in our workshops, we asked States 
to envision a rate of absenteeism that could approach 40 
percent. To cope with this possibility, States needed to 
develop detailed continuity of government plans and work with 
the private sector to ensure the availability of critical goods 
and services. This mild outbreak simply did not test these 
contingencies. They remain among the unknowns of our 
preparedness and should be revisited before we enter the next 
flu season.
    Finally, communication with the public. In the recent 
outbreak, government and the media did a good job informing the 
public on the spread of the disease and what individuals should 
do to avoid infection. However, the Federal Government did not 
adequately explain the type of response options they had at 
their disposal, what was being considered or rejected, and why. 
This led to a great deal of confusion in the early stages 
regarding what might happen next. To address this gap, the 
public must be given information on the appropriateness and 
implications of specific actions, such as quarantine, social 
distancing, travel bans, school closings, and the use of 
personal protective equipment.
    In conclusion, the spring outbreak has so far resulted in 
less than 9,000 confirmed cases nationwide. In contrast, we 
must remember that a severe pandemic would produce tens of 
millions of infections. Before the onset of the next influenza 
season, we should take the time to address the weaknesses this 
initial outbreak exposed. We should clarify the guidance on 
school closures to ensure consistency. Information exchange 
should be improved so that responders can allocate their time 
more efficiently. The public must be educated on the benefits 
and costs of mitigation strategies. And States should be 
encouraged and supported to conduct periodic pandemic exercises 
with Federal agencies, local governments, and the private 
sector.
    Thank you, Mr. Chairman. I am pleased to answer any 
questions later.
    Senator Pryor. Thank you. Dr. Jarris.

TESTIMONY OF PAUL E. JARRIS, M.D., MBA,\1\ EXECUTIVE DIRECTOR, 
     ASSOCIATION OF STATE AND TERRITORIAL HEALTH OFFICIALS

    Dr. Jarris. Mr. Chairman, thank you for the opportunity to 
speak. I would like to make a couple of points that have not 
been made before.
---------------------------------------------------------------------------
    \1\ The prepared statement of Dr. Jarris appears in the Appendix on 
page 62.
---------------------------------------------------------------------------
    One is that this is not over. We still have an outbreak and 
an epidemic going on in this country. Just over the last day, 
the cases have increased to 11,000, which is a tremendous 
undercount, and your State of Arkansas is now nine rather than 
seven. You have been relatively spared, but other States have 
been hit much harder, including New York and currently 
Massachusetts has a dramatic outbreak ongoing. So this has 
never gone away. It is really not a matter of if it comes back 
in the fall. It hasn't left yet. The question will be, when it 
comes back in the fall, will it have evolved to a more severe 
pandemic or epidemic than the epidemic we are having right now?
    Furthermore, it is not just another seasonal flu, as we 
hear people saying. This is not the time of year you have a flu 
outbreak. That is one of the ways we search for new viruses and 
find them.
    Second, this is primarily young people being affected. The 
average age of individuals being affected is between 11 and 19 
years old. The average age of someone in the intensive care 
unit is 23 years old. And the average death rate is in the 40s. 
That is not seasonal influenza, which largely affects the 
elderly and otherwise people with immune compromise. So this is 
a novel virus, and what we have to understand is we do not know 
how this is going to behave.
    In 1918 at this time, it was behaving very similar to this. 
Now, whether or not it will come back as severe a category four 
or five in the fall, we simply don't know. But the prudent 
thing is to plan for a range of an outbreak consistent with 
what we have now all the way to a severe pandemic worldwide. 
The World Health Organization is right now considering whether 
to raise it to a pandemic level six, but frankly, that is not 
that important to this country because we already have an 
epidemic ongoing. Pandemic just means the epidemic has spread 
around the world. We have it already.
    The response to date, I believe, has been a good response. 
The Federal Government, State government, and local governments 
have acted in concert with each other and as a National 
Government response. Harvard did a study which showed 80 
percent of Americans were satisfied with the response. Eighty-
eight percent were satisfied with the information they were 
getting. That was the result not only of the Federal Government 
giving us guidance, but the State public health officials and 
homeland security officials going back to the Federal 
Government to say, here is what is happening on the ground and 
giving them situational awareness.
    We also have learned that there is much to be done with our 
planning. There were many assumptions made which proved not to 
be true. There were many planning plans that were made which 
were not nearly granular enough. So now that we are in a 
response, much more so than just a drill, we have learned about 
the shortcomings in our planning and what has to be happening. 
We have now a window of 12 to 16 weeks before this thing would 
escalate, as the 1918 virus did, before the return of the 
seasonal influenza, which will come on top of this current 
influenza outbreak.
    The reason I say it is not scalable, there has been about a 
25 percent cut in State and local emergency preparedness 
funding over the last several years. We have had about a 20 to 
25 percent cut in hospital preparedness funding. And the single 
appropriation of pandemic influenza funding in 2006 was 
completely spent by August 2008. There is no money from the 
Federal Government to state and local government, public 
health, to respond and plan for the fall and we simply have no 
alternative. So we must take advantage of this window of 
opportunity now to protect the American people.
    And let me give you the orders of magnitude here because 
frankly, I think we are all having a little bit of sticker 
shock when we think about what it will take to respond and 
protect the American people. For one, we are asking for $350 
million, another bolus, if you will, of planning money to carry 
the State and local governments not only through the response 
right now, but to plan and work on transitioning from planning 
to implementation for the fall.
    But importantly, there has been much talked about vaccine, 
the single most effective thing we can do to protect our 
population. Our plans call for protecting the entire U.S. 
population. That is 300 million people. We do believe that it 
will be two doses per person. By the time we know different, it 
is too late to produce the extra doses. So if conservatively 
that is $5 per dose, we are talking about $6 billion just to 
buy the vaccine.
    Now, vaccine isn't a good luck charm. It has to be given to 
people. We can give you the numbers and the information, but 
conservatively, it is $15 a dose to provide vaccine under the 
government-run program. That is less than the private sector. 
But much of the workforce giving this will be private sector. 
So we are talking about $15 billion to give those 600 million 
doses. So just there alone, we are in the $14 to $15 billion 
range. So we really have to come to grips very rapidly with how 
serious are we as a Nation in protecting the people of the 
United States and will we make those resources available now or 
will we stare the American people in the eye come the fall and 
say, when we had an opportunity, we didn't do it. Thank you, 
sir.
    Senator Pryor. Thank you. Dr. Ostroff.

  TESTIMONY OF STEPHEN OSTROFF, M.D.,\1\ DIRECTOR, BUREAU OF 
    EPIDEMIOLOGY AND ACTING PHYSICIAN GENERAL, PENNSYLVANIA 
                      DEPARTMENT OF HEALTH

    Dr. Ostroff. Thank you, Senator. Influenza is 
unquestionably one of the most unpredictable public health 
issues we face. Just when you think you understand what is 
going on, it always throws you a curve ball.
---------------------------------------------------------------------------
    \1\ The prepared statement of Dr. Ostroff appears in the Appendix 
on page 69.
---------------------------------------------------------------------------
    For several years, we have been focused on the emerging 
threat of bird flu in Asia, and rightly so. It is highly 
lethal, it has continuously circulated for 6 years, and it has 
devastating consequences for agriculture. Most of our planning 
assumptions have been based on a scenario that a pandemic would 
start in Asia, that it would be noticed there, and that we 
could delay its introduction and spread.
    And then out of nowhere, a new virus lands right on our 
doorstep, isn't noticed until it is already here, and renders 
many of our planning assumptions irrelevant. Fortunately, so 
far, its public health impact as measured by illness and death 
has been modest, but its overall impact has been anything but. 
It has caused tremendous disruption to individuals, families, 
schools, and communities, and we don't know what the future 
holds for this virus.
    Like the other States, we in Pennsylvania immediately 
ramped up our disease monitoring and response as soon as we 
learned of this new flu strain. Over the last 2 months, despite 
the fact that we have not had that many cases in Pennsylvania, 
it has been enormously labor intensive and challenging to 
address the myriad of issues that it presents.
    We have established a State-wide task force that includes 
our public health and emergency response partners. We have 
partly activated our emergency operations center. And we set up 
an internal health department task force. We have reached out 
to the education and agriculture sectors, migrant centers, 
medical societies, the rich array of academic centers in our 
State, the pharmaceutical sector, and the State's major vaccine 
manufacturer. And most importantly, we have closely integrated 
our work with that of our network of district and local health 
departments who form our front-line eyes and ears through daily 
group phone calls to discuss cases and disease clusters.
    We have greatly relied upon the excellent work done by the 
CDC, including their guidelines, lab support, the 
pharmaceutical stockpile, and their technical back-up. We in 
the States have had an ongoing dialogue with CDC about all 
aspects of this event, and sometimes we have disagreed, like in 
the school closure area. But CDC has been very willing to 
listen and change course when appropriate.
    Some aspects of our response have gone quite well. These 
include risk communications, disease monitoring and 
investigation, and applying control measures to limit disease 
spread. Other areas have been more challenging, especially lab 
support, where backlogs quickly developed when specimens had to 
go to CDC.
    We in Pennsylvania continue to individually count, 
investigate, and respond to each identified case of illness due 
to this new virus. With less than 300 cases, even this has been 
very resource intensive and has strained our disease 
investigators and our laboratory. Like most States, we have 
been impacted by the economic situation. We have hiring freezes 
in place and our bench strength is not very deep at all.
    Because in general we don't count individual cases of 
seasonal influenza, many of the most heavily impacted States 
are now no longer doing it for this new flu strain, either. 
Instead, they only count severe cases and those in special 
circumstances, like health care workers and pregnant women. 
This makes the national numbers that you are hearing now being 
reported very tough to interpret, since States are counting 
cases differently.
    In Pennsylvania, because many parts of the State have still 
been minimally affected by this virus, we think it is important 
to understand where the virus is, how it is spreading, and who 
it is affecting, so we will continue to count until it is no 
longer feasible for us to do so.
    So far, many aspects of our preparedness efforts have not 
been engaged. As examples, we have not dipped into our 
pharmaceutical stockpile. We have not mass distributed vaccines 
or antivirals. We have not handled large numbers of sick or 
dying people. And we have not implemented full community 
mitigation efforts, and hopefully we won't have to do so. But 
it is important to be prepared in case we need to.
    So we in Pennsylvania have just initiated a process to 
review our efforts to date and see what has gone well and where 
we need to improve. We are also embarking on a planning effort 
to prepare for what the virus has in store for us in the coming 
months. This includes doing better monitoring, planning for 
distribution and administration of stockpile material and 
vaccines, and dealing with health care surge needs.
    The flu is just one of a long line of emerging infectious 
disease threats. Others include SARS, MRSA, West Nile, 
foodborne outbreaks, and vaccine-preventable diseases. All of 
these highlight the need for a robust and a well-trained public 
health workforce and for flexible resources that allow us to 
best apply the resources that we have where they are needed.
    At the State and local level, the same people address all 
these problems in the field and in the lab. While our 
preparedness resources have helped, they do not cover nearly 
all of our needs and our resources for emerging infections have 
dwindled in recent years. Despite these problems, all of us are 
firmly committed to continue to address this new flu virus 
while continuing to confront the other public health threats 
that we face.
    I will be happy to answer any questions.
    Senator Pryor. Thank you.
    Let me start with you, Ms. Steinhardt. In your GAO report, 
you have several criticisms of the state of affairs right now. 
One of those is that the roles are not very clear between 
State, Federal, local, and who makes the decisions on certain 
things. What would you recommend that State and local officials 
do to clarify their roles?
    Ms. Steinhardt. Well, the important thing, and this is the 
lesson that we learned, I think, most vividly from Hurricane 
Katrina, the important thing is to test and exercise. It has 
often been said that you don't make friends in the middle of a 
disaster. People need to know each other and figure out how 
they are going to work together in advance of a true emergency, 
and that is what needs to happen here, as well.
    Senator Pryor. OK. I notice that the GAO, the NGA, and the 
ASTHO have reports that say that you need more guidance in 
school closures, you mentioned, and several other areas, like 
private sector workforce, situational awareness, etc. Do you 
think the Federal Government could distribute policies on these 
issues by this fall or is it too late for this year?
    Ms. Steinhardt. I would hope that the Federal Government 
could do that. As my fellow panelists have said, there is a lot 
that we are still learning about this virus. But certainly 
there is more--some of those lessons learned can and should be 
shared with States and local governments, as well.
    Senator Pryor. Mr. Thomasian, in your experience in terms 
of defining roles and some of the gaps that Ms. Steinhardt has 
identified, how has the Federal Government been to work with?
    Mr. Thomasian. In the past Administration, I would say the 
lead agency was clearly HHS. Secretary Leavitt took it on 
himself. Under his watch, he was going to try to avoid not 
having these roles defined. So I think we got one strong but 
one siloed lens looking at that.
    Senator Pryor. He wanted to not define the roles?
    Mr. Thomasian. No, he did want to define the roles, but 
since he represented a single agency, he had certain 
boundaries.
    Senator Pryor. I see.
    Mr. Thomasian. So I think we got halfway there. I think we 
still have a ways to go. I was pleased to see that the 
Department of Homeland Security worked well together with HHS 
during this initial crisis. Again, we have not been fully 
tested, so all the roles have not been fully defined or 
explored and the tensions have not been exposed to a large 
degree. But it was an initial good first step.
    So I do believe they have tried to do a good job and I will 
reiterate my panelist assertion that the best way to define a 
role is to initially put some aspects down on paper, but you 
have to exercise. You have to test it. Relationships need to be 
built.
    Senator Pryor. OK. Let me follow up on that. When the 
National Response Framework and the National Pandemic 
Implementation Plan were being put together, there was a lot of 
criticism that the Federal Government did not work with and 
talk to the State and local governments effectively. Now they 
have been working on the First Responder Health Surge Capacity 
Action Directive. Have they been working with the States and 
with the local folks as they are putting that together?
    Mr. Thomasian. They are. We work very closely, I should 
say, with the Governors' Homeland Security Advisors. In fact, 
we have formed an association within our association called the 
Governors' Homeland Security Advisors Council, and it is our 
understanding they are working together with them. Again, 
though, it does take a while for all this to trickle down 
through the States. This has been a constant refrain from the 
Governors' Homeland Security community, that the Federal 
Government needs to fully advise and work through issues with 
the States. I believe we are on the right path. It is too early 
to tell that it is taking place in all cases, though.
    Senator Pryor. Dr. Jarris, did you have any comments on 
that?
    Dr. Jarris. Yes. I think it is worth questioning the model. 
The model that the Federal Government will sequester itself and 
develop guidance for the Nation is a model that doesn't work 
well. There is a certain amount of expertise, whether it is 
scientific or law enforcement, in the Federal Government. But 
actually, the people who implement this guidance are at the 
State and local levels, and what we fail to appreciate is the 
expertise in implementation. So a model that will work much 
better is if Federal, State, and local all work jointly on 
guidance. Right now, what we do is we play ping-pong. The 
Federal Government comes out with something, lobs it over the 
table. We say it doesn't work. We lob it back. We don't have 
time for that in 14 to 16 weeks.
    What worked well in this response to date is that we really 
were working together, information flowing up and down, 
modifying what each other was doing. Now we seem once again to 
be flipping back into the old model of the Federal Government 
will come up with guidance for the fall. It simply won't work.
    For example, school closure. That is primarily a public and 
political decision to close schools. It is not fundamentally a 
science-based decision. So what we need to do is to work with 
the mayors, the governors, and those who make the school 
closures, and the health officials who will make 
recommendations to them, to truly understand all the issues 
there so we can do, if you will, a cost-benefit analysis. There 
is no way that the Federal Government guidance can come out 
without true involvement of the local and State officials 
making these decisions and have it work.
    Senator Pryor. So are you recommending that we get some 
sort of summit together?
    Dr. Jarris. Well, a summit would be helpful, but an ongoing 
working relationship would be far more helpful.
    Senator Pryor. And does that not exist right now?
    Dr. Jarris. The tendency is for Federal Government to 
develop guidance. There may be input sought, but then it goes 
back into a sequestered environment and the guidance comes out. 
And I think it is much more efficient, actually, if we could 
sit down as Federal, State, and local and jointly work on 
guidance.
    Senator Pryor. OK. This is a little bit of a follow-up to 
something I think you said in your opening statement. There are 
a lot of assumptions about the flu and the H1N1 did not really 
follow those assumptions.
    Dr. Jarris. Yes.
    Senator Pryor. It didn't start in Asia. It didn't go from a 
bird population to human population. What do you recommend, or 
how do you recommend that we build in flexibility to all this 
planning so that if a different scenario presents itself, like 
H1N1 has so far, it doesn't really follow the textbook example, 
how do you build in the flexibility?
    Dr. Jarris. Yes. I think with a novel virus, it is a 
mistake to assume there is a textbook. They all operate 
differently. So really what we need is to have much more robust 
planning. It is not just a matter of scientifically planning 
for it. We need to have modelers in there. We need to have 
systems engineers come in and figure out what is going to 
happen. So, for example, we should plan for a best case, a 
worst case, and a most likely case scenario and hope that 
covers the bases. Of course, something out of the blue will 
happen.
    But, for example, if we look at the vaccination campaign 
for the fall, we will have an initial bolus of vaccine coming 
out probably sometime around October, but we don't know how 
fast it is going to grow. That vaccine will come out with an 
initial bolus. We don't know how much that will be. It will 
then come out with weekly numbers, so a certain amount per 
week. We don't know how much that will be. That will be 
distributed on a per capita basis to the country and we have to 
go down a priority list, which incidentally the priority list 
we have is for H5N1, not H1N1.
    So you see how many unknowns there are here. What will the 
adjutant do? We haven't gone through the safety studies yet. We 
actually don't know if it is one dose or two doses. So there 
are so many complexities here and we will not know ahead of 
time enough information to make the decisions. So at the 
outset, we have to come up with operational assumptions and 
plan around those assumptions with different scenarios.
    Senator Pryor. And you had mentioned the costs of providing 
a vaccine to every American. What is your overall estimated 
cost on that?
    Dr. Jarris. Well, we don't quite know again, what the 
vaccine is going to cost. It hasn't been developed yet. We 
don't know the cost of the adjutants that may be in it. So 
probably between $5 and $10 a dose, $10 is what it normally 
costs for regular seasonal flu. And we assume 600 million 
doses, so we are talking somewhere in the $6 billion range. It 
could be more, could be less.
    But then we actually have to give the vaccine, and we 
estimated this a number of ways. We had dozens of States and 
local health departments who did a cost basis for them to give 
a vaccine. Medicare pays $18 to $20. Medicare pays costs. We 
checked with Visiting Nurse Associations. We checked with 
private sector. So the ranges are anywhere from about $12 to 
$30. We picked $15, which we think is a reasonable dose. So $15 
times 600 million, we are talking about another $9 billion.
    Senator Pryor. And how does that square with your thoughts 
on planning, though, because at some point, you have got to 
pull the trigger on the vaccine, about whether you are going to 
go with this particular vaccine or not. And if the strain 
changes, like down in the Southern Hemisphere it could be a 
different strain this fall or whatever the case may be. So when 
is that point where you have to pull that trigger?
    Dr. Jarris. There is seed stock developed now, it is my 
understanding--and I am not Dr. Fauci--that the variation has 
not been tremendous around the world yet. So we think we will 
have a vaccine that will probably cover all the options unless 
there is a major mutation. So that seed stock will then have to 
go into production. At the same time, we need 2 to 3 months to 
do the scientific testing for safety, for response, for dosage, 
and things like that.
    So we will have to make a decision soon to purchase--we 
have already put a purchase order in for this country--not only 
because we need the lead time to develop the vaccine, but 
because other countries are already in line, Great Britain, 
France, things like that. So in order to put our place in line, 
we are going to have to make a purchase decision very soon.
    Now, it is one decision to purchase. That, we will have to 
do early. It is another decision to give it. We are going to 
have to look in the fall, based on the safety studies, to say, 
OK, given what we know, we have this vaccine. Should we 
actually give it to people? And I think we have to carefully 
consider that, because all vaccine has side effects and we will 
have to weigh the severity of the illness in the fall versus 
potential side effects of the vaccine. So that is a later 
decision, I would guess, that is going to be made probably in 
the August to September time frame.
    Senator Pryor. Mr. Thomasian, let me ask you a follow-up to 
what Dr. Jarris was talking about. We have talked about a lot 
of different scenarios about administering a vaccine and how to 
distribute it around the country, around the various States. 
From your standpoint, how should that be done? Should you let 
the various States make that decision on how it is distributed, 
or should there be one national policy that the States just 
follow?
    Mr. Thomasian. Well, the way it is currently laid out is 
the States have prepared plans on how they would distribute 
vaccines and antivirals and they have priority lists that match 
up to a good extent to the Federal senses of priority. So I 
don't think there is a huge variation out there. So I would 
say, let the States administer it with a joint discussion 
between the Federal Government and the States on the type of 
priorities.
    I am saying that because I am assuming, and I think it is 
safe to assume, that we would not have vaccines for everybody, 
so we would have to be focusing on the essential service 
individuals and the most vulnerable populations. Otherwise, I 
think we can probably go to the open market distribution of the 
vaccines.
    Senator Pryor. Dr. Ostroff, do you have any thoughts on 
that?
    Dr. Ostroff. Specifically about the vaccine? There is 
obviously a lot of unknowns, I think, as Dr. Jarris pointed 
out.
    Senator Pryor. And let me just interrupt there. It seems to 
me that you can do a lot of planning and you can be prepared in 
some ways, but because the vaccine needs so much lead time, 
that is sort of a separate question that just makes it hard to 
figure out what the best way to go is, but go ahead.
    Dr. Ostroff. Well, I think a couple of other points just to 
consider--one of them is, I think as Dr. Jarris rightly pointed 
out, we shouldn't look at the current situation as being in the 
past tense. We in Pennsylvania, our numbers have gone up by a 
third just since I put my testimony together this weekend, so 
it is quite active right now in Pennsylvania. It shows no signs 
of abating. I think that we all anticipated that it would 
dampen down over the summer months. The virus may not have read 
the textbook and may decide not to do that.
    The other thing that we have to remember is that in 1918, 
which is the model that we have all been looking at, the virus 
came back very early. It came back in September and it came 
back with a vengeance in September. It didn't wait until the 
usual winter influenza season. And so in terms of our thinking 
about what to do related to vaccine, I think that we have to 
really put our decision making on the fast track about what to 
do because by the time we make decisions over the next couple 
of months, the virus may have jumped out ahead of us and it 
could come back in a form that is more severe than it currently 
is.
    The other, I think, issue to also keep in mind is that we 
are relying quite heavily on antiviral drugs. The antiviral 
drug of choice, if you look at the seasonal strain that was 
just floating around the country, that was resistant to that 
particular drug. And so if this particular virus decides to get 
together with that one and transfers its resistance, then that 
is a program for our assumptions and planning.
    And so I think as far as the vaccine, I am not sure that we 
have a lot of time to be able to make these decisions. I think 
the virus is telling us, because right now, virtually all 
influenza in the United States--and again, it is a very unusual 
time to be seeing this disease--is this virus. And so it may 
not be an option, the regular one versus this one. I think that 
we have to look seriously at what the virus is telling us right 
now and make our decisions relatively quickly.
    Senator Pryor. OK. Given all the circumstances that we are 
in right now and also given the fact that in the supplemental 
appropriation that is working its way through the Congress and 
hopefully will get to the President's desk in the next couple 
of weeks, we put $1 billion in there for pandemic flu issues 
and preparedness. Do you have an idea on how that money should 
be prioritized, what the most critical needs are to get us 
ready for this?
    Dr. Ostroff. Well, there are a lot of needs and I think 
many of them have been pointed out. Again, we have not been 
fully exercising the full gamut of things that we would need to 
do for a full-fledged pandemic. I think that we do need to very 
quickly come up with our plans as to how we would distribute 
the vaccine. I think when the vaccine becomes available, there 
is not going to be enough for everybody and we are going to 
have to make decisions about how to prioritize who gets it and 
who doesn't, and we generally do that based on what we see 
about the patterns of disease.
    I think that we have to work out much better than we did 
how to distribute antiviral medications. In addition to that, I 
do think that we have to very quickly figure out what we are 
going to do about the medical surge issues, because again, most 
of us haven't had to exercise that part of our pandemic plan.
    And the last thing that I will say is that for us, if there 
is a lot of disease, both being able to monitor what is going 
on as well as do the diagnostic work in our laboratory--I mean, 
Pennsylvania is a large State. We are the sixth largest State 
in terms of population. We only have 300 cases, and it has been 
all we could do to be able to count what we are seeing and to 
make the diagnoses in our laboratory. We are sort of relying on 
two people in our laboratory to do all this work, and if one of 
them gets the flu, then we are down by 50 percent. So we need 
to, I think, pretty quickly figure out how we deepen our bench 
strength between now and the fall because I think that these 
will all be serious gaps for us.
    The last thing that I will say is that in terms of the 
Federal guidance, one of the things I think that is important--
and I have a fairly unique perspective, because I worked at the 
CDC for 20-some years, so I was on the giving end rather than 
the receiving end for all that time period--is that we don't 
like it to be so prescriptive that there is not a lot of wiggle 
room. We in Pennsylvania, as far as school closures, we set up 
our policy right from the very beginning. We have held to that 
policy all along. We didn't think that the initial 
recommendations from the CDC were quite correct and we didn't 
think the revised recommendations were quite correct, either.
    So we don't want them to be so prescriptive that it looks 
like we are not following what other people are doing. Each 
State has to take that guidance and interpret it and translate 
it to their local circumstances. That is what is being done in 
Arkansas and that is what we are doing in Pennsylvania.
    Senator Pryor. Let me ask about this medical surge question 
that you brought up. It is really just for the panel at large. 
Given the economic downturn and given that certain hospitals, 
first responders, you name it, there have been some layoffs and 
some cutbacks, a lot of cities and counties and States are 
having to do cutbacks and this can be very painful. But it 
seems to me this is the worst time that they could be cutting 
back on these type of health-related services, but the reality 
is what it is. So any advice for this fall? Dr. Jarris.
    Dr. Jarris. Yes. It is an excellent question, Senator. We 
have looked at the State and local public health agencies, and 
due to the budget constraints in the States, we have lost over 
11,000 positions in the last year and that pace is continuing. 
Given an outbreak, and we have already seen this in the last 
several weeks, we have taken a drastically diminished workforce 
and put them on two shifts from one shift. There is only so 
much people can do, and that really strained the system. On top 
of that, of course, we have had certain States who have 
actually run out of places to build the pandemic response so 
they are actually ramping down in the face of an escalating 
outbreak. So this is again the reason why we need some Federal 
assistance to mount the response and protect the American 
people.
    Senator Pryor. Mr. Thomasian, do you have any thoughts on 
that?
    Mr. Thomasian. Well, it is an excellent point. I will say 
that in our work at NGA, we projected even after the recovery 
dollars are spent that States will be facing over the next 2 
years somewhere between $170 and $230 billion in deficits 
across the States, so it is a tough time. It is very difficult 
to build a government around a peak event that may not occur.
    I do feel, though, that if further resources were available 
to States, there are some critical areas that would certainly 
help. It may not address all the surge capacity, but certainly 
one is laboratory capacity is sorely needed in the States. 
Also, assistance again on exercising. Clearly, States will need 
to build as much capacity as they can afford to do in these 
areas, but honestly, I think this is an area that we have not 
been tested in and we will probably find that we will be sorely 
behind if a large event does come.
    Senator Pryor. Yes, Mr. Steinhardt.
    Ms. Steinhardt. Just to add to the comments that have 
already been made, looking at vaccine production, at best, at 
least from my understanding, if we begin today, we are looking 
at November for the initial production lines for this virus. So 
we still have this long period between now and then in which 
communities have to be able to respond to the continuing 
epidemic or a resurgence in a more virulent form. And so the 
kind of planning, the kinds of activities that have to take 
place before we even have a vaccine are really our first--need 
to be our first considerations here. What kinds of capacities 
do we need to build into communities? And I think as we look at 
priorities for funding and allocations of funding, we need to 
keep that very much in mind.
    Senator Pryor. OK. As I understand it, the World Health 
Organization is deliberating whether to move this from a Phase 
Five to a Phase Six. First, I don't understand the complete 
significance of that. And second, I guess, Dr. Ostroff, if they 
move from a Phase Five to a Phase Six, what does that mean for 
the United States? How does that change things here?
    Dr. Ostroff. I think in practical terms, it really doesn't 
change very much for us. Our planning, our thinking, our 
activities are all predicated on what we think the appropriate 
things to do in the United States are. I do think that part of 
the difficulty and why World Health Organization (WHO) has been 
having such struggles around this particular issue is that when 
you move to Phase Six, it sort of trips off a whole lot of 
activities in other parts of the world, some of them 
appropriate and some of them inappropriate based on their 
particular circumstances. And so I think it does make a 
difference.
    I think that we have seen many countries do things that, in 
terms of entry and exit screening, etc., that may not 
necessarily be the best application of resources and if this 
would give them further reason to do some of those things, then 
I think it would be somewhat problematic. But in terms of the 
way that we would approach what needs to be done here in the 
United States, I don't really think it makes that much of a 
difference, which level they define it as.
    Senator Pryor. Dr. Jarris.
    Dr. Jarris. Yes. I would agree with my colleague that in 
terms of our response in the United States, within our borders, 
it probably doesn't change what we do because we have the 
epidemic. But as a global leader, it may very well change what 
we do.
    One is as this continues to spread around the world, which 
it has been, and frankly, it is almost academic whether they 
declare it Phase Six or not because I think they met the 
criteria a month or more ago but there have been political 
discussions. But the issue is what role will the United States 
play in terms of a health diplomacy role worldwide if we have 
outbreaks hitting undeveloped countries or developing countries 
who do not have an infrastructure for public health and we see 
many more deaths because some of these countries have high 
rates of HIV, what will the United States do? Will we feel a 
responsibility to go and assist these nations?
    And what is our responsibility to the rest of the world 
with regard to things like vaccine and antivirals? If we were 
producing antivirals with our domestic capacity only for the 
United States, we might produce it one way without the vaccine 
sparing adjutants. However, the whole world needs the vaccine, 
and if we need to help other parts of the world, we probably do 
have to put adjutants to stretch the supply that we can produce 
even further.
    So I would suggest that our political leadership involved 
and scientific community involved with global health issues 
will have some significant questions to address in terms of the 
U.S. leadership.
    Senator Pryor. That is fair enough.
    Let me ask about this map that we have here.\1\ You can see 
the confirmed cases around the world. When you see a map like 
this and when you look at the numbers, the quantity of this 
around the world and the fact that it is spread out 
geographically, from a scientific perspective, does that 
increase the chance of mutation or does that have any bearing 
on the chances of mutation?
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    \1\ The map referred to by Senator Pryor appears in the Appendix on 
page 93.
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    Dr. Jarris. Every infection increases the chance. Viruses 
do mutate rapidly, and as they travel around the world and are 
exposed to different populations of humans, of animals, there 
is an increased chance of resortment. So yes, the more it 
spreads, the more the chance of resortment.
    Now, one thing to consider is since this is a novel virus, 
there isn't a heavy evolutionary pressure on it to evolve. In 
and of itself, it is making people sick and surviving. So we 
can't conclusively say whether it will resort or not. The great 
fear, of course, is that it does mix with someone with an H5N1 
or mix with a seasonal influenza that is Tamiflu-resistant and 
then we are in trouble. But that really is another one of the 
unknowables.
    Senator Pryor. Mr. Thomasian, let me ask you about the 
Medical Reserve Corps. Can the States activate that, and what 
is that process?
    Mr. Thomasian. I am not completely familiar with the 
activation process. I believe they can, but I would have to get 
back to you on that.
    Senator Pryor. Dr. Jarris, did you----
    Dr. Jarris. Yes. There is a Medical Reserve Corps that has 
been very helpful in certain limited disasters around the 
country. What we have found in areas severely hit, in Texas and 
Louisiana during their hurricanes, though, is the Medical 
Reserve Corps are people who have other jobs, and so when you 
are mounting a sustained response, they can't be counted on to 
be there day in and day out in shifts, so the doctors have to 
go back to their office to practice and nurses have to go back 
to the hospital or the health departments to their shift.
    So what Texas has found, in fact, is that although they 
welcome them and like to work with them, they have actually had 
to go out and contract for paid professionals to come in and 
work for them because then you have performance standards that 
you can maintain. That again will be important with the 
vaccinations in the fall as well as if we have to do mass 
dispensing of Tamiflu. We are going to have to hire in contract 
nurses or hospital nurses or VNA nurses, which means with them 
having other jobs, time-and-a-half, weekend pay, and things 
like that.
    Senator Pryor. OK. Let me ask this. I am getting down to 
the end of my questions, and like I said, we will keep the 
record open and some other Senators will probably have other 
questions. But given the last few months where the flu was 
first discovered in North America and it was almost wall-to-
wall coverage there for several days on the cable news 
channels, etc., how did the media do and how did the public 
health officials and the elected officials do in getting the 
word out to the public and communicating the nature of this? 
Can you all grade that? Is that one of the lessons learned that 
we can improve?
    Mr. Thomasian. Well, in my comments, I addressed--I think I 
would give them high marks. I would give the Federal officials 
and the public officials at the State and local level high 
marks for communicating to the public and communicating to the 
media, and the media did a good job, I think, reporting on the 
nature of the disease and where it was. Again, I think where 
the breakdown began in some areas was, well, so what do we do? 
What is the appropriate government response? And I think there 
was some initial hesitancy at the opening to talk about issues 
like quarantine and why you should and why you shouldn't use it 
and issues like travel bans so that we got into this situation 
for a while where there was a discussion of, should we block 
the borders in Mexico, and that percolated for a few days. But 
initially, I do think that the communication was very good and 
I think the public had a sense that this disease was existing 
out there, it wasn't a disaster, and they were getting up-to-
date information.
    Senator Pryor. Does anybody else want to add to that?
    Dr. Jarris. There was a study done by Harvard University, a 
sample of the American people, and as I mentioned briefly 
before, 88 percent of Americans that were surveyed expressed 
satisfaction with the information they were getting. So I think 
we did a good job. I think it was clear, and Dr. Besser should 
be commended. He did a wonderful job, the Acting Director of 
the CDC.
    The one place I think we are falling down right now is we 
have shut it down. I mean, you can't find anything in the media 
anymore. We should be using this time to let people know that 
now is the time to prepare. Now they should figure out in the 
fall if their kids' school is canceled, how are they going to 
take care of the kids? How are they going to telecommute? What 
if their elderly parent gets sick? We are missing an 
opportunity now, ahead of time, to have people think about the 
fall.
    Ms. Steinhardt. If I can add to that----
    Senator Pryor. Yes, go ahead.
    Ms. Steinhardt [continuing]. I think I would agree that the 
response and the communications were first-rate. But I think 
from our experience, looking at what happened several years ago 
when we first began to see cases of bird flu and outbreaks of 
H5N1 virus in humans, there was an enormous amount of 
attention, and then it fell off, and for most of the public, it 
seemed as though this issue went away completely. 
Unfortunately, what the public loses interest in, government 
often loses interest in, as well. I think within the public 
health community, members of the public health community never 
lost sight of this problem, but otherwise, we let other issues 
take priority, and we know this from conversations we had with 
people in the private sector. Other food safety issues, 
whatever the issue of the day was, that is what took attention. 
So we need to, I think, somehow keep sight within government of 
our priorities and what the real dangers to the public are, 
whether it is covered in the media or not.
    Senator Pryor. Dr. Ostroff.
    Dr. Ostroff. Yes. I will just add a couple of comments, 
because I agree with everything that was said. I think that 
over the last few years, it has been ingrained in the public's 
mind that when something happens related to flu, it is going to 
be like the big bang. When that didn't quite happen right at 
the very beginning, I think there was a tendency for everyone 
to shrug their shoulders, saying, what is the big deal here?
    What you heard was a lot of descriptions of this as being 
mild. Flu is never mild, and we tried very vigorously to say 
that this is not a mild disease now and it could be even more 
severe in the coming months. And so I do think that there is a 
segment of the population who feels that this was sort of like 
oversold to them when, in point of fact, I think that many of 
us are very concerned about what we are seeing right now and we 
are awfully concerned about what is going to happen in the 
fall. So I do think that I would echo the comment that we have 
to continue to reinforce the message that what you have seen so 
far might not necessarily be what you see later on.
    But having said that, I would fully concur. I think that 
the Federal officials, in particular, did a fantastic job 
conveying information to the public. It was a transitional 
group of people, and given the circumstances and the amount of 
attention that this initially got, I think they did a wonderful 
job.
    Senator Pryor. Let me follow up on that. Ms. Steinhardt, 
you may be the best one to ask. There is sort of a lull period 
right now in terms of public awareness on this. If it comes 
back this fall, the lull will be over. A lot of people will be 
looking back and saying, why didn't we do something different? 
What would you recommend right now to the private sector in 
terms of the things they can be doing? It sounds like the 
government is going to continue to plan and work and try to 
coordinate, and there is a lot of work that we have talked 
about that needs to be done, but we haven't talked a lot about 
the private sector yet. Do you have any suggestions for the 
private sector?
    Ms. Steinhardt. Well, I have suggestions for the government 
in working with the private sector. We have this system of 
coordinating councils for critical infrastructure sectors. In 
fact, in work that we did here, we found that they could be 
used much more than they currently are. There are a lot of 
questions that the private sector has within these critical 
sectors that they have about how government policies are going 
to work. How are States and the Federal Government going to 
handle State border closings? These are vital issues for 
commerce. And those discussions should be happening today 
between private sector and government. We are not in this alone 
and these are issues that have to be resolved in tandem, and 
that is one area where we certainly would urge greater 
attention.
    Senator Pryor. I have one last follow-up question. It is 
really a two-part question. I want to ask each of you this, and 
that is what is the single most important step that we can take 
to increase our preparedness in the next 3 months, from now 
until the fall? What is the single most important step we can 
take, and how do you suggest that we do it? Dr. Ostroff.
    Dr. Ostroff. Well, I wish I could tell you that there was a 
single step, because there isn't. There is a series of steps 
that I think we need to deal with.
    Senator Pryor. Is there one thing, though, that----
    Dr. Ostroff. Well, I think that the two areas that I really 
think that we need to focus on is we need to get our house in 
order for issues related to vaccination because we know for 
influenza that is the single best preventive measure we have 
available. And I do have concerns that we will see more 
morbidity and certainly more mortality for this as we go along 
and I do think we have to think about how we deal with medical 
surge issues.
    Senator Pryor. And so you are thinking vaccine, even though 
it could mutate, but you are saying, place your bet on what you 
know----
    Dr. Ostroff. I think not placing your bet on what we 
currently know would be a significant mistake.
    Senator Pryor. OK. Mr. Jarris.
    Dr. Jarris. Limited to one, it is a very difficult question 
because there is so much that has to be done. But I would think 
that if I was in the shoes of Congress and the Administration, 
the single most important thing to do is to appropriate 
sufficient resources in the next 2 weeks with this 
supplemental. There is so much that needs to be done. We don't 
have time to catch up later.
    Earlier, you asked how to prioritize the $1 billion, and 
that is a very difficult question because just the vaccines are 
$15 billion.
    Senator Pryor. That sounds like a lot of money, but it is 
not----
    Dr. Jarris. Yes, in the old days. But frankly, if we 
appropriate less than what is needed, for example, the $15 
billion for vaccines, and we need more than that, then the 
question that makes sense would be, well, if we appropriate $1 
billion, which one-fifteenth of the American public are we 
willing to vaccinate and which fourteen-fifteenths are we not 
willing to vaccinate?
    Senator Pryor. Mr. Thomasian.
    Mr. Thomasian. Thank you. Well, this is an excellent 
question and I will take mine beyond the public health arena. 
The one thing that we need to keep in mind is that this was not 
really a test. This was not really even a pop quiz. When we did 
our workshops, we asked States to envision a scenario where 90 
million people came down with the disease and we had 1.5 
million people needing intensive hospital care and an estimated 
1.9 million deaths.
    And I would have the States, if they received resources for 
exercises and further planning, to consider how they would 
maintain continuity of society under those situations. How 
would public safety react? How would we handle the high degree 
of absenteeism in both State government as well as our critical 
services, such as food services, electricity, etc. So I would 
use these intervening months to examine what would happen if 
this became the true pandemic and the scenarios that we thought 
we would be looking at under the 1918 scenario and go beyond 
the public health aspects and look at the public safety, as 
well.
    Senator Pryor. OK. Ms. Steinhardt.
    Ms. Steinhardt. Well, I would certainly support that. I 
would say this is our time now to take a look at what our plans 
are, what our plans have been, what we have learned from what 
has happened over this last month. What assumptions do we need 
to revisit? This is our opportunity to learn from a real live 
test, and it is also our opportunity to actually pull in the 
results of a number of different tests that have happened over 
the last few years. I don't think we have learned nearly as 
much or incorporated the lessons learned from the various tests 
and exercises that have been done around the country and 
incorporated that into our thinking, but now we have this 
opportunity to just take that pause and think about what we 
know and what we need to change in our plans going forward.
    Senator Pryor. Good. I want to thank all four panelists. I 
hope I didn't grill you too much. We are going to leave the 
record open, as I mentioned, and I know Senator Ensign and 
others will submit some questions for the record. We would 
appreciate you getting those back to us within 14 days.
    Thank you very much for your attention, and I appreciate 
all the work you have done in your various capacities. You are 
playing a very important role in saving American lives and we 
just appreciate everything you are doing.
    So with that, we are going to conclude the hearing and 
leave the record open for 14 days. Thank you.
    [Whereupon, at 3:14 p.m., the Subcommittee was adjourned.]
                            A P P E N D I X

                              ----------                              


                  PREPARED STATEMENT OF SENATOR ENSIGN
    While the media attention for the H1N1 virus has subsided, this 
hearing is no less important. Health officials believe that this virus 
could come back stronger during flu season this fall, and we have to be 
prepared for that. Right now, Federal officials are beginning to track 
this virus as it heads to the southern hemisphere to gain a better 
understanding of what it does in populations that are just entering the 
winter flu season. I am hopeful that whatever characteristics are 
identified will help us in our preparedness efforts.
    While the number of confirmed cases of H1N1 in Nevada is on the low 
end at 102, a combination of guidance from the Federal Government and 
decisions made at the local level helped mitigate the spread of the 
disease. Two weeks ago, in Washoe County, Nevada, surveillance 
procedures revealed an increased absenteeism rate at Mendive Middle 
School. Local health district officials awaited word from the State 
laboratory as to whether or not the children were sick with H1N1. Upon 
confirmation, the Joint Health and Education Authorities Influenza 
Oversight Committee met quickly and decided to close the school. The 
decision was made when only five tests had come back positive for H1N1; 
however eight additional cases from the school have since been 
confirmed. State officials have noted that the guidance on school 
closures has been successful and the closure of Mendive is an excellent 
example of how the policy worked.
    Today we will hear from a number of witnesses who will help us 
understand how States have responded to this virus over the last month. 
Their testimony will highlight successful responses and areas that need 
improvement. As with any emergency, lessons learned can be invaluable. 
Ideally, the discussion we have here today will provide information for 
States as they update their State preparedness plans to address the 
potential for a more potent strain of H1N1.
    Approximately 36,000 people die as a result of influenza each year. 
Should this virus re-emerge as a stronger strain than we are seeing 
today, citizens should continue to exercise precaution and personal 
responsibility. While we can't predict the severity of a possible 
mutation, we can do our best to minimize its effects.
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