[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]
EMERGING BIOLOGICAL THREATS AND PUBLIC HEALTH PREPAREDNESS: GETTING
BEYOND GETTING READY
=======================================================================
FIELD HEARING
before the
SUBCOMMITTEE ON EMERGING
THREATS, CYBERSECURITY,
AND SCIENCE AND TECHNOLOGY
of the
COMMITTEE ON HOMELAND SECURITY
HOUSE OF REPRESENTATIVES
ONE HUNDRED TENTH CONGRESS
SECOND SESSION
__________
JULY 22, 2008
__________
Serial No. 110-131
__________
Printed for the use of the Committee on Homeland Security
[GRAPHIC] [TIFF OMITTED] TONGRESS.#13
Available via the World Wide Web: http://www.gpoaccess.gov/congress/
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COMMITTEE ON HOMELAND SECURITY
Bennie G. Thompson, Mississippi, Chairman
Loretta Sanchez, California Peter T. King, New York
Edward J. Markey, Massachusetts Lamar Smith, Texas
Norman D. Dicks, Washington Christopher Shays, Connecticut
Jane Harman, California Mark E. Souder, Indiana
Peter A. DeFazio, Oregon Tom Davis, Virginia
Nita M. Lowey, New York Daniel E. Lungren, California
Eleanor Holmes Norton, District of Mike Rogers, Alabama
Columbia David G. Reichert, Washington
Zoe Lofgren, California Michael T. McCaul, Texas
Sheila Jackson Lee, Texas Charles W. Dent, Pennsylvania
Donna M. Christensen, U.S. Virgin Ginny Brown-Waite, Florida
Islands Gus M. Bilirakis, Florida
Bob Etheridge, North Carolina David Davis, Tennessee
James R. Langevin, Rhode Island Paul C. Broun, Georgia
Henry Cuellar, Texas Candice S. Miller, Michigan
Christopher P. Carney, Pennsylvania
Yvette D. Clarke, New York
Al Green, Texas
Ed Perlmutter, Colorado
Bill Pascrell, Jr., New Jersey
I. Lanier Lavant, Staff Director
Rosaline Cohen, Chief Counsel
Michael Twinchek, Chief Clerk
Robert O'Connor, Minority Staff Director
______
SUBCOMMITTEE ON EMERGING THREATS, CYBERSECURITY, AND SCIENCE AND
TECHNOLOGY
James R. Langevin, Rhode Island, Chairman
Zoe Lofgren, California Michael T. McCaul, Texas
Donna M. Christensen, U.S. Virgin Daniel E. Lungren, California
Islands Ginny Brown-Waite, Florida
Bob Etheridge, North Carolina Paul C. Broun, Georgia
Al Green, Texas Peter T. King, New York (Ex
Bill Pascrell, Jr., New Jersey Officio)
Bennie G. Thompson, Mississippi (Ex
Officio)
Jacob Olcott, Director and Counsel
Dr. Chris Beck, Senior Advisor for Science and Technology
Carla Zamudio-Dolan, Clerk
Kevin Gronberg, Minority Professional Staff Member
(II)
C O N T E N T S
----------
Page
Statements
The Honorable James R. Langevin, a Representative in Congress
From the State of Rhode Island, and Chairman, Subcommittee on
Emerging Threats, Cybersecurity, and Science and Technology.... 1
Witnesses
Dr. Jeffrey W. Runge, Assistant Secretary for Health Affairs and
Chief Medical Officer, Department of Homeland Security:
Oral Statement................................................. 4
Prepared Statement............................................. 7
Rear Admiral W. Craig Vanderwagen, M.D., Assistant Secretary for
Preparedness and Response, Department of Health and Human
Services; Accompanied by Dr. Michael G. Kurilla, Director,
Office of Biodefense Research Affairs, and Associate Director
for Biodefense Product Development, National Institute of
Allergy and Infectious Diseases, National Institutes of Health;
and Dr. Daniel M. Sosin, Director, Biosurveillance Coordination
Unit, and Associate Director for Science, Coordinating Office
for Terrorism Preparedness and Emergency Response, Centers for
Disease Control and Prevention:
Oral Statement................................................. 12
Prepared Statement............................................. 13
Captain Peter Boynton, Deputy Regional PFO for Pandemic Influenza
and Federal Security Director, Bradley International Airport
(Connecticut), Transportation Safety Administration, Department
of Homeland Security:
Oral Statement................................................. 21
Prepared Statement............................................. 23
Panel II
Dr. David R. Gifford, Director of Health, Rhode Island Department
of Health:
Oral Statement................................................. 44
Prepared Statement............................................. 46
Major General Robert T. Bray, Adjutant General, Rhode Island;
Commanding General, Rhode Island National Guard; Director,
Rhode Island Emergency Management Agency; and Homeland Security
Advisor, State of Rhode Island:
Oral Statement................................................. 58
Prepared Statement............................................. 59
Mr. Thomas J. Kilday, Jr., Homeland Security Program Manager,
Rhode Island Emergency Management Agency:
Oral Statement................................................. 63
Prepared Statement............................................. 65
Mr. Peter T. Ginaitt, Director, Emergency Preparedness, Lifespan
Hospital Network:
Oral Statement................................................. 69
Prepared Statement............................................. 72
Appendix
Questions From Chairman James R. Langevin........................ 85
EMERGING BIOLOGICAL THREATS AND PUBLIC HEALTH PREPAREDNESS: GETTING
BEYOND GETTING READY
----------
July 22, 2008
U.S. House of Representatives,
Committee on Homeland Security,
Subcommittee on Emerging Threats, Cybersecurity, and
Science and Technology,
Providence, RI.
The subcommittee met, pursuant to notice, at 10:30 a.m., at
Rhode Island State House, Smith Street, Room 313, Providence
Rhode Island, Hon. James Langevin [Chairman of the
subcommittee] presiding.
Present: Representatives Langevin and Pascrell.
Also present: Representative Christensen.
Mr. Langevin. The Committee on Homeland Security will come
to order. The committee is meeting today to receive testimony
on ``Emerging Biological Threats and Public Health
Preparedness: Getting Beyond Getting Ready.''
Well, good morning. I'd like to thank my colleagues,
Congressman Bill Pascrell from New Jersey and Congresswoman
Donna Christensen from the Virgin Islands joining us here
today. Welcome to Rhode Island. You've traveled all this way to
be with us.
I'd also like to thank our witnesses on the Federal panel
for traveling here today, as well as welcoming and thanking our
Rhode Island witnesses and guests. It's certainly an honor for
me to be able to tackle such an important issue here in my own
State and also to highlight the practical efforts and best
practices of the State of Rhode Island and to have your
expertise and your guidance in these efforts.
Today, we will discuss the challenges States and localities
face in preparing for and responding to emerging biological
threats such as pandemic influenza or weaponized anthrax, among
other things, that could affect every sector of society and
every person potentially on a global scale.
Efforts to address biological threats are among the most
difficult. In fact, they are so challenging that for decades
planning for situations involving biological terrorism using
diseases such as smallpox, emerging infectious diseases such as
ebola, or re-emerging infectious diseases such as pandemic
influenza took a back seat to planning for other situations
where response would be more straight forward, such as
terrorism or accidents involving chemicals.
Now this, obviously, has changed. Our Government no longer
considers planning and preparedness for biological threats to
be too hard, nor do we think that they are unlikely events.
We've effectively determined what we need to do save lives, but
clearly, more needs to be done.
Now we all remember the anthrax events of 2001. Before and
since then, there have been other biological incidents that
have made equally vivid impressions. The outbreak of SARS, West
Nile fever, extensively drug-resistant and multi-drug resistant
tuberculosis; outbreaks of meningitis and mumps on college
campuses; super bugs such as MRSA and VRSA; and the recent
cases of salmonella and E. coli that have tainted our Nation's
food supply are only a few that have occurred here in the
United States.
Time and again, public and private sectors have responded
to these threats, but not without difficulty. Our Nation prides
itself on confronting the tough issues and not shying away from
a fight.
The citizens of Rhode Island exemplify this and it's
because of them and others like them throughout our great
Nation that we're here today.
It comes down to saving lives. In the case of pandemic
influenza and diseases caused by some agents of bioterrorism,
in the best case scenario we expect hundreds of thousands of
people to become sick across the Nation. In the worst case
scenario, hundreds of thousands could be sick just in one State
or territory with death resulting.
Now in the case of a biological weapons attack, I'm mindful
of the findings of the Hart-Rudman Commission on U.S. National
Security in the 21st Century which stated and I quote:
``Terrorists and other disaffected groups will acquire weapons
of mass destruction and mass disruption and some will use them.
Americans will likely die on American soil, possibly in large
numbers.''
It's a sobering finding. The price we have to pay in terms
of lives, the economy, and society is too great to make
preparedness for these events a low priority. Now we've
increased our readiness for any number of biological threats
and it is clear to me, and my colleagues on the subcommittee
that our resources and efforts have gone into ensuring that
we're more prepared. I know that those we have invited to
provide testimony today would agree that clearly still more
needs to be done and we have to also work to get beyond getting
ready and we have to actually be ready.
Now we've established and added to Federal and State
stockpiles of drugs and equipment, but we're not ready yet.
We've engaged in planning efforts, but we're not ready yet.
We've done a great deal of research on developing methods to
get us new drugs and better treatments faster, but we're not
ready yet. We've increased communications between public and
private sectors, but we're not ready yet.
Although we recognize that difficult decisions will need to
be made regarding the delivery of medical care, when resources
are short, and patients number in the millions, we're not ready
yet to make those decisions.
There are many issues that need to be addressed, but among
them the most important are encouraging different sectors to
partner with each other to counter these threats; integrating
efforts to increasing efficiencies in public health and
emergency response to biological events and helping our health
care professionals save as many lives as possible when
resources are strained by biological disaster.
Now when it comes to large-scale issues like diseases for
which we have few or no treatments and which could sweep across
the country and the world, it's clear that no one sector or
entity is solely responsible for prevention, deterrence,
preparedness, detection, response, recovery, or mitigation.
Different sectors must partner with each other and the kinds of
partnerships that we need to see between the Department of
Homeland Security and the Department of Health and Human
Services or the State Emergency Management Agency and the State
Department of Health are critical.
There are hundreds, if not thousands of efforts going on
right now to address Federal requirements for getting ready for
a variety of different situations that would affect the health
of the public. Now we've talked about coordinating those
efforts before, but we need to go from coordinating to
integration.
Public health and public health care resources are limited,
so the efforts of these sectors need to be as efficient as
possible. This efficiency must be inherent in what the Federal
Government is asking the non-Federal, public, and private
sectors to do, the way shelf life is extended for various
medications and the way grants and planning guidance go out to
the States and the territories--in a way that truly means to
hold the States and territories accountable to the Executive
branch, and the Executive branch accountable to the Congress
and ultimately to the American people.
Decisionmaking when lives are at stake is difficult at best
especially when large number numbers of people could be
affected. I realize that there are certain decisions that no
leader wants to make. But emergencies, disasters, and
catastrophes demand this of us. To the greatest extent
possible, we need to decide now what we're going to do when the
number of people ill with a disease far exceeds the number of
resources available to treat them.
The Federal Government has issued some guidance in these
and other areas, but we have not made enough headway. Everyone
needs to roll up their sleeves, work their way through these
challenges and develop decisionmaking criteria for those that
will have to make the tough calls in the midst of a crisis. We
must not back down from the fight against biological threats of
any type whether naturally occurring or intentionally produced
by a terrorist. We cannot let artificial situations like
boundaries between States and countries or change of
administrations keep us from continuing that fight.
I certainly appreciate the efforts of the public and the
private sector witnesses here today. Together, we will address
a number of issues including partnering across sectors and
creating greater efficiency in public health and other
preparedness efforts and making the most difficult decisions of
all, those that affect the lives of our families, our friends
and our citizenry.
Again, I want to thank everyone for being here this morning
and also I want to point out something. It has certainly taken
a tremendous amount of work to put this hearing together and I
appreciate the interest that is shown by the number of people
who have turned out for the hearing today. We also have an
overflow room down in the House Finances Committee room down in
the basement. However, if the room gets too crowded and people
get uncomfortable and want to go down there--I thank everyone
for attending.
Because this is an official congressional hearing, it was
also mentioned that we have to abide by certain rules of the
committee and of the U.S. House of Representatives, so I would
kindly ask that there be no applause of any kind or any kind of
demonstration with regards to testimony. I would also ask that
cell phones be turned off and put on vibrate mode. It's
important to respect the decorum of the rules of the committee
and again, I want to thank everyone for being here.
With that, I would just ask if any Members have opening
statements they would like to make?
I'm reminded of the committee rules that opening statements
may also be submitted for the record.
Well, let me begin by welcoming our Federal panel here
today. I want to begin by welcoming our first panel of
witnesses. Our first witness is Dr. Jeff Runge. He is the
Assistant Secretary for Health Affairs and the Chief Medical
Office of the Department of Homeland Security. This will be his
last appearance before this or I believe any committee of the
Congress as he's set to depart from his current post and we
thank you for your service, Dr. Runge. We thank you for being
here.
Dr. Runge. Mr. Chairman, thank you.
Mr. Langevin. Our second witness is Rear Admiral Craig
Vanderwagen, Assistant Secretary for Preparedness and Response
at the Department of Health and Human Services. Dr. Vanderwagen
was the senior Federal health official in response to Hurricane
Katrina and Rita. Welcome to you, Dr. Vanderwagen.
Our third witness is Dr. Michael Kurilla, Director of the
Office of Biodefense Research Affairs for the Institute of
Allergy and Infectious Diseases at the National Institutes of
Health; and also Dr. Daniel M. Sosin, Director of the
Biosurveillance Coordination Unit at the Centers for Disease
Control and Prevention for being here to answer questions in
regard to the Agency's efforts specifically and also Captain
Peter Boynton is here to answer questions as the Deputy
Regional PFO.
With that, without objection the witnesses' full statements
will be submitted for the record and I now ask each witness to
summarize their testimony for 5 minutes, beginning with Dr.
Runge, who as a courtesy will actually be given a couple extra
minutes since he's departing.
Welcome, Dr. Runge.
STATEMENT OF JEFFREY W. RUNGE, MD, ASSISTANT SECRETARY FOR
HEALTH AFFAIRS AND CHIEF MEDICAL OFFICER, DEPARTMENT OF
HOMELAND SECURITY
Dr. Runge. Mr. Chairman, thank you for the going-away
present. I want to thank you for the chance to be here with the
subcommittee, and I also want to thank Congressman Pascrell and
Dr. Christensen for making the trip. I'm a veteran of these
field hearings. I know it's not the easiest thing to be here
and you all have consistently demonstrated your interest and
passion on this issue and I want to thank you for being here.
Mr. Chairman, I also wanted to thank you publicly for all
that you have done to ensure the success of our new Office of
Health Affairs. You have sat through the classified briefings.
You have been a great partner with you and your staff and I
really appreciate your helping us accomplish what we have been
able to do.
As you and I have discussed, our efforts toward readying
our Nation for widespread disease outbreaks are not centered
solely around pandemic influenza, but on the broader threat.
Fortunately today on the panel are the Nation's preeminent
experts on pandemic management, so I'm not going to dwell on
that topic. We'll take a slightly different tack on emerging
infectious diseases by discussing the intentional use of
biological agents against our Nation.
The multi-use biological preparedness planning that we've
been doing in preparation for a pandemic will pay off
regardless of whether an attack is naturally occurring or a
terrorist attack. But it's the intentional use of biological
agents by a terrorist or terrorist group that keeps me up at
night. I'd ask the subcommittee to consider first the current
biological threat environment and the effect that a biological
attack might have in a mid-size city like Providence, Rhode
Island; second, the need for effective biosurveillance and
environmental detection; and third, the roles and
responsibilities of Federal, State, and local governments and
the private sector and the public down to the family level in
responding to and recovering from a biological attack.
Now this discussion is not to cause fear and we're not
fear-mongering here. Rather, making the public aware of and
prepared for such an event creates, in our view, a more
resilient community. By reducing the elements of surprise and
creating a culture of readiness, we can eliminate the terror
associated with such a horrific event and make the public's
reaction a key part of the solution to a successful response,
rather than part of the problem.
So what is the risk? We believe that a large-scale,
biological attack on the Nation is significant. We know that
terrorists have sought to use biological agents as instruments
of warfare and we are searching for better assessments of their
capability. Our intelligence sources have determined that in
the late 1990's, al Qaeda began developing a biological weapons
program for anthrax production. Fortunately, this facility was
disrupted by our military during Operating Enduring Freedom,
but the intent to use biological agents as a weapon of mass
destruction has not gone away.
You may recall that in 2002 al Qaeda stated that they had
the right to kill 4 million Americans, 2 million of them
children. An advisor to bin Laden later increased that number
to 10 million. There are not many weapons that can kill
millions of people, but it can come close if one considers a
coordinated attack on multiple cities. This should not be
confused with the type of anthrax attack that occurred through
the mail in 2001 which killed five people and injured three
times that many. Even though it cost disruption to the Postal
Service's building in Washington and elsewhere, it had an
economic impact in the billions.
The magnitude in both lives and economic effects is very,
very small when compared to the scenario of an aerosolized
anthrax attack envisioned by our enemies. It is that threat
which we vigorously plan on, invest in, and intend to defeat.
We cannot depend strictly on receiving action or specific
warning of an imminent biological attack which is why it is
imperative that we continue to enhance our Nation's efforts to
provide the earliest possible detection and warning immediately
after an attack, to strengthen our preparedness and response
efforts and to increase our capacity to recovery, physically,
psychologically, and environmentally.
While it may be easy to assume that terrorists are only
interested in striking major cities like Washington, DC or New
York City, we cannot ignore the attractiveness of softer
targets to our enemies. No one can forget that Oklahoma City
experienced the horrors of terrorism when a truck bomb was
detonated in the Murrah Federal Building killing 168 people
including 19 children, and injuring hundreds more. Who would
have thought that Oklahoma City would have been a target for
terrorism? Is it therefore imperative that every State and
every local jurisdiction be adequately prepared to handle
catastrophic events across the threat spectrum.
The city of Providence, Mr. Chairman, like many mid-sized
cities has a number of characteristics that make it and many
cities like it a potentially attractive target, proximity to
military assets, concentrated population, and a vital
transportation route along the East Coast. Without an
environmental detection system in place, an aerosolized anthrax
would not necessarily be detected in time for HHS and local
health providers to provide prophylactic antibiotics. Clinical
symptoms of inhalational anthrax would appear after 2 to 6 days
following the release. But the earliest clinical cases would be
harbingers of tens of thousands or more, nearly all requiring
intensive care in medical facilities including ventilatory
support and whatever anthrax countermeasures we have in the
national stockpile. But by then the die is cast. We predict
that if an attack of a plausible magnitude were directed at
Providence, the number around 180,000 people would be exposed
to a sufficient dose of anthrax spores to make them ill and we
would expect about 90 percent of those to die without
aggressive treatment which in those numbers may simply not be
available.
We can reduce the numbers of people who would die only by
ensuring that affected people receive treatment before they
show symptoms. This requires an environmental warning system.
Moreover, without detection devices to characterize the area of
exposure, I'm very concerned about managing the immediate
aftermath with respect to giving valid information to the
public about the extent of the release and the maintenance of
public confidence.
Mr. Chairman, the response to such an attack would be a
monumental effort requiring seamless cooperation and
coordination at all levels of government. That's why Congress
created DHS. We do not provide the health care or the medical
countermeasures. HHS does that. We do not catch the bad guys.
FBI and local law enforcement does that. We don't clean the
environment. EPA does that. We do not manage the international
ramifications of such an attack. The Department of State does
that.
We do, however, Mr. Chairman, have the responsibility for
coordination of all of those efforts and for several programs
that are multi-agency and are under your oversight
jurisdiction. They are crucial and in need of the support of
the subcommittee.
While we're continuing to make significant strikes in our
BioWatch Program which provides that early and necessary
detection of biological attack, we are quickly moving toward
the next generation of detectors that will significantly reduce
that time to allow our health providers to get countermeasures
into the hands of the affected populations within the time
window to save lives. However, we need the funding to continue
this vital progress.
We are also developing the National Biosurveillance
Integration Center known as NBIC, authorized in the 9/11 Act,
which brings together data from other Federal departments, the
public domain and eventually the private sector in State and
local governments to understand and characterize biological
events and incidents across the areas of human health, animal
health, food, water, and the environment.
Mr. Chairman, I have a number of recommendations for the
subcommittee to consider which I put into my written testimony
and I will enumerate here.
Again, I sincerely appreciate your personal dedication
toward the security of the Nation. It has been a real pleasure
working with you, with Dr. George, with Chris Beck and others
on the committee staff during my time at DHS. I think I have
created an office that is completely ready for the transition.
I'm the only political in the office in the programmatic area
and I think we're ready. I would ask for the subcommittee's
continued support of my career staff in the office.
Thank you, Mr. Chairman.
[The statement of Dr. Runge follows:]
Prepared Statement of Jeffrey W. Runge
July 22, 2008
INTRODUCTION
Good morning Mr. Chairman. Thank you for the opportunity to testify
before the subcommittee on this important and timely issue. My
colleagues and I have testified before your subcommittee on several
occasions on this topic, and I appreciate your continued interest in
ensuring that an outbreak of a disease, intentional or natural in
origin, does not threaten our homeland security, economic stability,
and our Nation's critical infrastructures and key resources. I am thus
pleased to have the opportunity to share our views with you and your
constituents through this hearing in Providence, RI.
As you know, Mr. Chairman, this is one of the last events where I
will appear as the Assistant Secretary for Health Affairs and Chief
Medical Officer of the Department of Homeland Security (DHS), as I will
be leaving Federal service at the beginning of August. I delayed the
timing of my departure in order to testify once again to the urgency
and importance of giving sufficient attention to biological threats to
our Nation. At this, my last hearing, I would like to take this
opportunity to thank you personally for all that you have done to
ensure the success of the Office of Health Affairs and our mission to
make the Nation safer and more secure.
Today I will discuss a number of important issues surrounding
emerging biological threats and our Nation's preparedness, including:
the current biological threat environment as illustrated by the effect
a biological attack might have in a city like Providence, our approach
to biosurveillance and environmental detection, and the roles and
responsibilities of Federal, State, local and the private sector in
response to and recovery from a biological attack. Providing this
information to the public creates a more resilient public. By reducing
the elements of surprise, fear and panic, we can reduce the terror
associated with such an event, making the public reaction a key part of
the solution rather than the problem.
CURRENT BIOLOGICAL THREAT
The risk of a large-scale biological attack on the Nation is
significant. We know that our terrorist enemies have sought to use
biological agents as instruments of their warfare, and we believe that
capability is within their reach.
I know many here today recall the anthrax attacks of 2001. As you
know, Mr. Chairman, certain buildings occupied by Members of the
Legislative branch were temporarily closed while they were
decontaminated. The magnitude of that terrorist attack is miniscule
compared to the larger, anthrax release envisioned by our enemies. It
is nonetheless exemplary of the potential health and economic damage to
which we are vulnerable. Unfortunately, the threat has not diminished
since then--in fact, it has been building since well before the attacks
of 9/11.
We know that, in the late 1990's, al Qaeda began developing a
biological weapons program and constructed a low-tech facility in
Qandahar, Afghanistan for anthrax production. Fortunately, U.S.
military forces disrupted this activity and additional American and
coalition operations in the region have damaged al Qaeda leadership and
operational capabilities--but not their intent to use biological
weapons. You will recall that in 2002, al Qaeda stated that they had
the right to kill 4 million Americans--2 million of them children--and
cripple thousands. An advisor to bin Laden later issued a fatwa on the
permissibility of using weapons of mass destruction and increased the 4
million casualty figure to 10 million.
We have determined that al Qaeda seeks to develop and use a
biological weapon to cause mass casualties in an attack on the
homeland. Our analysis indicates that anthrax is a likely choice; and a
successful single-city attack on an unprepared population could kill
hundreds of thousands of citizens. A coordinated attack on multiple
targets would come much closer in magnitude to our enemy's goal.
Because of this, we see the threat of an aerosolized anthrax attack as
our No. 1 bioterrorism concern, and it is that threat which we
vigorously plan, invest and intend to defeat. Our efforts are not
optional or discretionary. The ramifications of such an attack include
tremendous loss of life, economic costs, damage to critical
infrastructure, and unprecedented environmental contamination.
A biological attack would impact every sector of our society--not
just the medical and public health communities. A biological attack
respects no geographic or geopolitical boundary and will have an impact
well beyond our Nation's emergency departments and public health
infrastructure. Absenteeism across multiple sectors due to illness,
fear of contagion, or public health measures could threaten the
function of critical infrastructure, the movement of goods and
services, and the operation of our institutions. No Federal department
or agency will be exempt from the consequences of such an attack.
Further, critical life-saving activities will depend on actions taken
in the first few moments of the event. State and local governments will
be called on to take several critical actions--alerting the public of
the crisis without inciting panic; maintaining public confidence while
making critical decisions; and bolstering local communities to rebound
quickly.
As we work together to counter this threat, we must keep in mind
that acts of biological terrorism don't go ``bang.'' It could be hours
or even days before we realize the full extent of an incident. Because
of the lack of an explosion or immediate visual damage, many do not
perceive the threat of bioterrorism to be as significant as that of a
nuclear or conventional strike, even though such an attack could kill
as many people as a nuclear detonation and have its own long-term
environmental effects. This has caused a lack of public urgency in
devoting significant resources to countering this threat--a luxury we
simply cannot afford.
Mr. Chairman, many people ask me ``what keeps you up at night?'' It
is the possibility of a large-scale biological attack on our homeland.
THREAT AWARENESS
Given the challenges we face in assessing current terrorist
capabilities and identifying plots, it is unlikely that we will receive
actionable or specific warning of an imminent biological attack.
Furthermore, many of these deadly biological agents, including anthrax,
are readily available in nature, relatively easy to procure, culture,
and weaponize. There are numerous domestic and international biological
research programs using these agents for legitimate purposes, making it
more difficult to separate the ill-intentioned research initiatives. As
a result, it is unlikely that we will have credible knowledge of an
imminent biological threat before it occurs.
This is why it is imperative that we continue to enhance our
Nation's efforts to disrupt biological plots, provide the earliest
possible detection and warning of an attack, strengthen our
preparedness and response efforts, and increase our capacity to quickly
recover.
Secretary Chertoff and I have been promoting the inclusion of
health and medical expertise in our State and local fusion centers as
they develop and expand. OHA is working with the DHS Office of
Intelligence and Analysis to provide information on biological threats
to communities in harm's way and to encourage fusion centers to tap
into local expertise in public health and health care to be a part of
their information fusion. We have begun discussions with the HHS
Assistant Secretary for Health regarding the incorporation of officers
from the corps of the U.S. Public Health Service to help communities
achieve this capability. DHS will be holding meetings in the late
summer and early fall with States and local representatives with the
goal of providing information on the biological threat and discussing
the value of public health in fusion centers.
PROVIDENCE, RI
While it is easy for us to assume that terrorists are only
interested in striking major cities such as Washington, DC or New York
City, we cannot ignore the attractiveness of softer targets to our
enemies. On April 19, 1995 Oklahoma City experienced the horrors of
terrorism when a truck bomb was detonated in front of the Alfred P.
Murrah Federal Building, killing 168 people, including 19 children, and
injuring hundreds more. Who would have thought that Oklahoma City would
have been a target for terrorism? It is therefore imperative that all
States and local jurisdictions are adequately prepared to handle events
across the chemical, biological, radiological and nuclear spectrum, as
well as more conventional attacks or naturally occurring outbreaks.
The city of Providence, like many mid-size cities, has a number of
characteristics that make it potentially attractive as a target, such
as its proximity to military assets, major metropolitan areas, and an
important transportation routes. An aerosolized sprayer releasing air-
borne anthrax particles into the air throughout a city like Providence
would not necessarily be detected in the immediate aftermath of the
release. Clinical symptoms of inhalational anthrax would not be
discovered for at least 2 or 3 days after the attack occurred, yet the
health effects and environmental consequences could be catastrophic.
SURVEILLANCE AND DETECTION
It is critical to receive warning of a biological attack as soon as
it occurs and to identify the causative agent immediately. Such a
warning would enable the prevention of most cases of inhalational
anthrax, through the combined response of the CDC and its State and
local partners in distributing sufficient prophylactic antibiotics to
the public before the onset of disease. A delay of just 1 day in
detection of an anthrax release--and therefore treatment of affected
populations--would result in thousands of unnecessary deaths.
Sufficient early warning through environmental detection is one of
the Department's top priorities, one for which the Office of Health
Affairs, working with the Science and Technology Directorate (S&T), is
responsible. We are investing significant amounts of taxpayer resources
to our BioWatch program, which provides detection and warning of a
biological attack in our Nation's highest-risk urban areas through a
series of pathogen detectors. With S&T, we are developing the next
generation of detectors, known as Generation 3, which will be automated
and significantly reduce detection time to allow our health providers
to get countermeasures into the hands of affected populations within
the critical window of time to save lives.
Complementing our BioWatch capabilities is our establishment of a
robust biosurveillance integration center, where other departments and
agencies come together to monitor their biological data and analyze
potential biological threats. The National Biosurveillance Integration
Center (NBIC), authorized in the 9/11 Act (Pub. L. 110-53), will bring
together data from other Federal departments, the public domain and
eventually the private sector and States and local government to
understand and characterize biological events and incidents across the
areas of human health, animal health, food, water and the environment.
Through robust data analysis and integration across these sectors, we
aim to provide the earliest possible warning of outbreaks and threats
to human and veterinary health and the food and water supply. Over the
past several months, we have made great progress in our governance
structure. We now have all the relevant departments coming to an
``ownership meeting,'' which recognizes that DHS is the host for NBIC,
but the system belongs to every department across the Federal
Government that needs access to a bio-surveillance common operation
picture (BCOP). We are working very closely with the CDC as they
develop improved human health surveillance systems, which will be a
vital element of the Government's BCOP. It is in all of our interest to
ensure the success of our partner agencies' improvements in their data
systems.
FEDERAL, STATE AND LOCAL RESPONSE AND RECOVERY
If a large-scale biological attack occurred here in downtown
Providence using aerosolized anthrax, it would likely go undetected for
days, until large numbers of people begin showing up in emergency
departments and doctors' offices 2 to 5 days after the attack.
Unfortunately, most cases would progress quickly to a form of pneumonia
that is very resistant to treatment once it has started. The sentinel
cases would be those receiving the highest doses of anthrax spores, and
would be the harbinger of tens of thousands more, nearly all requiring
intensive medical care, including ventilatory support and the anthrax
countermeasures we have in the Strategic National Stockpile (SNS).
Federal, State and local law enforcement would seek to identify the
perpetrators to prevent subsequent attacks. Since we do not know the
extent of the exposure, Federal and local health officials would likely
mobilize the SNS for antibiotics to be given to the population as
environmental sensors and samples identify the affected areas. In such
a scenario, State and local resources, including medical assets, would
be taxed if not overwhelmed. Rather than a smoking building defining
the extent of the victims, every man, woman, and child in the area--and
every building and every farm in the plume--could be affected. This is
not a pretty picture, so preparedness is required to minimize the
impact.
In such a case, the Secretary of Homeland Security would stand up
all of the power and assets of Federal Government to manage the
incident. The Federal Emergency Management Agency (FEMA) would stand up
its National Resource Coordination Center to bring Federal assets to
bear. The responsibility for the public health and medical response
lies within the Department of Health and Human Services under the
Public Health Services Act and as the lead for Emergency Response
Function (ESF) 8: Public Health and Medical Response, with the
Assistant Secretary for Preparedness and Response (ASPR) as the HHS
Secretary's principal advisor and as the official responsible for
certain functions. In order to have the tools to execute its mission
successfully, HHS has invested thousands of hours and billions of
dollars to make sure we have the appropriate medical countermeasures to
deal with the threats to human health. This includes research and
development of new medicines, vaccines and anti-toxins, as well as
their stockpiling and distribution. DHS has been their advocate and
partner every step of the way.
Additionally, law enforcement and security measures are directed by
the Department of Justice as the lead for ESF-13: Public Safety and
Security; decontamination activities and environmental cleanup are
directed by the Environmental Protection Agency as the lead for ESF-10:
Oil and Hazardous Materials Response; and the terrorism crime scene
investigation, as well as attribution and characterization to prevent
second attacks are led by the Federal Bureau of Investigation. Our
success is dependent on their success, Mr. Chairman. I encourage you to
lend them your support in this effort, and encourage the support of
your congressional colleagues. While homeland security may not be the
primary mission of these agencies, their homeland security
responsibilities are crucial to our mission.
The Department of Homeland Security is charged with leading the
overall domestic incident management, including coordinating the
Federal response and integrating it with the State and local response
efforts. OHA leads the DHS biodefense activities, which includes
oversight and management responsibility for implementation for Homeland
Security Presidential Directive 10, Biodefense for the 21st Century,
although many other components and offices have major related
responsibilities. The DHS National Biodefense Analysis and
Countermeasures Center, a component of S&T, is responsible for the
bioforensics analysis, and working with I&A and law enforcement, to
determine the likely source of the germ. Our National Operations Center
(NOC) coordinates all of the Federal operations and monitors the
responses and requirements of local entities. DHS would quickly stand
up a Joint Information Center (JIC) with all the relevant departments
and agencies to ensure accuracy and timeliness of information to the
public. Under a Stafford Act declaration, FEMA coordinates Federal
assistance to requesting States. In accordance to the National Response
Framework and because a biological incident would likely be an
unusually complex incident requiring extraordinary coordination
Secretary Chertoff has named a pre-designated a Principal Federal
Official (PFO) to lead the response to a biological event. The PFO
would assist States, local and tribal governments by overseeing a
coordinated Federal response. A PFO is a senior Federal official with
proven management experience and strong leadership capabilities. Vice
Admiral Vivien Crea of the U.S. Coast Guard is our predesignated PFO
for biological events and provides excellent leadership and knowledge.
RECOMMENDATIONS
Mr. Chairman, I have a number of recommendations for the
subcommittee to consider to enhance the state of preparedness in the
event of a biological attack or natural outbreak.
1. Continue to support our development of next generation automated
detection technologies to reduce the time-to-detect to allow
the necessary time to deliver life-saving medical
countermeasures to the population. Because a biological attack
is so challenging to accurately predict, we must continue to
refine our early detection and warning capabilities. If our
partners at HHS are to deliver life-saving prophylactic
antibiotics, we must be able to detect a biological release
sooner. Our current detection equipment has a built-in delay of
up to 36 hours, which is not consistent with the requirements
of disease prophylaxis. Over time, we must seek to cover more
of our Nation's population with earlier environmental warning.
Such an expansion must be risk-based which takes into account
population density and critical infrastructures.
2. Continue to support the development of the National
Biosurveillance Integration Center (NBIC). It is the one place
where agencies can come together to share data across the
sectors of human health, animal health, food, water and the
environment. The center illustrates the very nature of DHS--to
integrate the assets and resources of sister Government
agencies in a protected, open environment for the purposes of
subject matter expertise and information sharing. The service
we must provide is a common operating picture for
decisionmakers before and during events to afford them the best
possible information upon which to make good decisions. The
oversight of NBIC belongs to the Committee on Homeland Security
in full view and participation of other congressional
committees and sister agencies.
3. Support the full integration of health expertise into
information fusion centers. While intended initially for law
enforcement, with the threats including biological and chemical
events, the expertise of the health community is needed in the
information fusion process. The assistance of HHS may be
available to assist local agencies where needed. DHS will work
with local health directors to ensure necessary security
clearances and information analysis training to ensure the
success of such participation.
4. Consolidate the committee's jurisdiction over issues of homeland
security. While DHS is by its authorization (Pub. L. 109-295) a
collaborative agency, so must Congress work collaboratively to
ensure a more secure homeland, empowering an effective yet
supportive oversight environment. As Secretary Chertoff has
mentioned on numerous occasions, the current threat environment
does not lend itself to jurisdictional disputes in Congress
over the Department's authorities and responsibilities.
Homeland Security is a team sport and we all should have the
common goal of a more secure Nation as our first priority.
CONCLUSION
The threat of bioterrorism against the United States remains a
significant concern. We continue to face an enemy determined to acquire
and develop biological agents into weapons of mass destruction against
the homeland. The Office of Health Affairs and the Department of
Homeland Security takes this threat very seriously and are doing
significant work to prevent, enhance early detection and surveillance
and integrate Federal, State and local preparedness and response
capabilities to reduce the catastrophic consequences of a biological
attack on the homeland.
Mr. Chairman, I sincerely appreciate your dedication and efforts to
enhance the security of the Nation. Thank you again for the opportunity
to testify. It has been a real pleasure working with you during my time
at the Department of Homeland Security. I have created an office that
is completely ready for the transition. I leave the office in the
experienced and capable hands of Dr. Jon R. Krohmer, the Principal
Deputy Assistant Secretary and Deputy Chief Medical Officer. I ask for
your support of Dr. Krohmer over the coming months, as he is eager to
work with you to better secure the homeland.
Mr. Langevin. Thank you, Dr. Runge. I appreciate your
testimony and for your service to our Nation. The Chair now
recognizes Admiral Vanderwagen to summarize your statement for
5 minutes.
Welcome, Dr. Vanderwagen.
STATEMENT OF REAR ADMIRAL W. CRAIG VANDERWAGEN, M.D., ASSISTANT
SECRETARY FOR PREPAREDNESS AND RESPONSE, DEPARTMENT OF HEALTH
AND HUMAN SERVICES; ACCOMPANIED BY MICHAEL G. KURILLA,
DIRECTOR, OFFICE OF BIODEFENSE RESEARCH AFFAIRS, AND ASSOCIATE
DIRECTOR FOR BIODEFENSE PRODUCT DEVELOPMENT, NATIONAL INSTITUTE
OF ALLERGY AND INFECTIOUS DISEASES, NATIONAL INSTITUTES OF
HEALTH; AND DANIEL M. SOSIN, DIRECTOR, BIOSURVEILLANCE
COORDINATION UNIT, AND ASSOCIATE DIRECTOR FOR SCIENCE,
COORDINATING OFFICE FOR TERRORISM PREPAREDNESS AND EMERGENCY
RESPONSE, CENTERS FOR DISEASE CONTROL AND PREVENTION
Dr. Vanderwagen. Thank you, sir. It's always nice to be in
Providence. I think the history and beauty of this place is
pretty remarkable. I've appreciated every opportunity I've had
to come and visit here.
I want to add then my piece to Jeff's overview because
really DHS has the overview on these issues. They provide us
with threat assessments that we analyze the public health
impacts of so that for anthrax, for instance, what is the real
public health impact that we would expect to have and what are
the tools that we have to address it?
These are the medical countermeasures that Jeff was
speaking to. This begins with the research pipeline and Mike
Kurilla here today I think can talk a little bit about the
research pipeline activities. What are we studying? What do we
know from the science that offers us an opportunity to develop
countermeasures?
Then we move to develop those ideas into a productive
product that can be utilized in a meaningful way to the
delivery platforms owned, operated, and managed in the local
environment.
Dan Sosin is going to be able to speak today to questions
you may about biosurveillance that are supportive to the
systems that Jeff described earlier. But our responsibility
runs from the development of those countermeasures to delivery
platforms at the community level to assure that those medical
countermeasures get to the people who need them.
As you suggested in your opening statement, Mr. Chairman,
we are much better prepared, however, we are not fully ready
and part of that is because we still exist in our operational
silos more than we reasonably should. That's not to say that
tremendous effort has not gone into the process of developing a
national response plan as opposed to a Federal, State, local
response plan, but there is more work to be done to synergize
and harmonize the planning from the Federal level through the
local level to assure that we have a national response plan as
opposed to a series of localized plans for action.
I think second there is much more work to do in the area of
bringing about public and private partnerships that is shared
responsibility that extends beyond the public sector, whether
that's State, local, or Federal and embraces the opportunity
for local, private sector entities to have an active role. This
is important as Jeff suggested because of the resiliency that
is built when you provide people with the opportunity to build
tools and activities that will lead to control in the face of
chaos in these kinds of events.
As Jeff has said and as you have alluded to in your opening
statement, Mr. Chairman, there's much focus on kinetic events,
IEDs, improvised nuclear devices, and there is no question that
these are threats that are significant and important. But it's
our belief that the biothreats have a much broader impact in
our society, both from a public health perspective and from the
wider intersectoral perspective in economics, in transportation
and energy, et cetera.
Therein lies another challenge that we have not fully
addressed and that is the broad multisectoral involvement. DHS
has done a great job in establishing the national response
framework and promoting and working forward with that, but
there continues to be challenges at the local and State level
in assuring that all the sectors are talking to each other.
I've traveled around the country significantly over the
last year and a half, much like Jeff, and one of the things
that I've observed is some places there is great intersectoral
cooperation, planning, action, exercise, et cetera, and that
has brought about meaningful best practices. But there are
other places where the guns and hoses don't talk to the health
people, don't talk to the banking people, et cetera. No blame
placing here. It's just a matter of the fact that people aren't
necessarily working in an intersectoral way to maximize their
local capability to respond.
Indeed, as Jeff has suggested, therein lies the resiliency
that will be needed when we face a significant event of the
kind of proportions that we're talking about here. The other
thing that's uniquely problematic with bio events is unlike an
IED or even an IND or a natural event like a hurricane, it is
not geographically and temporally limited. This is very
difficult because you're not sure exactly when it started, as
Jeff pointed out. The technical challenge there is a large one
and you're not exactly sure when it's going to end. Quite
commonly it will extend over a wide geographic area.
Again, this argues for the fact that we need to have broad,
intersectoral dialog, communication, planning, and activity. We
need greater investment in tool development, the advanced
development of some of these good research ideas is not
progressing as fast as it reasonably could. So we think there
are things ahead that will allow us to be beyond prepared and
begin to become ready in effect, as you suggested.
Thank you, Mr. Chairman, for the opportunity.
[The statement of Dr. Vanderwagen follows:]
Prepared Statement of W. Craig Vanderwagen
July 22, 2008
Good Morning Chairman Langevin, Mr. McCaul, and Members of the
committee. I am RADM W. Craig Vanderwagen, M.D., the Assistant
Secretary for Preparedness and Response (ASPR) at the U.S. Department
of Health and Human Services (HHS). I appreciate this opportunity to
discuss the HHS plans and initiatives in public health and emergency
preparedness to respond to emerging biological threats, including
pandemic influenza. HHS's Office of the ASPR has adopted an ``all-
hazards'' approach to our preparedness and response activities, moving
us from stand-alone plans to a process that addresses all of the
hazards that potentially threaten the public's health. We have
collaborated and coordinated closely with our Federal interagency
partners and have provided States and municipalities with funding to
enhance their public health and medical preparedness.
EMERGENCY PREPAREDNESS
Our ``all-hazards'' preparedness involves a shared responsibility
among our entire Department, our partners in the international
community, the Federal, State, local, tribal and territorial
governments, the private sector, and, ultimately, individuals and
families. Additionally, before an event, government agencies at all
levels work with the private sector to plan and exercise so they can be
ready when a disaster occurs. During an emergency, local and State
response agencies, including public health departments, are the first
to respond. For regional or severe emergencies, the Federal Government
may be asked to provide additional resources and coordinate response
efforts across multiple jurisdictions.
In that context, some of the emergency preparedness efforts
currently being led by HHS involve working with our Federal, State, and
local partners. For instance, we support State and local authorities
through the Hospital Preparedness Program and the Public Health
Emergency Preparedness Program for a broad range of medical and public
health preparedness activities, including the development of medical
and public health plans for response, increasing the number of
exercises to evaluate these plans, increasing the training
opportunities in key preparedness areas, increasing epidemiological and
laboratory detection capabilities, establishment of local stockpiles of
critical medical equipment and supplies, improving surveillance and
investigation capabilities, maintenance and distribution of
countermeasures, and sharing of resources.
EMERGENCY SUPPORT FUNCTION NO. 8--PUBLIC HEALTH AND MEDICAL SERVICES
The National Response Framework (NRF) Emergency Support Function
(ESF) No. 8--Public Health and Medical Services--provides the mechanism
for coordinated Federal assistance to supplement State, local, tribal,
and territorial resources in response to a public health and medical
disaster, potential or actual incidents requiring a coordinated Federal
response, and/or during a developing health and medical emergency. The
Secretary of HHS; here forth the Secretary, leads all Federal public
health and medical response to public health emergencies and incidents
covered by the NRF. The response addresses medical needs and other
functional needs of those requiring medical care and other assistance
during an emergency.
Except for the personnel and assets under the command of the
Department of Defense, the Secretary assumes operational control of
Federal emergency public health and medical response assets, as
necessary, in the event of a public health emergency. The Secretary,
through ASPR, coordinates National ESF No. 8 preparedness, response,
and recovery actions.
HHS has implemented an incident command system that is National
Incident Management System compliant. Additionally, all States have
established emergency operation centers and have also implemented an
incident command system. We have trained and equipped response
personnel who include not only the National Disaster Medical System
(NDMS) teams, but also Public Health Service Commissioned Corps
Officers.
The operational command of personnel deployed under our auspices is
fully consistent with and supportive of the Department of Homeland
Security's (DHS's) role as overall incident manager, including liaisons
in the National Operations Center, National Response Coordination
Center, and the Joint Field Office. The HHS recognizes and supports the
overall lead of DHS in coordinating the Federal response and we take
seriously our role as the lead Federal agency for Public Health and
Medical Services through ESF No. 8, of the NRF.
PANDEMIC AND ALL-HAZARDS PREPAREDNESS ACT (PAHPA)
Consistent with requirements contained in the Public Health Service
Act, as amended by the Pandemic and All-Hazards Preparedness Act
(PAHPA), HHS has updated the performance measures for both the Hospital
Preparedness Program and the Public Health Emergency Preparedness
Program. Specific improvements include greater clarity in language, the
use of definitions, and the addition of targets. For example, in fiscal
year 2006, HHS asked grantees to report participating hospitals'
ability to track bed status electronically, and report it to the
grantee's Emergency Operations Center within 60 minutes of a request.
In 2007, the numerator and denominator were defined to improve clarity.
For fiscal year 2008, the target percentage of hospitals able to report
was increased to 100 percent by the end of the end of the year.
HHS strongly supported the new accountability provisions included
in PAHPA and is implementing these provisions. First, fiscal year 2009
award funds will be based on the successful achievement of targets
during the previous budget cycle. In addition, the matching provision
will be applied to the Public Health Emergency Preparedness Program
(PHEP) in fiscal year 2009. We also intend, through notice and comment,
to apply the matching provision to the Hospital Preparedness Program
(HPP) in fiscal year 2009. The audit and carryover provisions apply to
both the PHEP and HPP programs currently; the withholding provision
will be applied to these programs in fiscal year 2009. The HPP and PHEP
programs implemented the maintenance of funding provision in fiscal
year 2007.
PUBLIC HEALTH EMERGENCY PREPAREDNESS (PHEP) PROGRAM
From fiscal year 2002-fiscal year 2008, the Public Health Emergency
Preparedness (PHEP) program has provided $6.3 billion to State, local,
tribal, and territorial public health departments. This amount includes
targeted supplements to prepare for smallpox (in fiscal year 2003) and
for an influenza pandemic (fiscal year 2005-fiscal year 2007). This
program has greatly increased the preparedness capabilities of public
health departments:
All States can receive and evaluate urgent disease reports
24/7, while in 1999 only 12 could do so.
All States now conduct year-round influenza surveillance.
The number of State and local public health laboratories
that can detect biological agents as members of CDC's
Laboratory Response Network (LRN) has increased to 110 in 2007,
from 83 in 2002. For chemical agents, the number increased to
47, from 0 in 2001. Rather than having to rely on confirmation
from laboratories at CDC, LRN laboratories can produce
conclusive results. This allows local authorities to respond
quickly to emergencies.
All States have trained public health staff roles and
responsibilities during an emergency as outlined in the
Incident Command System, while in 1999 only 14 did so.
All States routinely conduct exercises to test public health
departments' ability to respond to emergencies. Such exercises
were uncommon before PHEP funding.
HOSPITAL PREPAREDNESS PROGRAM (HPP)
We have made considerable investments in building the health care
preparedness and response capabilities required during an incident
resulting in mass casualties, and are committed to performance
measurement. Over the past 5 years, the Hospital Preparedness Program
(HPP) has provided more than $2.6 billion to fund the development of
medical surge capacity and capability at the State and local level. As
a result of HPP funds awarded to States and territories, hospitals and
other health care entities:
Increased their ability to provide needed beds during an
emergency;
Can now track bed and resource availability using electronic
systems;
Engaged with other responders through interoperable
communication systems;
Appropriately train their health care workers for all-
hazards approach to emergencies;
Protect their health care workers with proper equipment;
Have installed equipment necessary to decontaminate
patients;
Have developed fatality management and hospital evacuation
plans, and
Coordinate regional exercises.
REGIONAL EMERGENCY COORDINATION
HHS has worked diligently to partner with State, tribal,
territorial, and local officials to enhance their level of preparedness
and to ensure they can see how HHS will respond to disasters. Our
Regional Emergency Coordination/Coordinator (REC) program has been
enhanced. In the past year, we have increased the number of RECs from
10 to over 30. The REC's role is to work with the States and local
jurisdictions to coordinate and enhance preparedness within the region.
I have personally been to each of the 10 HHS regions to participate in
local exercises and meet with State and local health leadership to
discuss the level of preparedness and how HHS can support them.
U.S. PUBLIC HEALTH SERVICE, VOLUNTEER PERSONNEL
HHS has a number of resources that are rapidly available to deploy
in response to a biological event. The full-time U.S. Public Health
Service (USPHS) responders include the Rapid Deployment Force (RDF)
Teams, Applied Public Health Teams (APHT), Mental Health Teams (MHT)
and additional USPHS Officers. Volunteer health care professionals are
available through the Medical Reserve Corps, which has over 160,000
members in approximately 700 teams. The Emergency System for Advance
Registration of Volunteer Health Professionals (ESAR-VHP) ensures the
availability of volunteers for quick exchange between jurisdictions.
NATIONAL DISASTER MEDICAL SYSTEM
We are also continuously improving HHS's operational capabilities
to respond to emergencies. The NDMS, transferred from the Department of
Homeland Security to HHS, remains the ``tip of the spear'' as the
Federal disaster health care response capability, maintaining 6,200
medical and public health professionals and over 1,800 participating
hospitals that offer definitive care services, with approximately
34,000 available beds (at most recent count). NDMS field teams include
the Disaster Medical Assistance Teams (DMAT), Disaster Mortuary
Operational Response Teams (DMORT), National Medical Response Teams
(NMRT), and International Medical and Surgical Response Teams (IMSRT).
Since the transfer of NDMS last year, we have achieved a number of
accomplishments aimed at improving the system including the integration
of NDMS into the larger ESF No. 8 response framework and
regionalization of NDMS response operations and caches to provide
increased accountability and standardization for supplies as well as
fiscal savings. Future goals for NDMS include enhancing readiness and
accountability through regionalization of NDMS response operations and
enhancing equipment caches.
FEDERAL MEDICAL STATIONS
The HHS Federal Medical Station (FMS) is a deployable health care
platform that can provide non-acute hospital bed surge capacity and
special medical needs sheltering. A standard FMS can house
approximately 250 patients and is staffed by the Rapid Deployment Force
teams. The FMS are useful in care of patients with suspected or
confirmed exposure to biological threats, and who may require for
example, observation, limited definitive care, or primary care.
PLAYBOOKS
HHS prepares playbooks for the different scenarios of man-made and
natural disasters. For biological emergencies response there are
separate playbooks including anthrax, Clostridium botulinum, small pox,
and pandemic influenza. These playbooks are used by HHS during an event
and include sections for the:
Scenario;
Concept of operations, or CONOPs, for the response;
Action steps;
Briefing and decision papers; and
Essential elements of information.
The action steps are time-oriented, and include pre-event steps
should there be credible intelligence that the risk of an event is
high. The action steps are arranged into natural stages for a response
and include a trigger for each stage, a recommended strategy to follow,
and specific actions to take.
ASPR has written and exercised playbooks based on 11 of the 15
national exercise scenarios. The process of developing these playbooks
provides opportunities for input from our ESF No. 8 Federal partners.
Additionally, HHS playbooks, starting with the hurricane playbook, will
be placed on the HHS web site to facilitate their examination and use
by State, local, tribal, and territorial, officials. We will make
additional playbooks available as they become ready for release.
THE MEDICAL RESPONSE SYSTEM FOR TRIAGE, TRANSPORT, TREATMENT
HHS has developed a response system called the TR system for
Treatment, Triage and Transport in an event, that takes into account
the factors and character of the agent or threat, in determining
medical response. The triage of individuals will be based on medical
evaluation including where they were during and shortly after the event
with particular attention to special needs that they may have. The
initial triage will attempt to separate people into three broad
categories:
those needing immediate medical attention, which would
include those with clinical effects of known exposure to a
biological agent or highly suspect exposure risk;
those without clinical effects to the biological agent but
at risk from potential exposure (due to location, etc.);
those with minimal or no likelihood of exposure and no
clinical effects from the biological agent, who do not require
immediate medical care.
MEDMAP
HHS is developing an interactive geographic information system
(GIS)-based mapping system, called MedMap, which will include data for
resources in a response to any type of hazard such as potential medical
care sites and assembly centers in the United States, evacuation
routes, hazards, etc. so that up-to-date information will be
immediately available by which to organize the response. Determining
which local medical care and assembly center facilities are functional
or not in the exposure area is essential, as is having information on
what regional and Nation-wide resources are available.
RESPONSE OPERATIONS
HHS maintains an operations center 24/7/365. The Secretary's
Operations Center (SOC) is directly connected to the DHS National
Operations Center and the FEMA National Response Operations Center. It
serves as the focal point for situational awareness, information
management and response coordination for HHS. We have established
relationships with subject matter experts from within HHS Operating and
Staff Divisions such as NIH, CDC, FDA, and ASPR.
HOMELAND SECURITY PRESIDENTIAL DIRECTIVE NO. 18
In January, 2007 the President issued Homeland Security
Presidential Directive (HSPD) No. 18, which directed the Secretary and
the Federal Government in development and acquisition of medical
countermeasures for weapons of mass destruction. The HSPD-18 builds on
the National Strategy to Combat Weapons of Mass Destruction and
Biodefense for the 21st Century by focusing on medical countermeasure
research, development, and acquisition efforts. The HSPD-18 objectives
for countermeasure include: (1) Identification of target threats with
potential for catastrophic impact on public health and able to be
mitigated; (2) yielding rapidly deployable and flexible capabilities to
address threats; (3) integration with WMD consequence management
through risk assessments of threats, vulnerabilities, and capabilities;
and (4) development of realistic, effective concepts of response for an
attack. With this in mind, the research, development, acquisition of
medical countermeasures is driven by principles that focus on: (1)
Current and anticipated threat agents with greatest potential for use,
and catastrophic consequences; (2) greatest potential to prevent,
treat, and mitigate WMD threats; and (3) integration with effective
deployment strategies supportable by realistic current or future
operational and logistical capabilities.
The biological threats focus of HSPD-18 addresses four distinct
categories which present unique challenges and significant
opportunities for development of medical countermeasures.
(1) Traditional agents are naturally occurring microorganisms or
toxins with the potential to be disseminated to cause mass
casualties. Such agents include Yersinia pestis, plague; and
Bacillus anthracis, anthrax.
(2) Enhanced Agents are modified or selected traditional agents
that enhance their ability to cause mass casualties. Such
agents would include antibiotic resistant organisms that as
such, circumvent medical countermeasures.
(3) Emerging Agents are pathogens that previously did not pose a
recognizable risk to human populations, but are now identified
to pose this risk, such as Severe Acute Respiratory Syndrome
(SARS).
(4) Advanced Agents are novel pathogens or biomolecules that have
been artificially engineered, and can circumvent current
medical countermeasures to produce a more severe or enhanced
spectrum of disease. In a way, genetically engineered smallpox
strains could fit under this guise, as would engineered Ebola
strains.
The HSPD-18 authorizes the Secretary to lead Federal Government
efforts to research, develop, and acquire medical countermeasures via
establishment of an interagency committee to provide advice in setting
medical countermeasure requirements, research, development, and
procurement activities; and establishment of a strategic planning
initiative to integrate requirements, development and acquisition of
countermeasures across the full range of research and life cycle
development. The Public Health Emergency Medical Countermeasures
Enterprise (PHEMCE) and the PHEMCE Strategy and Implementation Plan for
CBRN Threats address these directives respectively.
MEDICAL COUNTERMEASURES
Biomedical Advanced Research and Development Authority--Development and
Acquisition
Our progress in securing medical countermeasures begins with and
depends on effective planning. The central framework for medical
countermeasures planning and implementation in the Federal Government
is the HHS PHEMCE, established in July 2006. This coordinated
interagency group is led by the ASPR, and includes the Centers for
Disease Control and Prevention (CDC), the Food and Drug Administration
(FDA), and the National Institutes of Health (NIH) as well as our
partners from the Department of Defense (DOD), DHS, and Department of
Veterans Affairs (VA). Through this Enterprise-wide effort, we are able
to ensure that Federal activities with respect to needed medical
countermeasures are effectively coordinated from research and
development to acquisition and ultimately deployment. This supports a
range of programs that I will briefly summarize for developing and
acquiring medical countermeasures for man-made and naturally occurring
public health threats while building domestic manufacturing
infrastructure.
HHS established the Biomedical Advanced Research and Development
Authority (BARDA) to direct and coordinate the Department's
countermeasure and product advanced research and development
activities. In support of the mission and priorities of PHEMCE, BARDA
establishes systems that encourage and facilitate the development and
acquisition of medical countermeasures such as vaccines, therapeutics,
and diagnostics, as well as innovative approaches to meet the threat of
chemical, biological, radiological and nuclear (CBRN) agents and
emerging infectious diseases, including pandemic influenza. The BARDA
provides an integrated, systematic approach to the development and
purchase of the necessary vaccines, drugs, therapies and diagnostic
tools for public health emergencies. It directs and coordinates the
Department's countermeasure and product advanced development activities
and medical countermeasure domestic manufacturing infrastructure
building, including strategic planning for medical countermeasure
research, development, and procurement. This coordinated approach is
critical to achieving success in the area of bioterrorism preparedness.
Anthrax.--Anthrax remains a top priority for ongoing public health
emergency preparedness efforts at HHS. The Department is committed to
developing and acquiring a robust, comprehensive portfolio of medical
countermeasures against this threat. Antibiotics represent the first
line of defense to protect the Nation following an anthrax attack.
Today, we have over 60 million courses of antibiotics on hand and on
order for the Strategic National Stockpile (SNS). Anthrax vaccines are
also an essential element of our national preparedness. It is possible
that vaccines given as post-exposure prophylaxis in combination with
antibiotics could provide longer-term protection, or allow for a
reduction in the duration of the antibiotic regimen. HHS has awarded
contracts for the acquisition of nearly 30 million doses of anthrax
vaccine since 2005, including the recent contract award of 18.75
million doses of Anthrax Vaccine Adsorbed (AVA, BioThraxTM)
in partnership with the DoD. In addition, antitoxins are necessary to
treat individuals with advanced stages of infection, and may contribute
to a more successful therapeutic outcome. Beginning in 2007, HHS has
awarded contracts to two manufacturers to deliver antitoxins sufficient
for treating 30,000 people. These vaccine and antitoxin contracts were
awarded under the authorities of the Project BioShield Act of 2004. In
addition, three BARDA contracts for the advanced development of other
anthrax therapeutic candidates were recently awarded through a
partnership with the NIH/National Institute of Allergy and Infectious
Diseases (NIAID).
HHS remains committed to the development and acquisition of a
second generation anthrax vaccine. While procuring and continuing to
improve the currently available anthrax vaccine, HHS is investing over
$40 million in the continued development of a recombinant anthrax
vaccine. This investment builds on the recombinant vaccine program that
has been ongoing at the NIAID since 2002. BARDA also released a Request
for Proposals (RFP) in March 2008 for a recombinant anthrax vaccine
contract award. In addition, BARDA and NIAID released a Broad Agency
Announcement in September 2007 for vaccine enhancement that will
support important improvements in storage conditions and administration
for vaccines against a wide array of biological threats; these
proposals are currently under USG review.
Smallpox virus.--In June 2007, BARDA awarded a contract for a next
generation modified vaccinia Ankara (MVA) smallpox vaccine for use in
immune-compromised Americans. This was the first BARDA contract to
utilize performance-based milestone payments allowable under the
Pandemic and All Hazards Preparedness Act (PAHPA). HHS/CDC has also
procured ACAM-2000, a live, single-dose smallpox vaccine developed by
Acambis, which is the first new bio-defense vaccine to be approved by
the FDA.
Botulinum toxin.--In June 2006, HHS awarded a contract under
Project BioShield to the Cangene Corporation for 200,000 doses of a
botulinum antitoxin that targets all 7 serotypes of Clostridium
botulinum. The $363 million contract will expand greatly our existing
stockpiles in the SNS. Deliveries of this product to the SNS initiated
in 2007.
Pandemic influenza.--The pandemic influenza program is focused on
vaccines, antivirals, diagnostics, and non-pharmaceutical
countermeasures. In December 2005, and June 2006, Congress appropriated
$5.6 billion for HHS pandemic influenza preparedness efforts. With
these funds, scientists and public health experts at HHS have built an
aggressive and broad-based medical countermeasures program for pandemic
influenza. These funds support the acquisition of existing products,
advanced development projects to produce modernized and next-generation
countermeasures, and the retrofitting and construction of the
facilities necessary to produce pandemic influenza vaccines.
With respect to vaccines, HHS has a number of efforts underway.
These efforts supported the first U.S. licensure of an H5N1 vaccine in
April 2007, which was highlighted as the No. 1 medical breakthrough of
2007. By the end of 2007, HHS in coordination with DoD had stockpiled
12 million courses of pre-pandemic H5N1. However, maintaining a
domestic production capability for these priority countermeasures is
also an essential component of the pandemic influenza preparedness
strategy. In May 2006, HHS awarded five contracts for over $1 billion
to GlaxoSmithKline, MedImmune, Novartis (formerly Chiron), Solvay, and
Dynport (with Baxter) for support of advanced development of cell-based
influenza vaccines toward U.S. licensure and expanded domestic vaccine
manufacturing surge capacity. In June 2007, we awarded two contracts
for the retrofitting of existing domestic biological manufacturing
facilities to produce egg-based influenza vaccines and included warm
base operations for up to 5 years. Additionally, contract awards are
expected in 2008 for the construction of new domestic facilities for
manufacturing cell-based influenza vaccines that is expected to
quadruple the domestic pandemic vaccine manufacturing surge capacity by
2012.
A robust and groundbreaking advanced development program has led to
the rapid maturation of modernized cell-based influenza vaccine
production and antigen-sparing technologies. New combinations of
adjuvants and products provided by multiple manufacturers are currently
supported by performance-driven milestone contracts. More rapid vaccine
production may be afforded by the development of next generation
recombinant influenza vaccines, which HHS will support.
Antiviral drugs have become an increasingly important medical
countermeasure for influenza. Today, in coordination with DoD and VA,
the SNS contains 50 million treatment courses of antiviral drugs,
completing the Federal stockpile 1 year ahead of schedule. HHS has also
supported antiviral stockpiling at the State level. Through a federally
subsidized program, States have purchased 22 million treatment courses
of influenza antiviral drugs to date and are expected to reach our goal
of 31 million courses by the end of 2008.
The nature of severe influenza infections has also required us to
focus on preparedness through non-pharmaceutical countermeasures, such
as ventilators which play an essential role in the health care of
critically ill patients. The fiscal year 2009 President's budget
includes $25 million to develop ventilators that are more amenable to
public health emergency use. This presents a prime example of the
integrative, all-hazards approach that the PHEMC Enterprise seeks. A
more portable and easier to use ventilator could be an essential tool
for responding to many different public health threats, when having a
sufficient supply of ventilators could have an impact on the morbidity
and mortality of exposure.
MEDICAL COUNTERMEASURES
Strategic National Stockpile--Distribution and Dispensing
The Division of Strategic National Stockpile (DSNS) at CDC can
deploy medical countermeasures rapidly after notification to do so. In
addition to medical countermeasures that can be tailored to meet the
event's specific needs, the DSNS inventory contains supplies and
materiel required in the medical management of burns, trauma, injuries
that may be seen in conjunction with explosive threats.
The collaborative arrangements DSNS has with a variety of agencies,
corporations, companies, and organizations are essential to not only
increase the ability of State and local public health agencies to
dispense medical countermeasures in a timely manner but also are
critical to identifying and overcoming many of the inherent challenges.
The broadness of the partnership is vital in that each of the
participants brings not only a different perspective to the challenges
but also expands the possibilities for finding answers to breach
obstacles and barriers. Developing partnerships with private and public
sector agencies to sponsor closed points of dispensing (PODs) is
necessary to alleviate the burden on PODs for the general public.
Lightening the load on these general public PODs reduces many of the
challenges faced by local health agencies, i.e., staffing, security.
These partnerships also reflect the directives within HSPD-21 and PAHPA
to cultivate, enhance, and maintain interagency collaboration.
An example of this collaborative partnership is demonstrated as
CDC/COTPER work with the Business Executives for National Security
(BENS) to promote the involvement of private corporations in
preparedness planning and response. BENS is working with the State of
Georgia and Los Angeles County to establish a model system, to
hopefully be duplicated nationally, of corporate points of dispensing.
This pilot initiative is funded through the CDC PHEP Cooperative
Agreement. BENS officials presented and networked with State and local
planners at all four regional Cities Readiness Initiative workshops.
HOMELAND SECURITY PRESIDENTIAL DIRECTIVE NO. 21
On October 18, 2007 President Bush signed HSPD No. 21, ``Public
Health and Medical Preparedness,'' establishing a new National Strategy
for Public Health and Medical Preparedness (the Strategy).
As directed by HSPD-21, HHS has been successful in establishing two
advisory committees. The National Biosurveillance Advisory Committee
has been established as a subcommittee to the CDC Advisory Committee to
the Director (ACD) and a Disaster Mental Health Advisory Committee is
being established as a subcommittee under the National Biodefense
Science Board (NBSB) which advises the Secretary. Additionally, HHS
leads the development of a national strategy on biosurveillance through
CDC's efforts and creation of the Biosurveillance Coordination Unit
charged with coordinating the necessary activities to address the
mandates of HSPD-21 in the development of a strategy and implementation
plan for the Nation's next-generation biosurveillance capability.
Under the leadership of CDC, the HSPD-21 requirement to ensure the
adequate flow of information before, during, and after an event,
including critical biosurveillance data and risk analysis has quickly
drafted a strategic plan of national scope. Planning is being
undertaken using a broad collaborative approach that will increase
stakeholder buy-in, assure effective implementation, and guide the
strategic allocation of resources.
Also delegated to CDC leadership, HSPD-21 requirements pertaining
to 48-hour post attack countermeasure distribution are being addressed
through the strategic development of new models of distribution and
dispensing of medical countermeasures that would enhance and improve
the existing capabilities of the DSNS and its State and city partners.
New models can incorporate other partners into a national network,
including the CDC Laboratory Network, Department of Veterans Affairs,
businesses, and hospital and pharmaceutical distribution systems.
Tasked to DHS leadership, HSPD-21 requirements for health risk and
threat briefings to non-health political leaders at the State and city
level are being met with active involvement of HHS health experts.
Finally, HHS is implementing HSPD-21 through the establishment of
the Emergency Care Coordination Center (ECCC). This new center, an
intradepartmental and interdepartmental collaborative effort involving
the DOD, DHS, Department of Transportation and VA, will serve as the
coordinating focal point for an Emergency Care Enterprise, coordinating
with the Federal Interagency Committee on Emergency Medical Services.
Its vision is exceptional daily emergency care for all persons of the
United States and its mission is to promote Federal, State, local,
tribal and private sector collaboration to support and enhance the
Nation's emergency medical care.
The ECCC will assist the U.S. Government with policy implementation
and guidance on daily emergency care issues and promote both clinical
and systems-based research. Through these efforts, ASPR and its Federal
partners will improve the effectiveness of pre-hospital and hospital-
based emergency care by leveraging research outcomes, private sector
findings and best practices. The ECCC will promote improved daily
emergency care capabilities to improve resiliency of our local
community health care systems. This will provide a stronger foundation
on which to advance disaster preparedness efforts and strengthen our
Nation's ability to respond to mass casualty events. Currently, the
ECCC Charter is being finalized and we anticipate having the center up
and running by the end of the year.
GLOBAL HEALTH COORDINATION
In addition to these domestic efforts, other approaches to
improving our national capabilities include partnering with allied
nations. At the recent Global Health Security Action Group ministerial
meeting, there was some consideration paid to the possibility of
establishing international laboratory networks among the member
nations. Links with Canada would be particularly useful given the
geographic proximity. Informal discussions among the scientists and
subject matter experts have been ongoing for a few years but no formal
arrangements have been made. We continue to explore possibilities that
serve the national interest.
CONCLUSION
HHS staff work diligently to progress and expand the initiatives in
public health and emergency preparedness for emerging biological
threats. We continue to assess potential biological threats in the
context of an all hazards approach, and compare the plans and programs
available to us for mitigating these threats to ensure we are focused
on the right initiatives. Through cooperation with our Federal
partners, and State, local, tribal, and territorial governments, we
have implemented a number of preparedness programs and assets that have
strengthened our ability to respond to a biological event.
Thank you for your time and interest. I am happy to answer any
questions.
Mr. Langevin. Thank you, Dr. Vanderwagen, thank you for
your testimony.
I now recognize Captain Peter Boynton, the Deputy PFO for
Pandemic Influenza and Federal Security Director for Bradley
Airport in Connecticut. He's standing in today for the Regional
PFO, Admiral George Naccara.
Captain Boynton, welcome and thank you for being here.
STATEMENT OF CAPTAIN PETER BOYNTON, DEPUTY REGIONAL PFO FOR
PANDEMIC INFLUENZA AND FEDERAL SECURITY DIRECTOR, BRADLEY
INTERNATIONAL AIRPORT (CONNECTICUT), TRANSPORTATION SAFETY
ADMINISTRATION, DEPARTMENT OF HOMELAND SECURITY
Capt. Boynton. Thank you, and good morning, Mr. Chairman,
and Members of the subcommittee. Thanks for the opportunity to
testify before the committee to discuss the Department of
Homeland Security's role in pandemic influenza outbreak.
I am Peter Boynton. I currently serve as the Federal
Security Director for the Transportation Security
Administration in Connecticut. I am also the Deputy Regional
Principal Federal Official for the Northeast Region in the
event of a pandemic or biological event.
I am here today on behalf of the Regional Principal Federal
Official, George Naccara, who was predesignated by Secretary
Chertoff in December 2006 to serve as the Regional PFO for
these issues. Region A encompasses both FEMA Regions 1 and 2
which is all of New England, the States of New York, New
Jersey, Puerto Rico and the U.S. Virgin Islands.
Based on projections from prior pandemics, an influenza
pandemic could result in 200,000 to 2 million deaths in the
United States, depending on its severity. Further, an influenza
pandemic could have major impacts on society and the economy,
including our Nation's critical infrastructure and key
resources as many of our Nation's work force could be absent
for an extended period of time either sick themselves or caring
for loved ones at home.
Under the Homeland Security Presidential Directive 5, in
order to prevent, prepare for, respond to and recover from
terrorist attacks, major disasters, and other emergencies, the
U.S. Government has established a single comprehensive approach
to domestic incident management with the Secretary of Homeland
Security designated as the Principal Federal Official for
domestic incident management.
Understanding the complex effects resulting from a
pandemic, in December 2006, the Secretary predesignated Vice
Admiral Vivien Crea, Vice Commandant of the U.S. Coast Guard,
as the National Principal Federal Official, and five Regional
Principal Federal Officials to assist States, local and tribal
governments by overseeing a coordinated Federal response. Five
``pandemic'' regions were established by the Secretary in order
to create a manageable span of control. Each region consists of
two FEMA regions combined into one ``pandemic'' region. In
March 2008, the Secretary issued an updated pre-designation of
PFOs letter to the States and to each Federal department and
agency. This letter expanded the role of the Principal Federal
Official for pandemic influenza to include other similar
Nation-wide biological events. Also, with the anticipation that
Joint Field Offices in each of the standard Federal regions
would be established in a pandemic or other similar Nation-wide
biological event, the Secretary also predesignated two Deputy
Regional Principal Federal Officials to assist of the five
Regional Principal Federal Officials.
The Principal Federal Officials serve as the Secretary's
representatives to ensure consistency of Federal support as
well as the overall effectiveness of the Federal incident
management. It is important to note that PFOs may be utilized
in situations covering the full spectrum of homeland security
operations, preventing, protecting, responding, and recovering
from major disasters or terrorist attacks. The Secretary
activates PFOs for the most complex and catastrophic terrorist
or natural disasters, pandemic influenza, and national special
security events.
In the spring of 2008, the national response framework was
released and the rules and responsibilities of the PFO and
other unified coordination group members as described in the
framework reflect the feedback given by our Federal, State, and
local partners.
In the case of a pandemic influenza outbreak, the PFOs
would identify and present to the Homeland Security Secretary
in coordination with the DHS Office of Policy and the Office of
Health Affairs any policy issues that require resolution. The
PFOs promote collaboration and as much as possible resolve any
Federal interagency conflicts that may arise at the operational
level. The PFOs serve as part of a unified coordination group
at the Joint Field Office.
Since the initial predesignation in December 2006 we have
received great cooperation from the Department of Health and
Human Services, the Department of Defense and components within
the Department of Homeland Security by the predesignation of
senior officials, defense coordinating officers, FEMA, Federal
coordinating officers, and DHS infrastructure protection
liaisons for pandemic influenza and other similar national
biological events. By working together before a pandemic or
biological threat occurs, these Federal partners have forged
professional relationships and an understanding of each of
their key roles and responsibilities.
Our PFO cell led by Admiral Naccara and the FEMA Regional
Administrator met with the Governor of Rhode Island and his
senior staff last fall, coincidentally in our parallel world of
PFO for hurricanes we exercised with the Governor and his staff
and held a mock press conference with the Governor and with
yourself, Mr. Chairman, during the hurricane exercise in April
2007.
In closing, DHS through this PFO framework will continue to
serve as State and local issues to policy officials at
headquarters for resolution and to foster and improve upon the
partnership with the Federal interagencies, State, local,
tribal, territorial, and private sector stakeholders to
complete the work of pandemic and biological threat
preparedness.
Thank you again for the opportunity to testify on behalf of
the Department of Homeland Security, and I'd be happy to answer
any questions you may have.
[The statement of Capt. Boynton follows:]
Prepared Statement of Peter Boynton
July 22, 2008
Good morning, Chairman Langevin, Ranking Member McCaul, and Members
of the subcommittee. Thank you for the opportunity to testify before
the committee to discuss the Department of Homeland Security's role in
a Pandemic Influenza outbreak. I am Peter Boynton, and I currently
serve as a Federal Security Director for the Transportation Security
Administration. I am also the Deputy Regional Principal Federal
Official for the northeast region (termed ``Region A'') of the United
States in the event of a pandemic or biological event.
I am here today on behalf of Regional Principal Federal Official
Rear Admiral (Retired) George Naccara, who was pre-designated by
Secretary Chertoff in December 2006 to serve as the Regional PFO for
these issues. Region A encompasses FEMA Regions I and II, which is all
of New England, New York, New Jersey, Puerto Rico and the U.S. Virgin
Islands.
To begin, I would like to take a few moments to review some basic
facts about pandemics and their potential impacts on our Nation.
Pandemic influenza occurs when a novel strain of influenza virus
emerges that has the ability to infect humans and to cause severe
disease, and when efficient and sustained transmission between humans
occurs. This scenario creates unique challenges. Unlike other
incidents, a pandemic is not a singular event, but is likely to come in
waves, each lasting weeks or months, passing through communities of all
sizes across the Nation and the world simultaneously making mutual aid
difficult if not impossible. The complete event may last as long as 18
months. Based on projections from prior pandemics, an influenza
pandemic could result in 200,000 to 2 million deaths in the United
States, depending on its severity. Further, an influenza pandemic could
have major impacts on society and the economy, including our Nation's
critical infrastructure and key resources, as many of our Nation's work
force could be absent for extended periods of time, either sick
themselves or caring for loved ones at home.
Under the Homeland Security Presidential Directive 5, in order to
prevent, prepare for, respond to, and recover from terrorist attacks,
major disasters, and other emergencies, the U.S. Government has
established a single, comprehensive approach to domestic incident
management, with the Secretary of Homeland Security designated as the
Principal Federal Official for domestic incident management.
Understanding the complex effects resulting from a pandemic, in
December 2006, the Secretary pre-designated Vice Admiral Vivien Crea,
of the U.S. Coast Guard, as the National Principal Federal Official,
and five Regional Principal Federal Officials to assist States, local
and tribal governments by overseeing a coordinated Federal response.
Five ``pandemic'' regions were established by the Secretary in order to
create a manageable span of control. Each region consists of two FEMA
regions combined into one ``pandemic'' region. In March 2008, the
Secretary issued an updated pre-designation of PFOs letter to the
States and to each Federal department/agency. This letter expanded the
role of the Principal Federal Officials for pandemic influenza to
include other similar Nation-wide biological events. Also, with the
anticipation that Joint Field Offices in each of the standard Federal
regions would be established in a pandemic or other similar Nation-wide
biological event, the Secretary pre-designated two Deputy Regional
Principal Federal Officials to assist each of the five Regional
Principal Federal Officials.
The Principal Federal Officials serve as the Secretary's
representatives to ensure consistency of Federal support as well as the
overall effectiveness of the Federal incident management. The PFOs
would identify and present to the Homeland Security Secretary, in
coordination with the DHS Office of Policy and the Office of Health
Affairs, any policy issues that require resolution. The PFOs promote
collaboration and as much as possible resolve any Federal interagency
conflicts that may arise at the operational level. The PFOs serve as
part of a Unified Coordination Group at a Joint Field Office.
Since the initial pre-designation in December 2006, we have
received great cooperation from the Department of Health and Human
Services, the Department of Defense, and components within the
Department of Homeland Security by the pre-designation of Senior
Officials, Defense Coordinating Officers, FEMA Federal Coordinating
Officers, and DHS/Infrastructure Protection Liaisons for Pandemic
Influenza and other similar Nation-wide biological events. Pandemic/
Biological Threat PFO Teams have been created, so these participating
Federal agencies/departments may work together now before the
catastrophic event may occur as well as to conduct outreach to States,
local and tribal governments and the private sector. Each of the five
Regional PFO teams would be comprised of the same members in a Unified
Coordination Group described in the National Response Framework.
However, by working together before a pandemic or biological threat
occurs, these PFO teams have forged professional relationships, and an
understanding of each of their key roles and responsibilities. In fact,
our PFO cell and the FEMA Regional Administrator met with the Governor
of Rhode Island and his senior staff last fall; coincidentally in our
parallel role of PFO for hurricanes, we exercised with the Governor and
staff and held a mock press event with the Governor and with Chairman
Langevin during the hurricane exercise in April 2007. Also, the States,
private sector, local and tribal governments will have familiarity of
these key Federal Government officials prior to a catastrophic event.
Since the initial December 2006 pre-designation, the PFO teams have
performed a myriad of training, exercise, and outreach activities.
Activities have included the following: Pandemic PFO training in
February 2007; PFO Orientation in January 2007; meetings with State
Governors, and State officials in both public health and emergency
management operations; exercise with the Centers for Disease Control
and Prevention in their pandemic influenza activities; participation in
the National Governors Association Pandemic Influenza Workshops;
participation in the Association of State and Territorial Health
Officers (ASTHO) Pandemic Influenza Table Top Exercises; participation
in an internal PFO Team Exercise Workshop in November 2007; and
participation in the Assistant Secretary Principal Level Exercise at
the White House in February 2008. In December 2007, Region A with great
support from FEMA Regions I and II held a regional pandemic influenza
exercise whereby a Regional Joint Field Office was established in
Maynard, Massachusetts and the Region A States stood up their Emergency
Operations Centers. In April 2008 and May 2008, Region C under Mr.
Edward Buikema, the Regional PFO, hosted two pandemic influenza summits
in Chicago, Illinois and Denver, Colorado, respectively, with
invitations to the States in Region C to participate. Both events
included a tabletop exercise sponsored by the U.S. Naval Postgraduate
School in Monterey, California.
Both the national and five regional PFO teams will continue to
conduct training, outreach, and exercise activities. In September 2008,
Region B PFO and Vice Admiral Crea will participate in a CDC Pandemic
Influenza Tabletop Exercise. In late October 2008, the Department of
Homeland Security will conduct an intra-departmental exercise with
participation from the pre-designated PFOs, the Office of Health
Affairs, FEMA Federal Coordinating Officers, and DHS/Infrastructure
Protection Liaisons. Finally, the Homeland Security Secretary recently
requested the Attorney General pre-designate a national and five
regional Senior Federal Law Enforcement Officers to join our respective
teams.
In closing, many of these accomplishments can be incorporated into
an all-hazards framework to promote the national culture of
preparedness, effective outreach and partnering. DHS, through this PFO
framework will continue to surface State and local issues to policy
officials at headquarters for resolution, to foster and improve upon
the partnership with the Federal interagency, State, local, tribal,
territorial, and private sector stakeholders to complete the work of
pandemic and biological threat preparedness, to promote the culture of
preparedness in general and to further the Nation's ability to prepare
for, respond to, and recover from all hazards.
Thank you again for the opportunity to testify on behalf of the
Department of Homeland Security on these issues of critical importance
to our Nation's security and well-being. I would be happy to answer any
questions you might have.
Mr. Langevin. Thank you, Captain Boynton, for your
testimony. I should have mentioned earlier that Dr. Vanderwagen
has submitted joint testimony along with Dr. Kurilla and Dr.
Sosin and has given the verbal testimony for both of those
gentlemen, so I know you'll be available for questions. I want
to thank the panel for their witness testimony today. I remind
each Member that he or she will have 5 minutes to question the
panel. It's my intention, time permitting, that we will do two
rounds of questions for Members for each panel.
Dr. Kurilla, tell me what is the current status of Project
BioShield that was created in 2002 to try to speed new vaccines
or drugs to the market to protect the public in the event of a
potential attack or response to such things as Avian Flu? What
meaningful treatments, antidotes, or vaccines have we produced
or are we close to producing right now?
Go ahead and answer that and I'll go with the second one.
Dr. Vanderwagen. We have just submitted a written report
for the progress through 2007 to the Congress and I would want
to make sure you have a copy of that for more detailed
reference.
We have used Project BioShield which is an acquisition
program, not a development program, to acquire a wide variety
of materials, most of which existed in the marketplace before
BioShield came into place, but the authority to acquire these
things was strongly enhanced by BioShield as an approach.
Congress augmented this by providing us with an advanced
development authority that is significant in its impact as
well. But let me speak to BioShield. The acquisitions there
have been focused on readily available market products, in
general. We have acquired significant products for chemical
events, for radical nuke events and that would include
chelating agents, KI, Prussian Blue and other radiation
medications which exist in the marketplace. We've acquired
antibiotics that exist under the program as well to assure that
we have existing broad-spectrum antibiotics available for
things like Bubonic Plague, for anthrax, et cetera.
We have through the Advanced Development Program, supported
the development of the development of a number of things
including anti-toxins for botulism, for anthrax, et cetera, and
the acquisition to that products now are reading to delivery in
the national stockpile and the other positive thing to be said
is some of our international partners now are purchasing from
the companies that we've supported in development so that they
have a wider market base of support so that infrastructure will
persist.
But I'll turn to Mike, and Mike, do you want to say some
more about the research developments in this area?
Dr. Kurilla. So with the publications----
Mr. Langevin. Pull the mic very close to you, if you could.
Dr. Kurilla. So with the publication by the Department of
the Public Health and Emergency Medical Countermeasures
Strategy and Implementation Plan, we have used that as a basis
for our more advanced research and development programs in
order to provide candidates that would be eligible for
BioShield.
In addition, as Dr. Vanderwagen has mentioned, although
there's been an acquisition for botulism antitoxin, we are
continuing to assist in that development through our animal
model and assay work that would be supportive of the FDA
licensure. We have supported through fairly well advanced both
a second generation anthrax vaccine, as well as a second
generation smallpox vaccine, the MVA, modified vaccinia Ankara,
for smallpox which has, in fact, been acquired by Project
BioShield.
We have a number of other activities going on.
Mr. Langevin. Let me question you there on that because as
we know with the cancellation of the VaxGen contract, the next
is developing the next generation vaccine for anthrax. That
seemed to go nowhere. Give me the current status, more
specifics of the next generation anthrax----
Dr. Kurilla. So given the high probability of failure for
products at the point when we entered into our contract with
VaxGen, we actually were supporting two separate companies,
VaxGen being one. Avecia Biologics being the second one, that
contract has continued successfully. That company has
subsequently been purchased by Pharmathene so the names keep
changing, but in fact, we have a second generation anthrax
vaccine that is currently undergoing validation of its
commercial scale process manufacturing and----
Mr. Langevin. When do you expect that to be completed?
Dr. Kurilla. The validation, we anticipate would be done
some time in early 2009 and then it would move on to generation
of their fill finish, that is the final product production will
be later in the year. There is currently a BioShield
acquisition contract for recombinant protective antigen that is
under review, but that's something for the Department to
address. That's not my acquisition contract, but that has been
moving forward reasonably successfully. It has completely two
Phase 2 clinical trials and so far it's looking very good as a
product.
Mr. Langevin. Dr. Vanderwagen, Dr. Kurilla, as you know,
BioShield, obviously is important, to contribute to public
health security. It's too important to fail, but there have
been numerous problems with the program as I mentioned earlier.
To remedy these problems, Congress enacted legislation to
create BARDA and how do you think BARDA has helped, if at all,
to improve the coordination between HHS, NIH, CDC, et cetera
and DHS and do you think that we're getting enough threat-
related information from DHS to inform these efforts to develop
countermeasures to make the link between threat and actual
resource development for the next generation antidotes?
Dr. Vanderwagen. Thank you, Mr. Chair. I think that the
threat determinations are proceeding along fairly well. There
are emerging infectious disease that go outside the threat
environment that we still have concerns about, but DHS is
setting the threats very effectively and our public health
modeling is working along fine.
The BARDA package goes to what I just alluded to earlier.
That is, there's a limited amount of advanced development that
NIH can do. They're in the research business. They can take
development to a certain point that have to sort to give it up
at that point. Neither the industry and venture capital pick it
up or not. What the Congress has done in providing us the BARDA
authority is allowing us to pick up more of those good research
ideas, help those companies develop those through the clinical
trials so we don't have a failure like we have with the VaxGen,
and then we can talk about an acquisition of those products.
We think that BARDA has come along very nicely in the kinds
of things that Mike just talked about, that is, products that
they have brought to a point that we will move forward with,
for instance, in the acute radiation area, not bio, but in the
acute radiation area, we had 20 products almost, come to the
fore that needed advanced development. We will fund half of
those in all probability through to the clinical trial base
that will allow us to make acquisition decisions about them as
mature products.
We think BARDA is a very effective tool and I'll let Mike
comment about the transition piece between the research world
and the advanced development world.
Dr. Kurilla. BARDA has been a welcome addition. At NIH we
are not, and do not intend to be, a commercial manufacturer,
distributor of products. So the products that we develop to a
certain point in the pathway toward licensure I have to hand
off to a customer. My customer is not the person on the sharp
end of the needle. It's the person holding the needle. BARDA is
that customer who can then carry forward with the commercial
scale development because those technical issues involved in
that phase of product development are uniquely dependent on the
specifics of procurement and since HHS is doing the
procurement, they really need to be involved in that major
advanced development commercial scale manufacturing. It allows
you to set the conditions that will make the product successful
and bring it in on time. It has been a welcome addition and we
work very, very closely such that we overlap our programs so
that by having a little bit of overlap we ensure that there
really are no gaps in the development which allows these
products to fall through the cracks. So it has been a welcome
relief.
Mr. Langevin. On that point let me ask what were the
lessons learned from VaxGen, that contract, and have you
changed your development and clinical trials process in
response to that failure?
Dr. Kurilla. The major lesson we learned that I think it is
very difficult to cast your bets on products in terms of
acquisition too early in the development cycle, simply because
and this is not anything unique to Government, this is industry
standards and industry benchmarks is that the failure rate
early in clinical development is exceedingly high, getting into
a Phase 1 first time in man, you are no better than a 10 to 20
percent success rate.
So what we have done in our development is that we have
tried to stage them a little more so that we work with options
so that if a company moves to a certain point and looks
successful, we can engage the option and carry them a little
further. It doesn't--it avoids us having to cast our bets on a
few possibilities and allows us to expand our repertoire of
candidate products that makes more available downstream for
BARDA and HHS in terms of Project BioShield to select from.
Dr. Vanderwagen. Yes, the relevant examples occurred in
pandemic influenza where we supported a number of manufacturers
through the early trial process and weeded out those that could
be successful and that ultimately led to an H5N1 vaccine that's
licensed and safe. That's the kind of process that Mike's
describing.
Early on, there may be four or five companies that have a
good idea, but they may not have the skill, capability to bring
it to a safe and effective product. We can support them through
that test phase and those that can't make it drop out and those
that can do the job then become candidates for a broad-scale
acquisition and with VaxGen there was no early indication about
whether they were going to be able to do it or not. It was a
high-risk venture.
Mr. Langevin. Thank you for those answers. Last question I
have in this round is for Dr. Runge, and then I'll go to Dr.
Christensen.
Dr. Runge, you said in your testimony that you were very
concerned about the threat of weaponized anthrax. Clearly, I
share that concern, of course. However, we receive many
biological threats for which we must be prepared, not just
anthrax.
How ready are we for terrorist use of anthrax and how do
you suggest preparing for this threat, while preparing for
other biological threats at the same time?
Dr. Runge. Mr. Chairman, thank you for that question.
First of all, with respect to other agents, as Dr.
Vanderwagen mentioned earlier, we--what keeps me up at night is
the intentional use of a biological agent and certainly anthrax
is not the only one.
The Science and Technology Directorate recently released a
draft of its integrated threat assessment that--risk
assessment, excuse me, that stratifies the agents by degree of
risk and once again our No. 1 is still our No. 1. But there are
others that are considerable.
We also have included zoonotic disease for the first time
in that analysis simply because of the tremendous economic
impact that something like foot-and-mouth disease might have on
our agriculture economy, on our ability to export food products
and so forth.
With respect to how ready are we, we are as ready as we can
be at this point in time, but again as Craig mentioned we are
better prepared, but we are not ready.
Every piece of our--the four pillars of biodefense have to
work seamlessly or we will not be able to answer this
challenge. We need improved intelligence. We need better threat
defense. We need enhanced biosurveillance.
Dr. Sosin is a key part of the governance now of our new
NBIC enterprise governance. The CDC is responsible for human
health. USDA is responsible for animal health. We are moving
forward very quickly with the more successful biosurveillance
integration system.
With respect to biodetection, we are not where we need to
be right now. We have a built-in delay of up to 30 to 34 hours
in our ability to detect a pathogen in the air. We must press
forward with the bridging technology that New York has
successfully deployed, as well as the successful completion of
Generation 3. Our target date for S&T is in spring of 2009 for
operational testing evaluation.
We have to improve our response and recovery. The CDC can
get medications out to local communities within 12 hours.
That's great, but we still do not have a uniform capability
across the country of countermeasure delivery within that very
narrow time window for both plague and for anthrax.
With respect to environmental recovery, EPA, HHS, and DHS
have been working very, very closely on protocols as to how we
would even begin to sample a building. How clean is clean? We
are codependent then on the development of vaccine, on third
generation antibiotics, for anthrax strains that may be
resistant to doxycycline or suprafloxicine, our current weapons
for medical prophylaxis. So every piece of this has to work. We
don't have a double-fail-safe mechanism for this. So this
integration, the working together and the concepts of
operations all the way down to the local level where if an
attack like this occurred our PFO cadre has to be trained along
with their Federal coordination officers and State and local
emergency management officials in order to do this work.
So I wish I could say that we were done, but we're not
done.
Mr. Langevin. Obviously, we need to continue to make these
things a priority, especially as you know, we just had the
hearing last week on Project BioWatch and the NBIC and I'm
anxious to get those next generation detectors deployed as soon
as possible as I know you are.
With that, I'm going to turn now to Congresswoman Dr.
Christensen for her questions.
Mrs. Christensen. Thank you, Mr. Chairman, and thank you
for holding this hearing which happens to include the Virgin
Islands since we're in the same region and I want to thank the
testifiers, I want to thank all of you for your service, but as
Dr. Runge is getting ready to leave us I want to particularly
thank him for the work he's done in really creating the Office
of Health Affairs. When you came there, we were not quite sure
what it was going to be. Now it's a little clearer.
I wanted to follow up on the biosurveillance question
because you spoke in your testimony about soft targets and the
importance of those and the impact it could have, a
bioterrorism event could have because of the slowness of
picking up the agent.
So I wonder if--well, to the best of my knowledge, BioWatch
detectors are in major cities and I wonder if there's a plan
for expanding to a second round of bio detectors in softer
areas and to what extent would the delay, the 1-year delay in
the Gen 3 biodetectors impact any expansion of BioWatch?
Dr. Runge. Thank you, Dr. Christensen. It's almost
rhetorical to say that if we had our way we would have
completely automated detection systems covering the entire U.S.
population. That is neither practical nor affordable. We have
modeled a number that we believe would cover the part of the
population that we believe is at risk. For instance, with an
intentional anthrax attack, one can probably draw the line
where it would simply not be worth the while of the terrorists
to use that weapon on a very sparse part of the population.
So we have a number in mind for what it would take to cover
the entire country in the areas that we consider the highest
threat. When BioWatch stood up, it stood up, I'd like to remind
the committee in 32 days. It was a phenomenal piece of work
that we did with the CDC, with the State and local governments
and the model that was created was to franchise the detection
and decisionmaking to local laboratories.
With the advent of automated detection systems, we can
actually move beyond that and will have to work out a better
partnership arrangement with local governments and with a
central biosurveillance system, along with the CDC so that we
can actually see things in real time.
I'm a little distressed about--there are naysayers out
there with respect to whether we actually need to do this sort
of environmental detection. Even to the point that the House
Appropriations Committee in their House report cut the budget
for BioWatch by $22.8 million to buy that bridging technology
which we've successfully deployed in New York City. It's
inexplicable to me. The Center, of course, included it. So I
would ask your attention to that as well when it comes to be
conference time.
But we will continue to enhance this program and we'll to
do this and we'll have to cover more of the population over
time until we have a universal vaccine and the policy becomes
that we can take this germ off the table with a recombinant
antigen that is safe and effective. So it's a long answer, I'm
sorry, but I hope I answered your question.
Dr. Christensen. We recognize that the Appropriations
Committee had had those kind of questions and I think they were
answered. We asked questions when we had that hearing back a
couple of weeks ago to the people who run the program in your
office. I think it was answered to my satisfaction.
Dr. Sosin, would you like to comment on that?
Dr. Sosin. Thank you, Dr. Christensen. Thank you for the
honor and privilege of being here representing biosurveillance
as an area broadly, nationally, and CDC.
It strikes me that your job is particularly challenging in
that it's not really a matter of weeding out unuseful or
wasteful solutions to biosurveillance or preparedness, but
weighing the relative values of them.
From where I sit and the public health community that I
reside in and in this exchange that we've having over the last
6 months around a national biosurveillance strategy, it's
striking that top all hazard, all jurisdiction capability for
biosurveillance falls in the context of our clinical public
health relationship. You're spending a lot of time talking
about partnerships and those relationships. Those have improved
dramatically. In the years that we've been funding preparedness
and building the capabilities of health departments to interact
with their clinical environments, to share information
effectively, and that keeping that strong and strengthening
that which is strained is a critical resource that we need to
consider.
As we look at the mass release aerosolized release of
agents such as anthrax, we anticipate that large exposures to
aerosolized anthrax can cause disease within 12 hours, so that
our clinical presentation and not just of single cases as has
been our experience with anthrax to date, but large number of
cases mixes virtually impossible not to be recognized in
clinical environments, not initially as anthrax, per se, but to
set up alarms and to initiate the types of investigation on
public health and clinical providers undertake for unknown
diseases.
So to think in terms of the capability that we need to
strengthen that's all hazards and all jurisdiction, it's really
important to keep the infrastructure of the health system in
mind.
Mrs. Christensen. You're singing my song. I'm glad to hear
the emphasis on the public health response side.
Dr. Vanderwagen, in your testimony, you talk about $2.6
billion having been spent over 5 years on surge, increase in
surge. How much surge have we bought with that $2.6 billion?
Can you quantify the increase in surge capability across the
country and can you tell us, for example, in terms of the
States, territories, and tribes, a ballpark percentage of who
is prepared, who has built capacity--sufficient capacity to
meet the standards you've set?
Dr. Vanderwagen. Right. Doctor, it's a great question. What
is surge?--and surge, to me, is a challenge.
It's wholly different if you're expecting to meet the
challenge of a train bomb as we saw in Madrid or if we're
expecting to deal with a pandemic flu. So surge capability I
think incrementally has improved significantly from the
perspective of can we meet the challenge of things like IEDs,
kinetic events, geographically, temporally limited, yes, we've
made significant improvement.
Here in Rhode Island, there are 15 hospitals, 14 of them
participate in hospital preparedness program. They've made
significant strides forward in training their staff, developing
things like IED capability, management of beds, management of
traffic, patient flow, et cetera.
I think these are the hallmarks of what's happened over the
last 5 years with funding in the surge, medical surge world. In
2006, there were over 9,500 exercises conducted by hospitals
and facilities involving their staff and action. That's pretty
dramatic stuff. What has happened is that JHACO and the other
accrediting organizations have begun to internalize these
higher standards of expectation into their performance
requirements for hospitals to get accredited and so the
profession, if you will, and the industry itself has begun to
internalize many of these kind of changes, what is effective
sheltering in place? What does it take to shelter in place?
Your generator shouldn't be two floors below ground level,
things like this, that become normative in the industry.
Where we have difficulty and the GAO report highlighted
this, is in a large-scale event where the demand far exceeds
the asset base that's available. What kind of decisions will we
be making about triage, about changing standards of care,
alternate care sites, et cetera.
Some communities are addressing this very aggressively.
Miami, the Board of Education and the schools and the public
health system have partnered to develop alternate care sites
using mothballed schools which they've warm based, they can use
them.
Other communities really have not done the heavy lifting.
In August, we met with Costco executives, Starbucks executives,
public health and hospital people in Seattle and they admitted
up front they hadn't done the heavy lifting to deal with some
of these issues yet.
Last week, we met in Indianapolis, 31 States, District of
Columbia and four territories, including the Virgin Islands and
Puerto Rico, to map out an approach to national consensus
generation in dealing with the ethics of high-demand, short
availability of assets. It will require community, State,
regional and national activity and the GAO report I think was
on target that now is the time people are ready and while we
will not dictate from a Federal perspective, we can facilitate
and provide guidelines for dealing with those tough issues.
So we've moved a long way in the last 5 years.
Notwithstanding that, we have not dealt with the worst event
which is high-demand, low-asset and that's the next challenge
in front of us.
Mrs. Christensen. We'll come back to that somewhat in the
second round.
I wanted to ask Captain Boynton, we've spent a fair amount
of funding and lot of time and exercises on pandemic flu which
everyone is pretty sure at some point it's going to come, we
don't know when. Can you tell me how this preparation may have
prepared us better for a more all-hazard kind of biologic
event?
Another part of my question is: How does the national PFO
relate to Admiral Vanderwagen?
Capt. Boynton. Thank you. From my perspective, and I'm
coming at this from a perspective of the regional perspective
as the Deputy PFO, we think that there are a lot of synergies
to be gained from our work in preparing for pandemic influenza
and other biological hazards. It doesn't mean that all aspects
of the incident response that the PFOs will be focusing on, the
incident response part of the operation. It doesn't mean that
they're all the same, but we do believe that there are a lot of
synergies that can be gained.
The five regional PFO cells have been, the cells have been
built. They all include PFOs, Deputy PFOs, senior health
officials, senior defense coordinating officials, and we have
exercised both regionally and nationally with the national PFO
team led by Admiral Crea, so we think there are synergies there
between them even though not every aspect of an incident
response would be the same.
Dr. Vanderwagen. The quick answer Vice Admiral Crea and I
are very close. She's a good person and right up front when
Secretary Chertoff named her, she got support from Dr. Runge,
but she reached right over to us and said: ``How do we play?''
She has my Deputy Assistant Secretary, Kevin Yeskie,
assigned to her to answer and work with her on any questions
related to the House sector, but as was alluded to here, this
will not be an ops response much like we would have in a
hurricane and so on. This is going to extend over time. So she
has used our health players in conjunction with the PFOs to
begin to reach out to the wider community to bring all the
sectors into play.
Mrs. Christensen. One more question in this round that sort
of comes out of that.
Dr. Runge, Mr. Kilday will testify later about a newly
imposed ban on using Federal resources for local emergencies
and are you aware of that?
Dr. Runge. I'm at a loss, Congresswoman. No. Recently
imposed ban?
Mrs. Christensen. I probably can't locate the exact place
in his testimony, but they used to be able to use the Federal
resources that were here. ``Until recently nearly all of the
team's equipment was Federal property and, as such, would not
be available for use within the State of Rhode Island.'' If I
understand that correctly, at one point they were able to use
it and now they have to purchase their own equipment. This is
in DMAT.
Dr. Vanderwagen. What you're referring to is the Disaster
Medical Assistance Team. There's one located here in Rhode
Island and it's had a long and illustrious history.
When NDMS, the National Disaster Medical System was
initiated back in 1982, 1983, 1984, it was designed to meet a
Cold War challenge, that is, the transport of a large number of
wounded warriors from Europe to the United States, how do we
get them to definitive care? How do we receive them at the
airheads, et cetera?
Emergency response teams were developed. Mobile emergency
rooms. Increasingly, that concept was extended into use in the
domestic response environment. These Disaster Medical
Assistance Teams of which there are about 56 active Medical
Assistance Teams at the moment, were predicated on they managed
their own assets, et cetera. They were required under the
Federal domain and they managed their assets.
What we have determined is that given the challenge we have
with wide domestic response capability that we believe that
regional caching and delivery of those caches on a regional
basis with the teams coming to play is a much more effective
way to assure that we have people and equipment in place and
it's allowed us to expand up to an additional 15 teams who are
available to play.
There are challenges to the existing teams because the
question of what will they train on and so on are still issues
that have not been fully resolved to their satisfaction, but I
would tell you that the regional caching of that equipment has
subserved our response capability significantly. My chief
logistician came to us from the Army Medical Command where she
was the director of logistics for a number of years and she
knows this business. FedEx is delivering for us on a Q6 hour
turnaround time. So we think there's been improvements in our
response capability overall. There are questions of how we
support the training requirements of the teams and that's still
an open question that will need further resolution.
Mr. Langevin. We're going to come back to this DMAT issue
in a lightning round, in the second round of questions. With
that, the Chair now recognizes the gentleman from New Jersey,
for his questions.
Mr. Pascrell. Thank you, Mr. Chairman, good morning. Thank
you for your service to your country.
I would like to ask an open question with a brief,
hopefully, a brief answer. Then we'll get into some other
questions.
It appears that you all agree that the risk of the
possibility of slowly detected outbreak of a specific situation
is more acceptable than the risk of vaccination. I would like
your responses to that.
Dr. Runge, why don't we start with you?
Dr. Runge. I'm not sure--my answer will be very brief, sir,
because I'm not sure I really understand the question. We have
to make choices.
Mr. Pascrell. Yes. We're not going to have a seamless
defense concerns. We passed that hurdle, is that correct? Is
that correct, gentlemen?
Do one of you believe we can create a seamless way to
protect the populations against the very diseases we're talking
about today?
Let's be straight about this.
Dr. Runge. Yes, I think we can approach it, sir. I'm not
sure that we can ever reach that perfection.
Mr. Pascrell. Then let me go back to my original question.
Is it better that we move toward the direction of vaccinating
everyone against a particular problem or is it best that we
develop the quickest means of responding after we realize
that--and after we detect something?
Is it an either/or?
Dr. Runge. I get it now. I don't think it's an either/or. I
do believe that until--and first of all, if we project into the
future that there actually will be a vaccine to take certain of
these threats off the table, it then becomes an issue of policy
that this Nation is going to have to face together, all
branches of government. Do we vaccinate against a highly--
excuse me, maybe not highly, but against a relatively
improbable event than measles, mumps, rubella, or chickenpox,
which are going to happen every season and we want our children
protected against that?
So then we really do have to rely on our health policy
folks as to the relative merits of a vaccine because there are
side effects to vaccines and if we universally vaccine everyone
against a disease, yes, that is probably the best deterrent we
could ever have for terrorists using that against us. But the
cost of that is some degree of untoward effects of those
vaccines and I think we have to have that dialog.
Mr. Pascrell. Admiral.
Dr. Vanderwagen. I agree with Jeff, I mean ideally I'd like
to have the vaccines, take this off the table. For instance----
Mr. Pascrell. Are we developing those vaccines?
Dr. Vanderwagen. We're moving ahead pretty aggressively.
The challenge here is--for instance, we have an H5N1 vaccine
that we know is safe and effective, but we don't know that
that's the bug that we could be hit with. So the events we are
moving to go after those threats that we know to try and
develop the appropriate vaccines. The emerging infectious
diseases present us a challenge with is it going to be the
right one.
I think the next horizon and I'll let Dr. Kurilla speak to
this because he's the expert, but the next horizon we're
looking for is can we develop a carrier that would allow you to
vaccinate with a single vaccine for a wide variety of diseases
as opposed to have to give unique vaccines for each and every
disease, but I'll let Mike comment on that dream.
Mr. Pascrell. Captain or Dr. Kurilla.
Dr. Kurilla. Well, I would agree with you and I agree with
Jeff and Craig that the prophylaxis is always desirable.
However, it's very clear even in the instance of vaccines we
have today that we require children to receive before they go
to school, there is still a considerable fraction of the
population that does not get vaccinated, and so as a result we
still need to focus on and develop countermeasures that would
address those situations.
In terms of universal vaccines, such as example for flu, we
are still back at the conceptual stage, but that is a direction
we are moving to to get us out of the requirement for an annual
flu vaccine every year that needs to be updated. We think it
will come down the way, but we are still some years away from
even having something that we can move into development at this
point in time, but it is a strategy and a concept that we are
pushing on and moving forward on. We think we will get there.
Mr. Pascrell. Thank you. Doctor or Captain, either one of
you want to respond?
Capt. Boynton. I'll defer to the medical experts.
Dr. Sosin. Because this is not really a medical question,
but more of a societal policy question, I think everything
you've heard, sir, does reflect the state of balanced
decisionmaking that has to be made.
Mr. Pascrell. Dr. Runge, thank you for your service. You've
brought some sanity to a real insane situation down there and I
think Chertoff has tried to clean up the act. I don't know how
far he's gone. You made a recommendation in your presentation
which I find very fascinating. It goes to the very heart of a
lot of problems in homeland security. I was just on the phone
concerning another problem, the question of evacuation.
We've had total bifurcation here of who is responsible, who
pushed JCAHO? You say that while DHS is by its authorization,
Pub. L. 109-295, a collaborative agency so must Congress work
collaboratively to ensure a more secure homeland empowering an
effective, yet supportive, oversight environment. Is the fact
that we have a bifurcated situation between DHS and HHS, do you
see that as essential to understand, that is essential to
getting over the humps that exist between those two big
departments?
Dr. Runge. I think it is very, very important that the
oversight committees on the Hill are in lockstep. We have gone
from a kind of creative dissonance to a much more collaborative
and synchronous relationship.
It's no surprise to you, Mr. Pascrell, that Secretary
Chertoff has said on numerous occasions we're sort of in an
environment where we have incoming coming from 360 degrees and
that happens you tend to get deeper into your foxhole. That's
not productive for collaboration.
We really need to be able to focus on our oversight
committees, transportation, energy, commerce and T&I and the
Senate commerce. It was very easy to form a relationship with
the Members, very easy to form a relationship with the staff
and there were very few extraneous issues that would parachute
in from other sides.
Since I've been at Homeland Security for the last 3 years
we have not enjoyed that sort of relationship. So I'm not sure
how leadership is going to get it done, sir, but I do think
it's essential, just as we have created a much more harmonious
and synchronous relationship with the CDC on bi-surveillance,
with ASPR on threats and countermeasures that that--if you can
get that to happen, that would be terrific.
Mr. Pascrell. We had some warnings about this through the
Chair in 2002 when we were putting this dinosaur together. The
Government's health care experts, it seemed anyway at the time,
would be split between health and human services and the
proposed homeland security deployment. In some cases the new
department would become a customer of HHS, contracting for
services. This is a splintered process rather than a
centralized one. That problem within those folks who get paid
for doing, protecting America, as compared to the committees,
83 of which--that's mind boggling.
Dr. Runge. Yes, sir.
Mr. Pascrell. How do we get to the central point here? How
do we get to see who is in charge?--and it would seem in many
areas including this one, we can't answer the question. So we
didn't bring them together. In fact, it was proposed in 2002
that there would be an undersecretary that would have that
responsibility. There's no such animal.
Would you like to take a swipe at that?
Dr. Runge. I'm not exactly sure what the administration
policy would be on that, sir, so I will defer right now.
Mr. Pascrell. The administration's policy is to protect
America.
Dr. Runge. Yes, sir.
Mr. Pascrell. It doesn't matter, it doesn't have to do with
politics, it has to do with protecting Americans and Americans
aren't going to accept the half-answers that we've been
getting.
Dr. Runge. DHS has been in the precarious position of
having responsibility without the authority.
Mr. Pascrell. I think you put it better than I could have
put it.
Dr. Runge. The thankless job of coordination among
departments and agencies that don't necessarily want to be
coordinated has been pounding one's head against the wall.
Mr. Pascrell. Mr. Chairman, I salute you and Dr.
Christensen for the work that you've done from the very
beginning on this. Not only that--it's not only important that
we talk to each other. We need results. The Chairman has been
there and the result has been changing the culture. It is a
culture. If we don't do that, then we're not doing our jobs on
this side of the table. You should be badgering us to make the
changes that are necessary.
Eighty-three committees examine homeland security. How in
God's name does anything get done? Then when they come to us
they don't give us the truth half the time anyway, so if you're
watching this and wondering who did push JCAHO?
I'm telling you, Mr. Chairman, thank goodness for this
committee and what your work is and I'm blowing smoke, I'm
telling you. You know I like to say it like it is.
Mr. Langevin. I've noticed that.
[Laughter.]
Mr. Pascrell. This is a very critical issue and we need to
bring some changes that have to get done so that the people on
the front lines know that they're getting support in our
rhetoric. Thank you.
Mr. Langevin. I thank the gentleman. We're going to go to
round two and I'm going to adhere us to the strict 5-minute
rule. We gave latitude on the first round and we appreciate our
guests here and the Members for traveling, but we have a lot of
questions we want to get in, so I'm going to go to a very
strict 5-minute rule in this last round of questions.
I want to begin with going back to Dr. Christensen's
question for Dr. Vanderwagen on DMAT issues.
Dr. Vanderwagen, it is my understanding that the original
vision for the national disaster medical system included having
at least one DMAT per State and territory. However, as you were
talking about recently, just a minute ago, the decision was
made by HHS to regionalize DMAT assets.
Can you explain that decision? How do you foresee
regionalized DMATs deploying, for example, and what I'm
concerned about primarily when an entire region or the entire
country is affected by widespread biological disease, per se,
for example, if there were to be a widespread outbreak of a
highly infectious disease in New England, how would DMAT assets
currently centralized near Boston be deployed to respond to the
needs of Rhode Islanders, for example, or those in nearby
States?
Would you answer that?
Dr. Vanderwagen. Yes. I think in the circumstance you just
described it's unlikely that we would be deploying any assets
for much more than the first 2 or 3 weeks of that event because
all this will become local inherently as the disease spreads
across the country.
Our current concept of operations, whether it's for Federal
assets or MRCs or any asset is that we're unlikely to be
deploying people from Point A to Point Z in a pandemic event
for response operations because once you get beyond the first
four or five cities that are involved everybody is going to
need to be in place in their location taking care of their own
community as opposed to looking to the feds to move people from
here to there.
Mr. Langevin. But doesn't that kind of speak though to why
it's so important to have one in each State as it was
originally planned?
Dr. Vanderwagen. Indeed, and in fact, the States themselves
now have gone to much more extensive investment in team
processes. When the group was over in FEMA it was determined
that these could not be used for State assets, that they were
only Federal assets available for Federal deployment.
We have encouraged States and are now supporting State
efforts to develop State-based DMATs and have them at the call
of States first and foremost. You've got 26 teams in North
Carolina. You've got six teams in California, et cetera, that
have been developed.
We will provide the original cash support to those folks if
called upon. If they need additional Federal assets, we would
bring people from Point A to Point Z, but we believe that our
job is to really try and build local capacity to the maximum
possible degree and where we have Federal assets, place them
regionally so they're more accessible to the local
requirements.
Texas is preparing for the storm to hit on shore. We have
pre-deployed two Federal medical stations, 500 beds' worth. We
have deployed the caches for DMAT teams to San Antonio well
ahead of the process. Those FMSs reside in Texas full-time.
Mr. Langevin. Well, we're going to keep following up on
this, on the DMAT issue, and I know our second panel, the State
folks, probably may have a slightly different perspective and
we're interested in hearing their input.
Dr. Runge and Dr. Vanderwagen, when we conduct exercises,
obviously, it's important to be as realistic as possible to the
extent that we can and use current requirements to show us how
well we might do in a future situation.
During a pandemic, DHS and HHS obviously will be the lead,
with Federal agencies managing the response. At a hearing I
held last September I stated that we should test our systems
now using seasonal influenza as a proxy for pandemic influenza.
Dr. Vanderwagen, starting with you, I also asked you to
take last year's influenza season and make a concerted effort
to see how many people we could vaccinate in the shortest
period of time, basically, intending that seasonal influenza is
actually pandemic influenza. The way I see it, we should be
testing our distribution systems now, stressing our
organizations in these sorts of real-time, real-world contexts
while improving the health of our citizens throughout the
Nation.
You agreed, and you also--I also told you that I'd be
asking about this again. So here we are at this hearing. Did
HHS do this? If so, how? What was the outcome? If not, why not?
Then for Dr. Runge, you were not at that hearing, but I did
ask Dr. Jolly a similar question, asking the Office of Health
Affairs to get the national biosurveillance integration system
in this to start tracking seasonal influenza during influenza
season and treating it as if it were pandemic influenza. I also
asked that the Department get our CBP offices on the board to
identify people who are obviously ill with something that looks
like the flu and divert them to secondary screening. Did these
and other activities occur and if so, how and if not, why not?
Let's start with Dr. Vanderwagen.
Dr. Vanderwagen. Yes, the primary event that can be tested
in seasonal flu that would approximate pandemic is immunization
practices and immunization access. In the first instance,
that's going to be the primary event response. In fact, many
States and localities have done extensive testing and
evaluation of various modalities from drive throughs to on-work
site to the standard go to the County Health Department
approaches.
We believe that there are best practices out there, but
increasingly we're engaging with local business to participate
in these processes as well, that they can become dispensing
sites and capture a significant number of people in those
events.
That's not only useful for pandemic flu, but it's also
useful for management of distribution of prophylactic
antibiotics and in other biological event, the use of
antivirals if we can expand to prophylactic, post-exposure
prophylaxis use. So a wide variety of those were tested last
year. Again, folks have been driving this train pretty hard,
depending upon where they are.
We've put it into the requirements for hospital
preparedness program and it's built into the FEP as well, that
they test and exercise these distribution schemes. What is
problematic is what about alternate care sites? That's the next
frontier, if you will, of exercising what are those alternate
care sites? What will the standards of care be that are applied
in those kind of environments? That's a little different than
the logistical challenge of how we get drugs into people's
arms.
Mr. Langevin. Thank you. Dr. Runge.
Dr. Runge. Mr. Chairman, with respect to the
biosurveillance piece, I can tell you--first of all, I cannot
tell you that there was an additional exercise that went on
within the NBIC. However, the domain of human health
surveillance is the CDC's contribution to NBIC. CDC has been
consistent in having a detailee in the Center who has access to
the human surveillance data, and thresholds are decided upon
over which they will enter into the situation report every day.
I do not believe that seasonal influenza met that criterion
and I don't recall seeing it in the daily situation report or
in the weekly summary. They do produce weekly summary on H5N1
which is based again on CDC's human surveillance efforts. I
will defer to Dr. Sosin for more detail on that.
With respect to CBP, I don't know that any special effort
went into looking for people with the flu. I can tell you
though that these law enforcement officers who are not trained
medically do a pretty darn good job of weeding people out and
sending them to secondary for additional screening when they do
appear ill. It is not an unusual occurrence for them to send
someone to secondary who appears ill and to summon health
authorities or in the case of the stations where we have
quarantine stations to summon a CDC officer for a second look
at the individual. I will inquire though as to whether
additional efforts were undertaken.
Mr. Langevin. That would be important. With that, I now
recognize Congresswoman Christensen for 5 minutes.
Mrs. Christensen. Thank you, Mr. Chairman. I think it might
be easier, I'm going to ask my three questions and then just
leave it to them and I think I may be able to make it in 5
minutes that way.
Dr. Vanderwagen, in your testimony you talk about the 2009
funding based on how well previous targets were achieved. So if
a State or a jurisdiction didn't meet its target, would funding
be denied or reduced? Might they not be the jurisdictions that
need the most funding and help? So how would you address that?
When you talk about matching requirements coming in, I
assume that meant that States would have to match at some
formula. Many States have already paid a lot of--spent a lot on
communications, training and how would that be accounted for?
I just came back from Louisiana. The second question, just
came back from New Orleans and I'm wondering why is there not a
mobile hospital or two in New Orleans? More than wondering why
they're not needed and I'd like to see at least one placed
there.
Last question is on this altered standard of care. I share
health with the Congressional Black Caucus. We see altered
standards of care every day, including disparities in people of
color and I'm very leery about these alternate standards of
care and I wonder ways do you see to ensure that--I understand
when you're overwhelmed and the resources aren't there, the
staff isn't there. It's not going to be tip-top medicine and
the best of facilities, but I want to know how do you see
ensuring that we won't be facing some of that systemic and
institutional discrimination that people face because of
language or color or gender in that situation?
Dr. Vanderwagen. What was the first one, ma'am?
Mrs. Christensen. The first one was about the funding.
Dr. Vanderwagen. Oh, matching.
Mrs. Christensen. Being tied to meeting targets.
Dr. Vanderwagen. All right, all very good questions. I'll
try not to be too windy.
As you know, I spend most of my--I was raised on a
reservation. I spent most of my career in Indian Health
Service. Indian Health Service, Congress has funded at about
$2,600 per capita per year and that's a 2005 figure, compared
to the general U.S. population of about $7,000.
Mrs. Christensen. And prison population, which is higher.
Dr. Vanderwagen. The running joke is if you want to get
better health care in Indian County, commit a Federal crime so
you can get better health care.
I have lived with that horrific, in my view, reality of
those kind of rationing decisions throughout most of my life
and career. This is a problem.
What we're talking about, however, is where you have too
few assets how will you reasonably and equitably consider your
triage decisions in that reality? No physician wants to be in
that position, but in fact, and indeed, this is a reality that
could occur.
It's our view that communities really need to think that
through ahead of time about how they will deal with those kind
of challenges. The answer of what constitutes equitability is
an ethical challenge that people at the community level really
need to work through and answer. I have my notions about that,
but I don't feel it's the Federal role to tell communities what
that standard should be, at least from the Executive branch
perspective and as a health professional.
So I understand your concern and the constraints and the
ground rules for that discussion have to be monitored closely
if we're going to assure that there's equity in that thought
process. It's a difficult challenge.
Mrs. Christensen. Should we reduce the funding to places
that haven't met their targets when they may be the most needy?
Dr. Vanderwagen. Congress in the passage of the Pandemic
and All Hazards Preparedness Act required that we institute a
matching program with appropriate penalties to be assessed in
the event that people did not meet the standards in the
requirements. We are acting against that authorization
requirement. Now it's our belief that we should have no one
fail, that it's our affirmative responsibility to work with
those communities, with those programs with our partners, both
Federal and State, to assure that we don't have that failure.
Notwithstanding that, I think it's a useful exercise in
assessing what is the investment that's needed across the
spectrum in this country to assure that we have sustainable
preparedness and response capability because I don't think we
understand fully what those costs look like. We know what some
Federal investments are. We know what some State investments
are. But part of my conversation with our State and industry
colleagues is this has been official tragedy and that it may
allow us to quantify more effectively what it takes to sustain
these kind of programs. We don't want to penalize. We're acting
under the law. We believe we should work to assure there is no
failure in this environment.
Lastly, in NOLA--I lived in that school for the blind for
months and this is my family now. My concern about NOLA is it's
not about the hospital biz, it's about what are doing at the
community level to provide effective chronic disease care,
effective primary care access, because if that exists, you
don't live in the emergency room.
In Indian Country where we could not afford hospitals, it's
our investment in that kind of chronic disease management and
primary care that led to health improvements in our population
that would be otherwise unexpected without those investments in
that part of public health and medical services. So I don't
know that the answer to NOLA is more hospital beds. They had
the highest per capita Medicare rate in the country and the
forty-eighth worst health status and yet they had 11 hospitals
sitting there in Orleans Parish. I don't know that hospitals
are the answer. I think there has to be a better solution to
meeting the health needs of their people than that.
Mrs. Christensen. I'd like to follow up back in Washington
on that.
Mr. Langevin. The Chairman now recognizes the gentleman
from New Jersey for 5 minutes.
Mr. Pascrell. Thank you, Mr. Chairman. Admiral Vanderwagen,
you make a lot of sense in what you say. As you know, and as
the Chairman is aware, we've been closely tracking progress on
the national preparedness efforts for pandemic influenza
outbreak, particularly the implementation of the national
strategy on pandemic influenza which was released back in
November 2005.
One of the key parts of the plan is that in addition to
Federal stockpiles of key medicines and supplies, we also need
States to act to establish their own stockpiles. It's very
clear in that charge to us. But the stockpile of antivirals, in
particular, the national plan calls for enough to treat 25
percent of the population and to reach that goal States have to
act. Am I doing all right so far?
To date, the Federal Government has purchased 50 million
courses of treatment as recommended under the NSPI. I
understand that States, on the other hand, have still only
stockpiled approximately 22.2 million of the 31 million courses
of antivirals which were called for in that strategy on
pandemic influenza, leaving us obviously short of the
requirement.
In New Jersey, we purchased about 880,000 courses of
treatment as of June, 2008, which is about 97 percent of the
State's allocation. It was done with some difficulty despite
the Federal match.
Obviously, with the economy as it is, many States are
struggling to meet this goal. So let me ask you this, for those
States that have not yet purchased or those that want to
purchase more, are you considering renewing a reduced national
price under which antivirals can be purchased either to
complete orders or to replace orders?
Dr. Vanderwagen. Yes.
Mr. Pascrell. You are considering that?
Dr. Vanderwagen. Through December.
Mr. Pascrell. If States can't purchase at the reduced price
and with a Federal subsidy, what are the chances we ever
complete the States' share of the national stockpiling goal?
Dr. Vanderwagen. I believe that we will achieve the 81
million doses that were called for which would cover 25 percent
of the population. I do not believe that every State will have
a State stockpile because of the decisionmaking in that State
and local environment and this is a Federal republic, after
all, and there are decisions.
In New Mexico, for instance, which is where I'm from really
elected to not participate because they wanted to acquire these
antivirals both for use in the seasonal influenza as well as
and they didn't want to be constrained by the Federal program,
so they're making their own acquisition. There are only a
couple of States that have totally said we're really not going
to buy any at this point. There is a question of equity there,
but----
Mr. Pascrell. That's my next question.
Dr. Vanderwagen. But again, this is a Federal republic and
we can't force States to make those determination where money
and their local considerations prevail. Again, they would get
their pro rata share of the Federal asset, but they are at risk
for the piece they didn't buy to cover their own.
Mr. Pascrell. Let me ask this question, if you have funds
left over that haven't been used to subsidize State purchases,
I certainly hope you would use those for additional Federal
antiviral purchases since this would directly affect any
national stockpiling shortfall.
Does that make any sense?
Dr. Vanderwagen. Yes, after December, we would reexamine
what remained in the balance for that subsidized acquisition
and we'd be likely to purchase antivirals for Federal use
beyond. It looks like that could be as much as $60 million
which would be about 3 million treatment courses. We'll just
have to see how this plays down as we go to the end of the
calendar year.
Mr. Pascrell. My final question to you, Admiral, is this.
You heard me discuss with Dr. Runge about the bifurcations
which exist throughout homeland security at the detriment, at
all of our detriment. Do you have any specific recommendation
that you would make to overcome these bifurcations that exist
all over the place in terms of your own specific experience?
What can we be doing to make your job easier and we haven't
done it?
Dr. Vanderwagen. Well, see, I believe that as Jeff alluded
to, I think we've worked through these issues between HHS and
DHS pretty well. In short, certainly DHS is the disaster
government, but within the organic assets of our department we
have tools that need to play in disaster response. What we've
come to understand is that it's our responsibility to build up
those assets so that they are available to play under the
direction of DHS and its elements in an event under the
national response framework.
I'm responsible for the ESF8, the public health and
medical. My DOD colleagues, my VA colleagues, HHS colleagues,
all need to be there to play when DHS needs us for the disaster
events.
I feel very comfortable that we've come to terms with that.
Now that's tough. You talked about a culture. Our culture is
subject matter expertise. We've got scientists and so on. They
live in that world. We have bureaucrats, law, regulation,
policy, procedure. They manage in that world to giving out
contracts and grants. For those of us in the preparedness and
response world, it's strategy, operations and tactics. It's how
do we talk across those three cultures that is the challenge
and that's an educative and mission-focused issue that I'm not
sure, sir, that the committees can influence as directly as we
in the leadership role have to be clear about the mission and
we have to be clear about those cross-cultural communications.
Mr. Pascrell. We need to put egos aside because otherwise
we cannot accomplish the goal.
Dr. Vanderwagen. Exactly.
Mr. Pascrell. We have problems in the Congress with that.
We have more chairmen and ranking members who serve on homeland
security than another committee I know of and everyone is
protecting their turf. So thank you for being a leader here.
Dr. Vanderwagen. It's about mission, not turf. It's
mission, not turf. The people expect us to be there. Thank you.
Dr. Runge. May I make one observation, Mr. Pascrell, if
you'll permit me? One of the reasons that there was this
dissonance between HHS and DHS is that the Congress actually
created an entity within HHS to do this work. Now they're not
unique as a department. We have requirements of many
departments to do their job of emergency support functions. I
would maintain that if all of the other relevant departments
had an entity, and by the way, these guys are sort of--they're
kind of weird within the HHS framework. They do operations and
they do preparedness and response. As you said, the rest of the
culture of the department, they pay for medical care. They do
science. USDA, DOD, State, EPA, all of those departments need
an ASPR-like function so that we can create more of that
dissonance with our departments so that we can get those issues
resolved. I would maintain that that's really something that
the Congress should look at and the reason that there appears
to be a bifurcation is that there was and frankly it took a
while to reach a more consonance.
Mr. Langevin. I will ask one parting question to Captain
Boynton. We appreciate you being here. I'd like to know what
activities have you personally undertaken as Deputy Regional
PFO for this region and for Rhode Island specifically, and do
you expect to be named Deputy Regional PFO for any other
biological events? I think that would be important to get on
the record.
Capt. Boynton. Thank you, Mr. Chairman. For Rhode Island,
it's principally been the Deputy PFO that's also the FEMA
Regional Administrator, Art Kleves. Admiral Lakai has two
deputies. One of those deputies is that FEMA Regional
Administrator, Art Kleves. He participates in most of the PFO
cell-related activities in FEMA Region 1 and as the second
Deputy PFO, I participate in most of the PFO's cell activities
in Region 2 which would be New Jersey and New York. So that's
been where most of my activity has been and I have also been
named as a Deputy PFO for hurricane in Region 2.
Mr. Langevin. Thank you very much. I thought that would be
important to get on the record. With that, the first panel will
be dismissed. I want to thank you all for your testimony today.
I want thank you very much for your service to your country. We
obviously have great challenges before us again with emerging
biological threats and public health preparedness. We stand
ready to work with you as partners in this effort to better
protect the country. Again, I want to thank you all for your
service, particularly, Dr. Runge, as you will be departing now
and leaving your current post. You've given great service to
the people of the United States and I thank you for your
service and your testimony.
Thank you. With that, this first panel is dismissed. Thank
you. I call up the second panel.
The hearing will come to order. I want to welcome our
second panel of witnesses here today, beginning with Dr.
Gifford, who is the Director of Health for the State of Rhode
Island Department of Health. Our second witness is Major
General Robert Bray. General Bray is the Adjutant General of
Rhode Island, the Commanding General of the Rhode Island
National Guard, the Director of the Rhode Island Emergency
Management Agency, and the Homeland Security Advisory for Rhode
Island. Welcome to you, General.
Our third witness is Mr. Thomas Kilday, Homeland Security
Program Manager at the Rhode Island Emergency Management
Agency. Welcome, Tom.
Our fourth witness is Peter Ginaitt, Emergency Preparedness
Director for Lifespan Hospital Network here in Rhode Island. As
many of us here know, Mr. Ginaitt is, of course, no stranger to
public service--he was eight-term Rhode Island State
Representative and a Veteran of the Warwick Fire Department. So
I want to welcome you, Peter, and again all of our witnesses
here, thank you for your service to our State and to the Nation
and for being here.
Without objection the witnesses' full statements will be
inserted into the record and I now ask each witness to
summarize his statement for 5 minutes, beginning with Dr.
Gifford. Because time is tight I should mention we'll have to
stick strictly to the 5-minute rule, both for statements and
for Member questions. So Dr. Gifford, welcome.
STATEMENT OF DAVID R. GIFFORD, DIRECTOR OF HEALTH, RHODE ISLAND
DEPARTMENT OF HEALTH
Dr. Gifford. Thank you, Chairman Langevin and
Representative Christensen and Representative Pascrell, welcome
to Rhode Island.
As the Director of the Department of Health, the Agency
that is responsible for promoting and protecting the public's
health, I'd like to thank you all for your continued focus on
the health and safety of Rhode Islanders and U.S. citizens.
As you know, all 50 States, the District of Columbia and
the territories receive public health emergency preparedness
and hospital preparedness through cooperative agreements with
the CDC and the Assistant Secretary for Preparedness and
Response. State health agencies use these Federal investments
to not only prepare for biological threats such as influenza
pandemic or bioterrorism, but also to enhance our capacities
and capabilities to address more frequently encountered
incidents.
Public health agencies are often at the forefront of
natural and unnatural events that impact all of our citizens.
During the 2007 calendar year, nearly all State health agencies
were involved in a response that required activation of their
incident command system, a system adopted Nation-wide as a
result of the Federal preparedness funding. More than a quarter
did this six times or more a month.
In my written testimony, I provided brief descriptions of
responses by health departments from around the country to such
incidents as weather-related disasters, tornados, blizzards,
floods, infectious disease outbreaks, food-borne illnesses,
drinking water contaminations, technology disasters, and acts
of violence. Each of the States were able to address these
because of their capabilities and capacities from the emergency
preparedness funding that you all have authorized.
Over the course of the past few years, the Department of
Health in Rhode Island has utilized the incident command system
on an average of every 3 to 4 months. We maintain a low, but
appropriate threshold when determining whether to utilize the
ICS to respond to health care issues and incidents, therefore,
we utilize the ICS structure for both major regional incidents
as well as for minor, less widespread events such as the TB
skin testing at a local high school in Central Falls, Hepatitis
A vaccine distribution to restaurant workers and to restaurants
are two recent examples.
These events also allowed us to test our medication
distribution plans developed for pandemic and bioterrorism
events. This approach has made us more efficient and effective
in our response to these situations and our response to these
situations has, in turn, made us better prepared to respond to
other potential emergencies such as a pandemic or bioterrorism.
Emergency preparedness funds and requirements have also
helped us purchase equipment and supplies that will help us not
only respond to unlikely events, but to more common health
issues. For example, we made significant upgrades in
modernizations of State laboratory equipment that can rapidly
detect biological agents and a whole array of chemical poisons.
This equipment and training in turn has helped us to better
test for pertussis, whooping cough, and mercury in cord blood.
By using this equipment for those nonemergency purposes has
helped our staff remain proficient and ready to use the
equipment for emergencies. For example, recently, we were able
to respond to a credible, white powder incident and provide an
answer to the FBI and law enforcement agencies in a matter of
hours, confirming that the powder was harmless and it was not
one of several possible biological agents such as anthrax or
ricin.
The funding has also helped us work more closely with other
State agencies with the health care provider community and with
the non-health care provider community such as the schools and
business. For example, we've worked closely with hospitals to
create a web-based hospital bed capacity system which provides
real-time information concerning hospital bed capacity 24
hours, 7 days a week. We use this system on a routine basis
which ensures that the hospitals are able to utilize it more
effectively during a major health incident.
We work jointly with the Rhode Island Disaster Medical
Assistance Team, DMAT, and the Medical Reserve Corps to develop
a database to register health care volunteers who can assist
during emergencies. This system allows us to check information
and credentials on potential volunteers long before an
emergency. With the next round of Federal funds, we'll be able
to upgrade the system to include an automated 2A alert system
that notifies and gives instructions to volunteers during an
emergency.
We've also worked with the Rhode Island Management
Association to create a special needs emergency register. This
registry targets Rhode Islanders with disabilities, chronic
conditions and other special health care needs which comprises
nearly 20 percent of the population in Rhode Island. This
registry will allow us to better plan for, but also to ensure
the delivery of needed services during emergencies. Future
funding will help us actually pilot test and actually implement
this.
As you consider reauthorizing the funds for this program, I
would recommend that you consider what you've heard here today.
Hopefully, I've highlighted the importance of supporting an
all-hazards approach to preparedness, rather than a focus on
just pandemic or just specific bioterrorist events.
Similarly, the training and equipment supported by these
funds must be incorporated into the routine activities of
agencies and tested on a regular basis, similar, Chairman, to
your suggestion of testing pandemic flu during the seasonal
influenza process.
Otherwise, without that incorporation in our daily
routines, it's much less likely that they will be utilized or
will be as effective when implemented during an emergency. I've
heard the military often say you should train the way you fight
which applies aptly to emergency preparedness.
In conclusion, I'd like to thank you and the committee
Members for your continued support to ensure that the Nation is
as best prepared as possible to respond to any incidents
impacting our public's health. I can confidently say that I
believe we as a State and for that matter as a Nation are
better prepared today to deal with a myriad of natural and
unnatural biological events. However, while the Nation has made
tremendous progress in a short amount of time, continued
support is necessary to ensure that we have the ability to meet
the challenges associated with each new event affecting the
citizens we all serve.
Thank you, and I'll be available for questions.
[The statement of Dr. Gifford follows:]
Prepared Statement of David R. Gifford
July 21, 2008
Congressman Langevin and committee Members, as the Director of the
Rhode Island Department of Health, an agency that is responsible for
protecting and promoting the public's health in Rhode Island, I would
like to thank you for continuing to focus on our Nation's health and
safety. This hearing today on ``Emerging Biological Threats and Public
Health Preparedness: Getting Beyond Getting Ready'' is just another
example of the attention by Congress to emergency preparedness that has
helped us become better prepared. The events of the world have not only
changed our mindset but have changed how we do our business in public
health. I can confidently say that I believe we as a State and as a
Nation are better prepared today to deal with a myriad of natural and
unnatural biological threats that we may encounter [Attachment A]. This
is due in large part to the funding and leadership provided by Congress
and the Federal agencies whom have worked in close partnership with the
States and local public health agencies.
All 50 States, the District of Columbia, five territories, three
freely associated States and three large metropolitan areas (New York
City, Chicago, Los Angeles County) receive Public Health Emergency
Preparedness funding from the Centers for Disease Control and
Prevention (CDC) and Hospital Preparedness Program funding from the
U.S. Department of Health and Human Services (HHS) Assistant Secretary
for Preparedness and Response (ASPR) through cooperative agreements.
The CDC and ASPR cooperative agreements are the primary source of
preparedness funding for State and territorial health agencies. Since
1999, the Federal Government has invested more than $8 billion in
public health and health system preparedness at the State and local
levels.
Public health agencies are often at the forefront of natural and
unnatural events that impact our citizens. Core public health
functions, such as disease outbreak investigations and prevention, are
traditional responsibilities of State and territorial health agencies.
Yet, health agencies play surprising--and critical--roles in all types
of incidents. Natural disasters, environmental emergencies,
infrastructure failures, foodborne outbreaks and mass acts of violence
all have one thing in common--large numbers of people who must be
protected.
State health agencies have used Federal investments in public
health and health system preparedness to not only prepare for
biological threats which have a low probability of occurring, such as
pandemic influenza or bioterrorism incidents, but to also enhance
capacities, build new capabilities, and strengthen the overall public
health infrastructure Nation-wide that can help us address more
frequently encountered incidents that have a direct or indirect impact
on the public's health. Federal funding and requirements have helped
health agencies in 48 States plus the District of Columbia and Puerto
Rico to adopt National Incident Management System (NIMS). NIMS is a
systematic approach for seamless incident management at all levels of
government. When responding to incidents, State and territorial health
agencies follow the Incident Command System (ICS), an organizational
structure that integrates operations, logistics, planning, finance/
administration, and command functions across all responders at the
scene. The physical location where incident management activities are
coordinated is the Emergency Operations Center (EOC). Depending on the
scope of an incident, State health agencies may use their own agency-
specific EOC or they may be integrated into the EOC of another entity,
such as that of a State emergency management agency. In Rhode Island,
we have determined that all employees should have an understanding of
the ICS system since any employee of the Rhode Island Department of
Health may be called on to respond in an emergency. Therefore, every
employee at the Department of Health is required to be trained at an
ICS level that is commensurate with their job duties and
responsibilities.
Whether a federally declared disaster or an everyday occurrence,
State and local public health agencies are now able to respond faster
and more effectively to meet the health and medical needs of their
populations because of national emergency preparedness efforts. During
the 2007 calendar year, nearly 90 percent of State health agencies were
involved in a response that required activation of their Incident
Command System or participation in an Emergency Operations Center. More
than a quarter did this six times or more. Emergency preparedness and
response has become an integral service provided by State and
territorial health agencies. Attachment B provides a brief description
of some of the types of responses by our Nation's health departments in
the past year to such threats as weather-related disasters (e.g.,
floods, hurricanes, blizzards, tornados, etc), infectious disease
outbreaks (e.g., meningitis, measles, mumps, or TB), food-borne
illnesses (e.g. salmonella, E. coli, etc), drinking water contamination
(e.g. salmonella), technology disasters (collapsing bridges, dam/dike
failures), acts of terrorism or acts of violence (e.g. Virginia Tech
shootings). In Rhode Island, we have had to respond to several highly
significant disease outbreaks, food-borne illnesses, contaminated
drinking water and weather-related events, using our ICS. The funding
for emergency preparedness has made us much more effective in our
response to these situations; and our response to these situations has
in turn made us much more effective for other potential emergencies.
Over the course of the past few years, the Department of Health has
utilized the Incident Command System (ICS) on average every 3 months.
The Department maintains a low but appropriate threshold when
determining whether to utilize ICS to respond to a health care issue or
incident. Therefore, the ICS structure has been utilized not only in
major regional incidents such as the Mycoplasma outbreak in January
2006, but it also has been utilized in less widespread events such as
the recent large scale TB skin testing at the Central Falls High School
as part of an outbreak investigation and a hepatitis A exposure related
investigation, leading to immunization of a large number of restaurant
workers at two local restaurants. Not only has this allowed us to be
more efficient and effective in our response but has provided us an
opportunity to train HEALTH staff and improve our ability to utilize
ICS. Consistent use of the ICS system when responding to major
infectious disease outbreaks has built ICS skills and teamwork within
the various units of the Department of Health that will assist in
future disease outbreak responses that are either natural (e.g.
pandemic) or unnatural (e.g. bioterrorism).
Emergency preparedness funds and requirements have helped us
develop stockpiles of critical equipment and supplies intended for use
in a large-scale incident such as a bioterrorism event or pandemic and
have been invaluable in helping our department respond to highly
significant but smaller-scale events. Our department has utilized
supplies stockpiled in response to public health emergencies such as a
Mycoplasma related outbreak and the Central Falls High School TB
outbreak. There have been enormous logistical benefits realized for
responding in an expedient and efficient manner to such events,
leveraging State-wide and departmental resources when the core unit
responding to the situation had exhausted its resources. The Department
of Health has created and equipped an operations center within the
Cannon Building that can be utilized when responding to any public
health emergency that does not rise to the level requiring activation
of the State EOC. In addition another room in the Cannon Building has
been equipped with phone lines and data ports that are utilized to
house the Department's emergency hotline system. These resources are
possible because of Federal funding and are utilized on a regular basis
by response personnel, which as a result not only helps provide better
care to the citizens of Rhode Island during health-related events but
also make us better able to respond should we have some unusual natural
(e.g. influenza pandemic) or unnatural incident (e.g. bioterrorism).
In Rhode Island, the Department of Health works in partnership not
only with other State agencies such as the Emergency Management Agency,
but also the health care provider community such as hospitals and the
non-health care community such as schools, integrating them in our
planning, training, and our responses to events that have either a
direct or indirect impact on the public's health.
Using Federal funds, we have worked closely with hospitals to
create a web-based Hospital Capacity System which has provided the
State with a significant resource when dealing with emergency
situations. This system operates 24/7 and provides real-time
information concerning hospital bed capacity. In addition, this system
supports an event calendar that details upcoming State-wide trainings,
exercises and drills. In addition, interoperable communication
mechanisms are being utilized on a daily basis by hospitals within the
State. The hospitals currently have 6 redundant forms of communication.
There will soon be an additional system with the addition of the 800
MHz radios. Their daily use ensures that the system will be utilized
correctly and effectively during a major health incident.
Funds available through the Federal emergency preparedness grants
have permitted significant upgrades and modernization of State
laboratory equipment. The Division of Laboratories has been able to
introduce rapid molecular methods of biological agent detection and a
whole array of chemical detection equipment. These gains enhanced not
just preparedness for emergencies, but also day-to-day laboratory
operations. This equipment and training has also been used to help us
better test for Pertussis (whooping cough) and mercury in cord blood.
Such capacity development not only helps us serve to contribute to
public health laboratory functions, thus benefits the public's health
but also keeps our staff proficient, trained and ready to use the
equipment whenever required. For example, we were able to respond
recently to a ``credible'' white powder incident and provide an answer
in a matter of hours, confirming that the powder was not one of several
possible biological agents (e.g. anthrax) or biotoxins/poisons (e.g.
ricin). This was only possible because of the equipment and training
provided by emergency preparedness grants as well as the coordination
we have with the FBI and other Law Enforcement agencies required to be
developed through emergency preparedness training activities.
We work with each municipality in RI to support a point of
distribution (POD) plan that enables them to distribute medication or
administer vaccines to their entire population. As part of a Medical
Emergency Distribution System (MEDS) plan we provide municipalities
with ``Go Kits'' to be used at Point of Distribution (POD) locations.
``Go Kits'' are a conglomeration of supplies that would serve to
facilitate the operation of an established POD site in a municipality
that has been tasked to dispense medication. The ``Go Kits'' contain
such items as office supplies (pens, highlighters, clipboards, etc),
cleaning supplies (paper towels, garbage bags, etc), crowd control/
information dissemination items (bullhorn, whistles, lanterns, etc),
medical supplies (disposable thermometers, stethoscope, etc), sign
holders, communications devices (weather band radio, two-way radios,
etc), and logistical support/utility devices (batteries, extension
cords, etc).
We have developed in partnership with the Rhode Island Disaster
Medical Assistance Team (DMAT) and the Medical Reserve Corp (MRC), a
database called State Emergency Registration of Volunteers in Rhode
Island (SERVRI). The triad of resources from SERVRI, MRC and DMAT is
called ``RI Responds'' and has the capacity to register, verify and
mobilize health and medical volunteers in an emergency response
scenario. ``RI Responds'' is an advanced registration system utilizing
a secure database of verified information provided by health care
professionals who have expressed an interest in assisting in the event
of a public health emergency or other disaster requiring trained
medical professionals. Once registered, volunteer professional
information is immediately verified prior to an emergency, so that
health care professionals may be deployed quickly and efficiently. When
a decision is made to request the services of emergency volunteers
registered within the system, they are presently notified manually (via
e-mail and telephone). With maintenance of Federal funds we will be
able to upgrade the system to include an automated two-way alert
system. Volunteers will be able to receive instructions for response,
when activated during a significant disaster or public health
emergency, through the electronic notification system (ENS) that will
be procured to facilitate deployment and utilization of all volunteers
found within the database. This ENS system will also link to our
program for tracking the deployment activations and locations of ``RI
Responds'' volunteers to provide a comprehensive management tool.
The Department of Health has establish a standing internal Special
Populations Emergency Preparedness Workgroup (SPEP). The Special
Populations Work Group is charged with: (1) Making recommendations
about our Emergency Response Plan to reflect the needs of special
populations; (2) coordinating activities related with special
populations during public health emergencies; and, (3) participating in
the Incident Command Structure. We also work with the Minority Health
Promotion Centers (community-based organizations targeting primarily
racial and ethnic minority populations) to assess community and agency
preparedness for risk communication and response to public health
emergencies.
We have worked in partnership with the Rhode Island Emergency
Management Agency, to create and implement a Special Needs Emergency
Registry. This registry targets Rhode Islanders with disabilities,
chronic conditions and/or other special health care needs. The primary
objective of the registry is to develop a reliable system for the
identification of Rhode Islanders who require special assistance during
emergency events by collecting key information for use by emergency
personnel to plan and respond to emergency events. Populated through
the submission of online or paper enrollment forms, the system is being
developed with the capability to generate electronic reports for
individual city and town use for emergency planning and response and
will be activated by the operation of the Incident Command System.
Currently 20 percent of the total State's population fall into the 5
areas the registry covers: Life support: includes dialysis,
respirators, oxygen; Mobility; Hearing/visual related issues; Cognitive
issues; Mental health-related issues. To date the registry has reached
approximately 3,500 people.
SUMMARY
Public health agencies are often at the forefront of natural and
unnatural events that impact the health of our citizens. Health
agencies play a critical role in all types of incidents: natural
disasters, environmental emergencies, infrastructure failures, food-
borne disease outbreaks and mass acts of violence, all of which have
public health impacts. The CDC and ASPR cooperative agreements are the
primary source of preparedness funding for State and territorial health
agencies but the proposed funding for the ASPR cooperative agreement is
25 percent less over the same time period (see attachment C).
State health agencies have used Federal investments in public
health and health system preparedness to not only prepare for those
threats which have a low probability of occurring such as pandemic
influenza or bioterrorism events but to also enhance capacities, build
new capabilities, and strengthen the overall public health
infrastructure Nation-wide that can help us address more frequently
encountered incidents that have a direct or indirect impact on the
public's health. Strained economic conditions across the country
combined with steadily decreasing Federal funding for public health and
health system preparedness threaten the progress that State and
territorial health agencies, along with their local, tribal and Federal
counterparts, have made within the last decade.
Rhode Island has used these funds to build capacity in both
personnel training and equipment purchase both internally within the
Department and with key partners in the community to not only be better
prepared to respond to biological threats but to all types of natural
and unnatural incidents as well as enhancing capacity for our core
activities. Without this support, we would not have been able to
address several health incidents as effectively or efficiently. As you
consider reauthorizing funds for these programs, I would recommend that
you consider what you have heard here today to not only make decisions
on the funding level but on the requirements related to the use of
these funds. Hopefully my testimony has highlighted the importance of
supporting an all-hazards approach to preparedness, not restrictions
that focus just on pandemic or specific biological threats. Similarly,
the training and equipment supported by these funds must be
incorporated into the routine activities of the agencies and tested on
a regular basis. Otherwise they are much less likely to be utilized or
effective when an unusual incident occurs. I have heard the military
say one ``should train the way you fight,'' which applies aptly to
emergency preparedness.
In conclusion, I would like to thank you and the committee for
their continued support in ensuring that the Nation is as best prepared
as possible to respond to incidents impacting the public's health. The
Nation has made tremendous progress in a short amount of time but
continued support is necessary to ensure that we continue to have the
ability to meet the challenges associated with each new event affecting
the citizens that we serve.
Attachment A.--State Health Agency Emergency Preparedness
All 50 States, the District of Columbia, five territories, three
freely associated States and three large metropolitan areas (New York
City, Chicago, Los Angeles County) receive Public Health Emergency
Preparedness funding from the Centers for Disease Control and
Prevention (CDC) and Hospital Preparedness Program funding from the
U.S. Department of Health and Human Services (HHS) Assistant Secretary
for Preparedness and Response (ASPR) through cooperative agreements.
The CDC and ASPR cooperative agreements are the primary source of
preparedness funding for State and territorial health agencies. Since
1999, the Federal Government has invested more than $8 billion in
public health and health system preparedness at the State and local
levels.
The CDC began funding several State health agencies in 1999 and
expanded its cooperative agreement to 62 grantees following the
September 11, 2001 terrorist attacks and the anthrax attack that soon
followed. The CDC Public Health Emergency Preparedness cooperative
agreement supports more than 3,500 State and local public health agency
staff working on preparedness activities Nation-wide. Funding under the
ASPR Hospital Preparedness Program cooperative agreement to the same 62
jurisdictions began following the 2001 terrorist attacks. While CDC and
ASPR distribute preparedness funds to State and territorial health
agencies and four large local health departments, 75 percent of the
funds directly or indirectly support local public health departments
and hospitals. State health agencies use ASPR cooperative agreement
funds to support preparedness activities for more than 5,000 hospitals
Nation-wide. Additionally, State health agencies provide non-financial
support to many of the local health departments and other partners
within their jurisdictions. According to a National Association of
County and City Health Officials (NACCHO) survey of local health
departments, ``64 percent received technical assistance for planning;
56 percent received laboratory support; 55 percent received
surveillance support; and 53 percent received support for exercise
planning and administration.'' Thus, Federal public health and health
system preparedness funds are used to improve response capabilities at
all levels in communities across the country.
State health agencies have used this investment in public health
and health system preparedness to enhance capacities, build new
capabilities, and strengthen the overall public health infrastructure
Nation-wide. This investment has paid off. Whether a federally declared
disaster or an everyday occurrence, State and local public health
agencies are able to respond faster and more effectively to meet the
health and medical needs of their populations.
State and territorial health agencies have played integral roles in
responding to a wide range of emergencies. In 2007 alone, there were 63
federally declared disasters and health agencies played a role in
responding to almost all of them. During the 2007 calendar year, nearly
90 percent of State health agencies were involved in a response that
required activation of their Incident Command System or participation
in an Emergency Operations Center. More than a quarter did this six
times or more. Emergency preparedness and response has become an
integral service provided by State and territorial health agencies.
Public health agencies are often at the forefront, just as anyone
would expect. Core public health functions, such as disease outbreak
investigations, are traditional responsibilities of State and
territorial health agencies. Yet, health agencies play surprising--and
critical--roles in all types of incidents. Natural disasters,
environmental emergencies, infrastructure failures, foodborne outbreaks
and mass acts of violence all have one thing in common--large numbers
of people whose health must be protected.
Health agencies at the State, territorial, local, tribal and
Federal levels are incorporating emergency management principles into
their activities to be consistent with the National Response Framework
(NRF). The NRF details response principles, roles and structures for
all-hazards national response and how they should be applied at the
State, local, tribal and Federal levels as well as by private sector
and nongovernmental partners. Health agencies in 48 States plus the
District of Columbia and Puerto Rico have reached National Incident
Management System (NIMS) compliance certification. NIMS is a systematic
approach for seamless incident management at all levels of government.
Incidents are natural or manmade occurrences or planned events that
require a response to protect lives or property. When responding to
incidents, State and territorial health agencies follow the Incident
Command System (ICS), an organizational structure that integrates
operations, logistics, planning, finance/administration, and command
functions across all responders at the scene. The physical location
where incident management activities are coordinated is the Emergency
Operations Center (EOC). Depending on the scope of an incident, State
health agencies may use their own agency-specific EOC or they may be
integrated into the EOC of another entity, such as that of a State
emergency management agency. In most States, the health department is
the lead agency for Emergency Support Function 8 (ESF-8), meaning they
are responsible for health and medical resources during an incident.
Health agencies may also support some of the other 15 total functions,
such as ESF-6, which is mass care, or ESF-10, which is oil and
hazardous materials response. With trained staff who understand NIMS,
health agencies are able to work side-by-side with their response
partners, regardless of agency or jurisdictional boundaries.
Attachment B.--Public Health Preparedness in Action: Examples From
Other State or Local Health Agencies
State and territorial public health agencies and the health care
system are stronger today because of the investment in preparedness.
State and territorial health agencies make a difference every day in
protecting the health and preserving the lives of Americans across the
country. Using Federal cooperative agreement funds provided through the
Center for Disease Control (CDC) Public Health Emergency Preparedness
Program and the Assistant Secretary for Preparedness and Response
(ASPR) Hospital Preparedness Program, State health agencies
strategically invest in personnel, equipment, supplies and training
that are drawn on during critical incidents, whether they are
infectious disease outbreaks, natural disasters, or foodborne outbreaks
and Nation-wide product recalls. Public health agency personnel work
with their response partners every day in all types of incidents and
are therefore always simultaneously preparing for disaster through an
all-hazards approach to emergencies.
These are just some of the high-profile examples from last year.
DISEASE OUTBREAKS
Recognition and response to agents of bioterrorism are predicated
upon effective foundations of disease surveillance, outbreak
investigation and response. These are core elements of public health
practiced daily by departmental units of clinical epidemiology and
infectious disease.
Mycoplasma pneumoniae.--When five children in the community were
diagnosed with severe neurological illnesses, the Rhode Island
Department of Health [RIDOH] stopped a worrisome infectious disease
cluster in its tracks by activating ICS and its mass dispensing plan to
provide antibiotics to more than 1,000 at-risk individuals, launching
an extensive public risk communication effort, and closing schools to
encourage social distancing to interrupt disease spread. In December
2006, RIDOH learned of five school-aged children with severe
neurological illness, including one who died. The Rhode Island
Department of Health contacted the Center for Disease Control (CDC) for
assistance with the disease cluster on December 22, 2006. CDC
laboratory testing confirmed the first positive results for Mycoplasma
pneumoniae on December 29. Mycoplasma infection clusters are rare and
there was an unusually large number of severe cases in a single school.
As a precaution, the RIDOH activated Incident Command System (ICS) and
with the assistance of State DMAT offered antibiotics via a mass
dispensing clinic to all 275 students, 40 staff members and their
families between December 31, 2006 and January 2, 2007. In total, 1,183
people received medication.
Operating within ICS, State health agency staff used the mass
prophylaxis training they had received as part of their Strategic
National Stockpile planning to dispense medication over the holiday
weekend. One hundred percent of the affected population was accounted
for and many participated in voluntary blood testing. State health
officials and CDC personnel reviewed medical records from the school
clinic and interviewed students and staff. Health officials, including
the State health director, also held community information sessions
with parents to address their concerns and set up a telephone hotline
and Web site for those seeking additional information. The school was
closed until January 8, 2007 to interrupt the transmission of illness
and so that 5-day antibiotic treatment courses could be completed
before students and staff returned to school.
Health officials also investigated reports of higher-than-normal
absenteeism in other schools in the area. On January 4, 2007, RIDOH
recommended the closure of three school districts, impacting 20,000
students and their families. This was a precautionary measure to
control disease and give the State health agency and the CDC time to
further investigate potential cases. The CDC is using this incident to
study the social and economic effects of school closures as part of a
community containment strategy in the event of an influenza pandemic.
RIDOH's success in containing this outbreak was, in part, due to
the investments made in its Medical Emergency Distribution plan, risk
communication strategy, and ICS training of all staff as part of its
all-hazards approach to emergencies.
Meningitis.--When meningitis sickened ten young people and killed
two, the Chicago Department of Public Health [CDPH] launched a mass
vaccination campaign to boost coverage rates and provide years of
health protection to more than 7,200 at-risk children. The Department
also used the incident as an opportunity to test its mass vaccination
planning.
By April 23, 2008, the city of Chicago had ten cases of group C
meningococcal invasive disease and two deaths for the year. The city
only had 13 cases in all of 2007. Meningococcal disease is a bacterial
infection that can cause meningitis and infect other tissues. The two
individuals who died of the disease in Chicago lived in an area of the
city with a low compliance rate for receiving the new vaccine. CDPH
decided to pre-empt the situation to avert a potential epidemic. To do
so, they launched a mass vaccination campaign to accelerate vaccine
coverage rates in the community. Focused on children aged 11 to 18,
vaccination teams targeted 10,000 children in 50 Chicago schools. Staff
from the CDPH and five suburban health departments administered vaccine
to 7,213 children in 2 weeks. The vaccine coverage rate of more than 70
percent among the targeted population is an impressive improvement over
the historic rate of 20 to 30 percent. No additional children died of
the disease, and the success of the vaccine campaign will continue to
protect the at-risk population from future outbreaks in the years to
come.
In addition to protecting the community's health, CDPH seized on
the opportunity to use the vaccine campaign to implement their mass
dispensing and mass vaccination planning it has developed with support
from the Federal preparedness cooperative agreements. The ability to
vaccinate or dispense medication to large numbers of people is one of
the core capabilities that health agencies across the country are
working to develop. Being able to implement a mass vaccination or mass
dispensing plan would be essential during a bioterrorism attack with an
agent such as anthrax or smallpox or a natural disease outbreak such as
pandemic influenza. Prior to the heavy investment in public health
preparedness, CDPH would not have been able to accomplish a response of
this size in such a short amount of time.
DRINKING WATER CONTAMINATION
A system that supports early detection and response to potential
threats to our drinking water supply are critical public health
functions.
Salmonella.--When the water distribution system for the city of
Alamosa became contaminated with salmonella, sickening more than 400
people, the Colorado Department of Public Health and Environment
[CDPHE] used all its resources to identify the source of the problem,
provide extensive risk communications to the public, work with partners
to implement a solution, and restore safe drinking water to homes and
businesses. The first case of salmonella was reported in Alamosa on
March 6, 2008. Through case interviews, epidemiologists discovered that
breastfed infants were not getting sick while those fed formula mixed
with tap water were. Laboratory samples collected from individuals,
from water in homes and from businesses confirmed that the same strain
of salmonella was present in all. Further investigation determined that
the aquifer supplying the drinking water was not contaminated.
Epidemiologists and water experts concluded that the source of
salmonella was somewhere in the water distribution system.
On March 17, Alamosa County established its Emergency Operations
Center (EOC) and CDPHE notified Federal partners of the outbreak. CDPHE
issued a bottled water order on March 19 and advised residents not to
use their tap water. The health agency also activated its public
information hotline and issued a mutual aid request for water experts.
The State public health laboratory, with personnel and equipment
supported by Federal preparedness funding, conducted sampling for
salmonella, total coliform bacteria and heavy metals. This was the
first time the laboratory had to conduct testing for human and
environmental outbreaks at the same time.
The Water Quality Control Division coordinated with the city to
develop and implement a plan to flush the city municipal water system
and conducted water sampling for bacteria and heavy metals before,
during and after the system flushing. The division also provided
guidance for water use during each stage of the system flush. CDPHE and
the local Joint Information Center continually updated Web sites,
issued news releases, developed information flyers and fact sheets, and
worked with local officials to activate Reverse 911 to get the word
out. Community volunteers delivered much of the information door-to-
door.
The boil-water order was finally rescinded by CDPHE on April 11. As
of April 30, there were 424 cases of salmonella, including 117 that
were culture-confirmed. Twenty-two people were hospitalized and one
death was attributed to the salmonella outbreak. The successful
conclusion of this outbreak was made possible by the significant
investment in laboratory services, epidemiology, Incident Command
System (ICS) and communication through emergency preparedness.
NATURAL DISASTERS
Natural disasters are predictably unpredictable in that we can be
certain that they will occur varying by location, nature and severity.
Natural disasters such as hurricanes, wildfires, earthquakes, tornados,
snowstorms and floods can have catastrophic public health consequences
and require a high level of preparedness.
Wildfires.--Twenty-three wildfires struck southern California in
October and November 2007. The wildfires caused ten deaths and 139
injuries, and forced the evacuation of 321,500 residents--the largest
evacuation in California's history. The California wildfires were just
one of 63 federally declared disasters in 2007. State health agencies
were on the front lines of most, if not all, of them. The California
Department of Public Health (CDPH) responded to the wildfires
immediately, deploying its 2,000 alternate care site bed cache to
Qualcomm Stadium to support the primary shelter set up for evacuated
residents. Health agency staff, including Director Mark Horton, were at
Qualcomm Stadium to ensure the shelter operated smoothly and that
medical needs were adequately met. At the same time, the CDPH
coordinated evacuations from threatened health care facilities,
including 12 nursing homes, two acute care facilities and a psychiatric
hospital. Throughout the response, the CDPH provided critical
information to local health agencies and providers through its Health
Alert Network. When the fires were contained and people returned to
homes and businesses, the CDPH and local health agencies evaluated
drinking water systems potentially contaminated by the wildfires.
Thanks to State health agency assets that were not available before the
recent focus on preparedness, the CDPH now has increased capacity to
respond to wildfires, earthquakes, hurricanes, tornados, blizzards and
other natural disasters.
Snowstorms.--When a record-breaking snowstorm dropped over 2 feet
of snow in October and knocked out power to 400,000 homes and
businesses, some for as long as a week, the New York State Department
of Health successfully partnered with local health agencies to protect
residents of western New York from carbon monoxide poisoning, food-
borne diseases, and other health threats while working with local
hospitals to assure appropriate staffing by deploying volunteer nurses.
The New York State Department of Health [NYSDH] activated its risk
communication plan and jointly issued a press release with the New York
State Emergency Management Office. The agencies cautioned the public on
cardiac risks resulting from the physical exertion of shoveling snow,
warned of carbon monoxide dangers due to the use of generators and
alternate heating sources, reminded of the importance of the safe use
of candles and heaters in preventing fires, and offered advice on the
safety of refrigerated food unable to be kept cold due to electricity
loss. As the extent of the storm damage became clear, NYSDH also issued
advice for those with end-stage renal disease who might not be able to
get to their dialysis treatments. Throughout the storm response, NYSDH
monitored public water supplies, conducted water sampling, and provided
guidance through county health departments to restaurants and food
establishments on safe food handling. The State health agency activated
its Emergency Medical Volunteer Database to identify and deploy nurses
from other parts of the State. Using CDC cooperative agreement funds,
NYSDH set up the database following the September 11 attacks. From the
registry of 11,242 medical professionals throughout the State willing
to volunteer during emergencies, the State health agency deployed
nurses from unaffected areas of the State. The State-based Health
Emergency Response Data System (HERDS) system was also widely used at
the county level. The Erie County Health Department detected an
elevated number of carbon monoxide exposures using HERDS. The Erie
County Health Department worked with the media to publicize a carbon
monoxide fact sheet.
Tornados.--When a tornado killed 11 residents and destroyed the
town of Greensburg, the Kansas Department of Health and Environment
[KDHE] helped make the town habitable again by assuring access to
health and medical services, restoring identities, and protecting
residents and recovery workers from environmental and safety hazards.
The Center for Public Health Preparedness was instrumental in helping
to secure medical supplies, personal protective equipment and
sanitation equipment for some of the response and recovery workers. One
of the immediate needs of Greensburg residents was met by the
Department's Center for Health and Environmental Statistics. The
tornado destroyed approximately 95 percent of the town, including
personal records such as birth and marriage certificates that people
need to prove their identities. Set up at the Disaster Recovery Center,
KDHE staff assisted Greensburg residents in filling out simple
application forms that were printed and faxed to the Department's
headquarters for overnight processing. KDHE reissued 355 birth and
marriage certificates for Greensburg residents. The environmental
component of the KDHE also played a major role. Staff from the Bureau
of Air and Radiation inspected commercial and public buildings for
asbestos. While not generally a health risk when used in building
materials, asbestos can cause serious lung diseases if airborne
particles from damaged buildings are inhaled. Bureau of Air and
Radiation staff labeled risks with red tape to indicate the presence of
asbestos. This triggered clean-up crews to use special precautions when
removing debris within the marked boundaries. While the KDHE would have
had the same responsibilities if the Greensburg tornado had occurred 10
years earlier, what changed in 2007 was the way the Department was able
to respond. Health agency staff trained in ICS with CDC preparedness
funds were able to integrate into the emergency response structure
alongside other responders such as police and firefighters who have
been using Incident Command System (ICS) for years.
Floods.--When flooding hit nine counties, the Ohio Department of
Health [ODH] maintained State-wide situational awareness to support
local public health agency response efforts and test new surveillance
systems. As in other States, ODH works with local health departments on
preparedness planning. This collaborative effort was effectively tested
during flooding in nine Ohio counties in August 2007. In Allen County,
the local health department used its upgraded communications equipment
to share information with State and local officials about flood damage
and the needs of the community. Public information staff, who had been
trained with funding from the CDC cooperative agreement, worked with
the media to get consistent health information to the public about
building clean-up, mold prevention, and the appropriateness of tetanus
and other vaccines. Mass dispensing plans developed as part of
Strategic National Stockpile preparations were used to rapidly set up a
tetanus vaccine clinic using volunteers from the Medical Reserve Corps.
Mutual aid agreements established with other local health departments
enabled a more efficient response to calls for assistance. All of these
tools enabled the Allen County Combined Health District to maximize its
personnel and other resources and to effectively determine resource
gaps to be filled by the ODH and other local health departments.
The flood also tested ODH's Real-time Outbreak and Disease
Surveillance (RODS) System. RODS provides for real-time analysis of
emergency department chief complaint data and over-the-counter drug
sales information and may be useful for the early detection of clinical
syndromes due to agents of bioterrorism. The system is used by more
than 300 health department and hospital personnel to detect and track
health events such as bioterrorism, outbreaks, influenza, and seasonal
illness. Currently, more than 85 percent of Ohio's emergency department
visits and approximately 70 percent of over-the-counter drug sales are
captured and analyzed by the system.
Using chief complaint data from the RODS system, the ODH's Early
Event Surveillance Unit's analysis found a statistically significant
five-fold increase in chief complaints related to insect bites in the
flooded region 2 weeks after the flooding began--the approximate amount
of time it takes for a mosquito to reach maturity. Public health
officials have long known that many diseases, such as West Nile virus,
are spread among the human population by mosquito bites. They also know
that standing pools of water, which are common following floods, are
major breeding sites for mosquitoes and other insects.
TECHNOLOGICAL DISASTERS
The Minnesota Department of Health (MDH) activated its regional
response plan following the August 2007 interstate bridge collapse that
killed 13 and injured nearly 100. The MDH used its Health Alert
Network, funded through the CDC cooperative agreement, to notify MDH
staff, local health agencies, hospitals and emergency management
partners of the bridge collapse, inform recipients to be ready to
respond, and provide updates throughout the response. The MDH,
hospitals and EMS used MNTrac, a decisionmaking tool implemented with
ASPR cooperative agreement funds, to monitor ambulance runs, status of
patients, and coordination of patient care transport and emergency
room/trauma care. Based on information provided through MNTrac and the
Health Alert Network, area hospitals activated their response plans and
were able to handle all of the victims. Using its ESAR-VHP system, the
MDH identified and credentialed behavioral health volunteers and
provided their information to the city of Minneapolis and the family
assistance center to be called upon to assist the victims, their
families and first responders in the immediate aftermath and the weeks
that followed. During the recovery phase, the MDH worked with
environmental agencies to identify and assess potential health risks
related to the air and water. As our physical infrastructure ages,
State health agencies will likely have to respond to more technological
disasters.
FOODBORNE OUTBREAKS
Foodborne diseases cause approximately 76 million illnesses,
325,000 hospitalizations and 5,000 deaths in the United States each
year at a cost of $5 billion. State and territorial health agencies use
Federal cooperative agreement funds to support food-borne outbreak
response, including epidemiologists to conduct outbreak investigations,
public health laboratory personnel and equipment to confirm outbreak
causes and communications professionals to notify the public of risks.
In July 2007, the Indiana Department of Health and the Texas
Department of State Health Services independently notified the CDC of
suspected food-borne botulism cases. In both States, epidemiology staff
investigated patient food histories to determine the cause of illness,
laboratory staff tested patient and food samples, and health agency
officials requested and distributed botulinum antitoxin from CDC. Once
CDC confirmed botulism as well as the source, the FDA issued a consumer
advisory and the manufacturer voluntarily recalled its canned chili
products from about 8,500 retail outlets. State health agencies across
the country engaged in extensive public education campaigns to get the
products off store shelves and out of people's homes to prevent
additional botulism cases. Thanks to improvements made to the public
health infrastructure with Federal preparedness funding, State health
agencies and their partners limited the botulism outbreak to eight
cases in three States.
TERRORISM & ACTS OF VIOLENCE
In 2006, 20,000 deaths resulted from 14,000 terrorist attacks
world-wide. The last acts of large-scale terrorism on United States
soil occurred in 2001, but major acts of violence continue to occur.
After these events, State health agencies and the health care system
must mobilize to protect lives while coordinating with law enforcement
officials to preserve evidence.
The Virginia Department of Health (VDH) immediately responded when
a gunman killed 33 and injured 27 others at Virginia Tech in April
2007. Using CDC cooperative agreement funds, the VDH had established
five regional response teams as part of its State-wide preparedness
system. Under the Chief Medical Examiner, the VDH deployed three public
information officers, a planner and a team of forensic scientists to
assist the regional team already in place. With Assistant Secretary for
Preparedness and Response (ASPR) cooperative agreement funds, the VDH
set up Regional Healthcare Coordinating Centers in each of the State's
six hospital regions. ASPR funds also support yearly upgrades to the
WebEOC system installed in hospitals throughout Virginia, hospital
staff training, purchase of redundant communications, and sustainment
of the Regional Healthcare Coordinating Centers. Using the State-wide
Web Emergency Response Center (WebEOC) system, the VDH, hospitals, the
35 local health districts, and emergency management partners tracked
the transport and condition of all injured victims, checked the
diversion status of hospitals, and monitored and responded to resource
needs of the affected hospitals. The VDH also provided risk
communications to the public, identified victims, supported family
services established by the university, and kept Federal and
international entities informed. This tragic example is a reminder of
the importance of coordinated, State-wide public health and health care
preparedness systems for rapid responses to mass casualty incidents.
While these incidents were among the most widely publicized of the
last year, State and territorial health agencies respond to similar
events around the country every single day. For more examples, please
visit States of Preparedness on (Association of State and Territorial
Health Officers) ASTHO's Web site at www.astho.org.
Attachment C.--Federal Budget Appropriation Declining
Continued cuts to State and territorial public health and health
system preparedness programs threaten the ability of jurisdictions to
respond as rapidly and effectively to future events as to those that
occurred over the last year-and-a-half. Lives have been saved and
diseases and injuries have been prevented through the significant
support that the Federal Government has provided public health agencies
through the CDC and ASPR cooperative agreements. However, the proposed
fiscal year 2009 budget calls for a funding level for the CDC
cooperative agreement that is 33 percent less than in fiscal year 2005.
The proposed funding for the ASPR cooperative agreement is 25 percent
less over the same time period.
These continued funding decreases, combined with the difficult
economic conditions in many States, will hinder the ability of State
and territorial health agencies to sustain and continue the progress
that has been made in public health and health system preparedness.
State and territorial public health agencies are beginning to cut
response personnel; limit opportunities for staff to train, plan and
exercise with other first responders; lose their ability to maintain
supplies and technology such as surveillance systems, laboratory
equipment and communications devices; and decrease their capacity to
produce and distribute public safety information. These changes will
make it difficult for State and territorial health agencies to
duplicate the successful responses seen to date. A sustained commitment
to public health preparedness will ensure that health agencies will
continue to be able to rapidly respond to all hazards by protecting the
health and lives of the public.
Mr. Langevin. Dr. Gifford, thank you for your testimony.
I now recognize General Bray for 5 minutes.
STATEMENT OF MAJOR GENERAL ROBERT T. BRAY, ADJUTANT GENERAL,
RHODE ISLAND; COMMANDING GENERAL, RHODE ISLAND NATIONAL GUARD;
DIRECTOR, RHODE ISLAND EMERGENCY MANAGEMENT AGENCY; AND
HOMELAND SECURITY ADVISOR, STATE OF RHODE ISLAND
Gen. Bray. Mr. Chairman, committee Members, thank you for
the opportunity to provide testimony regarding National Guard
planning and preparations to address emerging biological
threats. In addition to my duties, roles, and responsibilities
as the Adjutant General, you've noted many hats that I wear.
This management structure provides one focal point for the
Governor as well as for the Federal agencies.
As of today, the Rhode Island National Guard's primary
asset to assist local authorities is the Rhode Island National
Guard 13th Weapons of Mass Destruction Civil Support Team. The
Civil Support Team is a highly trained, full-time unit
specifically designed to assist local authorities in the event
of a chemical, biological, radiological, nuclear, or high-yield
explosive incident. The team is available 24/7 and located
centrally within the State to ensure maximum response times of
no more than 90 minutes. The CST maintains a close working
relationship with the first response agencies, including the
hazardous material response units in the State as well as with
CST units in other States for joint training exercises and
mutual aid assistant.
The National Guard is not intended to be a first responder
or the lead agency. We are the State's larger response option
and as such we remain proactive in providing support through
training, preparation, and planning. The National Guard is
committed to the fundamental principle that each and every
State and territory must possess ten core capabilities for
homeland readiness. Amidst the most extensive transformation of
our Army and Air Force in decades, the National Guard intends
that every Governor has each of these essential ten
capabilities. Those capabilities are a Joint Force Headquarters
for command and control element with immediate access to a
quick reaction force; a Civil Support Team; engineering
capabilities; communications capabilities; all-terrain ground
transportation capabilities; aviation capabilities; medical
capabilities; security forces capabilities; logistics
expertise; and maintenance capabilities.
The Rhode Island National Guard is uniquely situated to
provide each of these ten core capabilities in support of civil
authorities for responding to a biological or other domestic
incident. Our ability to quickly assemble and deploy a critical
mass of disciplined personnel is our greatest asset.
Allow me to speak to this issue as I know there has been
national concern about this capability given our robust
operations template in support of the global war on terror. As
of July 15, 2008, the assigned strength of the Rhode Island
National Guard was 3,274 soldiers and airmen. As of July 15,
2008, minus mobilized, deployed, and those in training, 71
percent or 2,327 soldiers and airmen were available to support
domestic operations if requested by civil authorities,
exceeding the 50 percent threshold goal established by the
Chief National Guard Bureau to respond to domestic incidents in
support of civil authorities. Clearly, the Rhode Island
National Guard provides the State of Rhode Island with a
robust, all-hazard capability to include biological incident
response. All is not perfect to be sure. At the core of
capability is the need for clearly defined roles, missions and
responsibilities. The default for response should not be the
National Guard, due to a lack of capability at the local
response level.
Accordingly, local, State and Federal funding is essential
for adequate personnel, equipment, training, facilities, and
planning capabilities at these levels. Additionally, our
ability to assist civil authorities is dependent on our being a
properly- and full-resourced organization. We are now an
operational force. As such, we need 100 percent full-time
manning, 100 percent of authorized equipment, State, and
Federal support for our military construction budget, and full
funding of our operational and maintenance budgets. This will
also best posture us for civil support and disaster response
and recovery capabilities.
Consequently, I support the National Governors Association
letter to the Chairman and Ranking Member of the House and
Senate Committee on Armed Services which opposes past House
amendments to the Federal Insurrection Act. The National Guard
must not be ordered to Title 10 duty without the consent of the
Governor, particularly for natural disasters.
In closing, planning, preparation, resourcing, and
responding to a biological threat or other domestic incident is
a continual process that must adapt to a complex and changing
secured environment. The role and mission of the National Guard
and the command and control of the Adjutant General with the
Governor as Commander-in-Chief, past, present, and future, is
essential to the success of domestic preparedness and response.
Partnerships and resources at both the State and Federal level
are vital in our efforts to ensure that we stand ready,
relevant, reliable, and accessible in support of civil
authorities in the event of a biological or other domestic
incident.
Thank you for this opportunity to testify and I am
available for questions.
[The statement of General Bray follows:]
Prepared Statement of Robert T. Bray
July 22, 2008
Mr. Chairman, committee Members, thank you for the opportunity to
provide testimony regarding National Guard planning and preparations to
address emerging biological threats.
It is expected that in the event of a biological incident such as
pandemic influenza, the entire United States will be affected within a
matter of days. The impact will likely affect all dimensions of our
national infrastructure. In addition to actions at the local, State,
and Federal Government level in a coordinated response to the needs of
the public it should be noted that private sector resources will be
expected and needed. Included in a response to a biological incident
will be the National Guard of each State in concert with the Department
of Defense (DoD) and other Federal agencies in both a Title 32 and
Title 10 capacity.
INTRODUCTION
As always by law, the National Guard's primary mission is support
to local authorities in a domestic crisis. The National Guard is not
intended to be a first responder or the lead agency for any emergency
response effort. The National Guard will nevertheless be pro-active in
providing support through training, preparation and planning. The close
relationship, in the State of Rhode Island, between the Director of
Military Support and the Emergency Management Agency through the Rhode
Island National Guard Joint Operation Center and the State Emergency
Operation Center under the organization of the Office of the Adjutant
General facilitates the constant situational awareness required to
alert and mobilize the National Guard in a timely manner.
Presently, the Rhode Island National Guard Joint Operation Center
is minimally staffed for 24/7/365 operation. The State Emergency
Operation Center is presently staffed during regular business hours
with a ``call service'' during other hours to key personnel, unless an
anticipated situation demands that we implement 24-hour staffing. A
model for merging the capabilities between the two entities to ensure a
24/7/365 staffing of a single Joint Interagency Coordination Center for
full situational awareness toward a State-wide common operating picture
is being prepared for consideration. The limitations of facilities,
personnel, funding, and statutes impede progress toward this necessary
organization in support of the Homeland Security domestic response.
The National Guard Bureau (NGB) and by extension the Rhode Island
National Guard, is committed to the fundamental principle that each and
every State and territory must possess ten core capabilities for
homeland readiness. Amidst the most extensive transformation of our
Army and Air Forces in decades, the National Guard intends that every
Governor has each of these ``essential 10'' capabilities:
A Joint Force Headquarters for command and control;
A Civil Support Team for chemical, biological, and
radiological, nuclear and high-yield explosive (CBRNE)
detection;
Engineering assets;
Communications capability;
Ground transportation;
Aviation;
Medical capability;
Security forces;
Logistics and maintenance capability.
A RHODE ISLAND NATIONAL GUARD PERSPECTIVE
The Rhode Island National Guard possesses all of these capabilities
in the following organization:
A Joint Force Headquarters for command and control located
at the Command Readiness Center in Cranston, Rhode Island under
the command of a Brigadier General.
The Civil Support Team for chemical, biological, and
radiological detection, nuclear or high-yield explosive (CBRNE)
mission is assigned to the Rhode Island National Guard's 13th
Weapons of Mass Destruction (WMD) Civil Support Team (CST)
located in Coventry, Rhode Island.
Engineering assets are provided by the 861st Engineer
Company located in East Greenwich, Rhode Island and the 143d
Civil Engineering Squadron in North Kingstown, Rhode Island.
Communications provided by the 281st Combat Communications
Group and 282nd Combat Communications Squadron located in North
Smithfield, Rhode Island.
Ground transportation capability is supported by all the
organic units of the Rhode Island Army and Air National Guard
with HUMMWV and medium truck assets.
Aviation support is provided by the 143rd Airlift Wing and
the 1/126th Army Aviation Battalion located at Quonset Point,
Rhode Island.
Medical capability is limited through the Rhode Island Army
National Guard Medical Command, the 143d Air Wing Medical Group
and unit assigned medical personnel.
Security forces are supported by the 43rd Military Police
Brigade located in Warwick, the 143d Security Forces Squadron
in North Kingstown and through the detail of the Quick Reaction
Force.
Logistics and maintenance capability is supported by the
United States Property Book Office located in Providence, Rhode
Island and the Combined Support Maintenance Facility, as well
as the Forward Support Company of the 1/103d Field Artillery
Battalion.
The primary National Guard asset, in Rhode Island, to assist local
authorities with their response to a biological incident is the Rhode
Island National Guard 13th Weapons of Mass Destruction (WMD) Civil
Support Team (CST). The CST is an operational, State-based, full-time
unit specifically designed to assist local authorities in the event of
a chemical, biological, radiological, nuclear or high-yield explosive
(CBRNE) incident. The team is available 24/7 and located centrally
within the State at the Coventry Air National Guard Station and is able
to respond to a request by civil authorities within 60 to 90 minutes.
The CST maintains a close working relationship with first response
agencies, including the Hazardous Material Response units in the State
as well as with the CST units of the other States for assistance.
In the event of a biological incident, we anticipate that in
addition to the 13th CST, civil authorities will request personnel,
transportation and communications support to augment their response
efforts. Additionally, the CBRNE Enhanced Response Force Package (CERF-
P) and the CBRNE Consequence Management Response Force (CCMRF) are two
national assets supported by the National Guard and the Department of
Defense designed to provide regional support for a catastrophic
homeland event.
As of July 15, 2008, the assigned strength of the RING was 3,274
soldiers and airmen (2,107 Army National Guard and 1,167 Air National
Guard). Mobilizations and training requirements reduce the amount of
available personnel who are able to support domestic operations.
As of July 15, 2008, 71 percent (2,327 soldiers and airmen) were
available to support domestic operations if requested by civil
authorities. This figure exceeds the threshold goal established by the
Chief, National Guard Bureau when he ensured Governors that his goal
was to maintain a minimum of 50 percent of a State's personnel and
equipment in the State to respond to domestic incidents in support of
civil authorities. We anticipate that civil authorities will request
personnel to conduct security, logistics, transportation, and
communications operations.
In the planning process, we make the assumption that that
individuals currently assigned to the RING and working in civilian
health care, police, emergency medical service and fire professions
will not be available for mobilization with the Rhode Island National
Guard. The limited medical assets within the Rhode Island National
Guard's current force structure will primarily support the medical
needs of service members activated to conduct domestic support
operations.
The current force structure and projected force structure provides
sufficient resources to conduct security and logistic operations. We
anticipate that civil authorities will request personnel to man traffic
control check points and establish area security. Our military police,
security forces and other units provide the RING with sufficient
capability to accomplish these operations. Additionally, we anticipate
that civil authorities will require National Guard support to move
supplies and manage points of distribution. Current personnel levels
and the transportation assets described below provide sufficient
capabilities to conduct these operational tasks.
The RING maintains a variety of transportation assets which include
wheeled vehicles, helicopters and fixed wing aircraft. These assets
provide civil authorities with a capability to move personnel, supplies
and equipment to critical areas. Additionally, the airstrip at the
Quonset Air National Guard Base provides civil authorities with an
alternate port of embarkation/debarkation for resources transiting in
and out of Rhode Island.
Communications assets within the RING provide a valuable capability
to civil authorities. In addition to those assets assigned the 13th
CST, the Joint Command, Control, Communications, and Computer (J4)
Coordination Center, which is commonly referred to, as the JCCC is
located in North Smithfield, Rhode Island. The JCCC is a sub-component
of the Joint CONUS Communications Support Environment (JCCSE). The JCCC
assists in maintaining situational awareness, planning, and
coordination during homeland defense and civil support operations. The
JCCC serves as a single control agency for the management and direction
of the joint force command, control, communications, and computer
systems. Rhode Island also has the capability of another component of
the JCCSE which is the Joint Incident Site Communications Capability
(JISCC). The JISCC is a satellite package that can be towed or
airlifted to an incident site. It contains communications assets that
can communicate via high-frequency radio, telephone, video and
satellites to interface a variety of communications equipment used by
first responders, State, and Federal agencies and can be operational
within 90 minutes upon arrival at the incident site. Additionally, the
NGB has the capability to deploy a Joint Enabling Team (JET) to the
State. JETs assists in the collection, reporting and sharing of
information in order to identify potential response needs, coordinate
the response, and facilitate the support requested by civil
authorities.
PARTNERING WITH STAKEHOLDERS
While the RING has sufficient capabilities to support civil
authorities in the event of a biological incident or other domestic
support operation, we recognize the changing nature of the security
environment. We recognize that gaps may exist between our capabilities
and those needed by civil authorities. As we identify challenges and
opportunities we continuously engage our strategic partners. For
example, in an effort to engage our Emergency Management Assistance
Compact (EMAC) and other strategic partners within FEMA Region I, we
recently hosted the Regional Interagency Steering Committee (RISC)
conference.
The RING, specifically the 13th CST, is currently partnering across
all sectors of the State in the areas of planning, training, and
response thereby increasing the State's ability to respond to incidents
of national significance. We are currently experiencing tremendous
success at the second tier response level (State level) and have
established partnerships with a myriad of State agencies and Federal
agencies to include:
RI Emergency Management Agency;
RI Department of Health;
RI Department of Environmental Management;
Rhode Island State Weapons of Mass Destruction Tactical Team
(RI-WMD-TT);
RI regional HAZMAT teams;
RI regional DECON teams;
RI HAZMAT Working Group;
RI Disaster Medical Assistance Team (DMAT);
RI State Police Fusion Center;
U.S. Attorney's Office Anti-Terrorism Advisory Council;
Newport Naval WMD Decontamination Team;
Boston FBI Office, CBRNE Division, Hazardous Response Team;
U.S. Army North;
Northern Command;
National Guard Bureau;
FEMA Region I.
Current examples of joint training conducted with these partners
include the RING's recent hosting of the Defense Threat Reduction
Agency (DTRA) CST Radiological Response Course, and the 13th CST
Advanced Chemical Special Topics Laboratory Scale Preparation of Field
Expedient and Improvised Chemical Weapons with Hazard Assessment
Laboratory. In addition, the Rhode Island National Guard conducted
numerous regional training exercises focused on support to civil
authorities during which we exercised our collective response
capabilities to include our National Guard Response Force (NGRF), WMD
CST, Joint Operations Center (JOC) and Joint Incident Site
Communication Capability (JISCC). Ongoing initiatives include
participation in the Ingestion Pathway Response Plan Annual Review, CST
Critical Facilities Informational Site Packets, the development of
tabletop and situational training exercises with the Providence Urban
Area Security Initiative (UASI), Transportation Security Administration
(TSA), Army North (ARNORTH) and U.S. Northern Command (NORTHCOM).
Additionally, three out of the four General Officers currently assigned
to the National Guard are trained and certified as Joint Title 10 and
Title 32 Task Force Commanders for domestic operations.
TAG DUTIES, ROLES, AND RESPONSIBILITIES
The duties, roles, and responsibilities of my position in the State
create a positive environment for partnerships and cooperation. In
addition to my duties, roles and responsibilities as The Adjutant
General of Rhode Island and the Commanding General of the Rhode Island
National Guard, I also serve as the Homeland Security Advisor for the
State of Rhode Island and the Director of the Rhode Island Emergency
Management Agency. This unique management structure provides one focal
point for the Governor, as well as for the Federal agencies.
Additionally, it helps to ensure a common direction for all
stakeholders. Clearly defined goals and objectives facilitate a unity
of effort, common operating picture and situational awareness.
CONCLUSION
Clearly the Rhode Island National Guard provides the State of Rhode
Island with robust all-hazard capability as well as for biological
incidents. All is not perfect to be sure. At the core of capability is
the need for clearly defined roles, missions, and responsibilities. The
default for response should not be the National Guard due to a lack of
capability at the local response level. Therefore, local, State, and
Federal funding is essential for adequate personnel, equipment,
training, facilities, and planning. As an operational war fighting
organization, the Rhode Island National Guard must be properly
resourced. The Rhode Island National Guard is an operational force. It
is an all-hazard, full-spectrum force engaged today in combating
terrorism, war fighting, and domestic support. The Rhode Island
National Guard needs 100 percent full time manning, 100 percent of TO&E
equipment, State and Federal support for our military construction
budget, and full funding of its operational and maintenance budget.
Consequently, I support the National Governors Association (NGA) letter
to the Chairman and Ranking Member of the House and Senate Committees
on Armed Services, which opposes House amendments to the Federal
Insurrection Act. If enacted as part of the 2009 National Defense
Authorization Act, these provisions would empower the President to
order military Reserve components other than the National Guard to
Title 10 duty for domestic missions, including natural disasters and
emergencies for which States qualify for Federal funding under the
Robert T. Stafford Act.
In closing, planning, preparing, resourcing, and responding to a
biological threat or other domestic incident is a continual process
that must adapt to a complex and changing security environment. The
role and mission of the National Guard under the command and control of
The Adjutant General with the Governor as Commander-in-Chief, past,
present, and future is essential to the success of domestic
preparedness and response. Partnerships and resources at both the State
and Federal level are vital in our efforts to ensure that we stand
Ready, Relevant, Reliable, and Accessible in support of civil
authorities in the event of a biological or other domestic incident.
Mr. Langevin. Thank you, General Bray, for your testimony.
The Chair now recognizes Tom Kilday for 5 minutes.
STATEMENT OF THOMAS J. KILDAY, JR., HOMELAND SECURITY PROGRAM
MANAGER, RHODE ISLAND EMERGENCY MANAGEMENT AGENCY
Mr. Kilday. Thank you, Mr. Chairman, and Members of the
committee. I want to thank you for inviting me to speak with
you today to discuss the current successes and on-going
challenges in planning and preparing for all-hazard events here
in Rhode Island.
I need to share with you my dual perspective as a homeland
security program manager for the Rhode Island Emergency
Management Agency and a former public health response
coordinator at the Rhode Island Department of Health.
The Rhode Island Emergency Management Agency serves as the
State's primary coordinating agency for State-wide preparedness
and response to all-hazards events. Prior to 2001, preparedness
efforts in Rhode Island, as in many other areas of the United
States, were focused only in the State's Emergency Management
Agency. Work was limited to the new domestic preparedness grant
activities and preparing for natural disasters. The events of
September 11, 2001 followed by the October 2001 anthrax attacks
catapulted public health into the preparedness arena and forced
cooperation with emergency managers and other first responders.
Rhode Island EMA and Health, in coordination with Federal,
State, and local partner agencies implemented many preparedness
systems and response capabilities since that time. Rhode
Island's small geographic size, diverse ideas, lack of county
government, and close working relationships among government,
public, and private sectors are some of the key agreements that
enable Rhode Island to have an effective preparedness planning
program.
Rhode Island's EMA is currently working on multiple
projects including developing situational awareness tools to
common operating solutions in order to link numerous, disparate
systems currently utilized in the State into a consolidated
information hub to facilitate planning and response, building
the Rhode Island communications network, RISCON, which is a
border-to-border, 800-megahertz digital radio system designed
to provide seamless digital voice communications to all
responders. Most recently, we're in the process of purchasing
1,400 radios for placement in front line fire, police, and EMS
vehicles. State-wide continuity of operations planning,
including the development of State-wide pandemic flu plan in
cooperation with the Department of Health.
In addition, Rhode Island EMA participates in Federal, 15
Federal preparedness grant programs, including the application
process, development, monitoring, and subgrant support. A
common grant concept that has fostered interagency cooperation
has been surge capacity management and planning over the years.
In Rhode Island the Station Night Club fire served as an
important event highlighting the need for improved coordination
and management of surge capacity. In February 2003, the Station
Night Club in West Warwick, Rhode Island caught fire with an
estimated 400 persons attending a rock concern. Hundreds were
sent or self-transported to area hospitals. The fast-moving
fire caused 100 fatalities, making it the fourth-deadliest fire
in the United States history at that time. This tragic event
provided Rhode Island with a real-world mass casualty fatality
response experience. Since then, the emergency planning
community in Rhode Island continues to revisit actions and
lessons learned from this incident and have, to date,
established procedures and protocols for the activation of
surge capacity plans, implemented bed tracking, web-based
software, expanded interoperable communication system within
the hospital and first responder community, redesigned our
emergency operation center, expanded the State-wide mutual aid
plan, established regional mass casual response teams, and
enhanced the capability of the Rhode Island Disaster Medical
Assistance Team.
I want to talk a little bit about DMAT. Rhode Island DMAT
is a category 1 team of the National Disaster Medical System.
The team has more than 250 medical professionals and support
personnel with its Federal cache of medical and logistics
equipment and is prepared to deploy anywhere in the country
within 6 hours' notice. The State has acquired a cache of
medical and logistical equipment that will enable Rhode Island
DMAT to act as an alternative care site, a stand-alone
emergency department or a mass immunization and medication
clinic within the State, even if the team has been deployed
out-of-State with their Federal cache.
NDMS recently regionalist DMAT Federal caches and closed
multiple team warehouses throughout the country, including
those of Rhode Island DMAT. This move effectively eliminates
the ability of Rhode Island team to utilize their Federal cache
to serve their own community during disasters and limits their
maintenance and training capabilities. This is of special
concern during a pandemic flu event when State borders may be
closed and movement of materials is restricted.
In conclusion, Mr. Chairman, efforts outlined in this
testimony are just a snapshot of the numerous programs and
activities designed to enhance the preparedness of Rhode
Island. I ask for your support in leading congressional efforts
to increase surge capacity management and response
capabilities, enhance, interoperability among hospitals and
first responders, encourage common operating picture solutions
in place of disparate systems, emphasize the importance of
developing nontraditional partnerships, and finally, continue
support for the development of the Disaster Medical Assistance
Team.
Additionally, at this time, it is important to also mention
that multiple grant programs, disparate time lines, numerous
reporting requirements and a continually changing Federal focus
detract from our programmatic preparedness efforts. It is
critical that all Federal preparedness grant programs be more
closely aligned and coordinated, while locally a larger grant
management team would be helpful, Federal support, such as
combining grants, multi-year funding, and alignment of program
deadlines would allow for much more efficiency.
Mr. Chairman and Members of the committee, I thank you for
this opportunity to discuss these important issues with you
this morning and I'd be happy to answer any questions.
[The statement of Mr. Kilday follows:]
Prepared Statement of Thomas J. Kilday, Jr.
July 22, 2008
Mr. Chairman and Members of the committee, my name is Thomas J.
Kilday, Jr. NREMT-P. I serve as the Homeland Security Program Manager
for the State of Rhode Island Emergency Management Agency.
Additionally, I serve as a practicing Paramedic for the Rhode Island
Disaster Medical Assistance Team. I previously served as the Emergency
Response Coordinator at the Center for Emergency Preparedness and
Response, at the Rhode Island Department of Health where I worked on
public health preparedness activities.
Since 1999 I have worked in various capacities serving in local,
State, Federal and international arenas. Most recently, I served as a
public health preparedness manager who transitioned to working in the
field of emergency management. This experience provides me with a broad
perspective on the all-hazards approach to preparedness focusing on the
collaboration between public health and emergency management, which is
the focus of this testimony.
I want to thank you for inviting me to speak with you today to
discuss the current successes and ongoing challenges in planning and
preparing for all-hazards events. I am eager to share with you my dual
perspective as both the Homeland Security Program Manager and a former
public health preparedness team member for our Nation's smallest State.
As of today, although the progress made in preparing Rhode Island has
been significant there is still considerable work that needs to be
done, and there are challenges both of scope and depth of preparation
that need to be addressed.
RHODE ISLAND EMERGENCY MANAGEMENT AGENCY (RIEMA)
The Rhode Island Emergency Management Agency serves as the State's
primary coordinating agency for State-wide preparedness and response to
all-hazards events. Rhode Island Emergency Management is provided
authority under RI General Law 30-15 to provide the following:
To reduce vulnerability of people and communities of this
State to damage, injury, and loss of life and property
resulting from natural or man-made catastrophes, riots, or
hostile military or paramilitary action or acts of bio-
terrorism.
To authorize and provide for coordination of activities
relating to disaster prevention, preparedness, response, and
recovery by agencies and officers of this State, and similar
State-local, inter-State, Federal-State, and foreign activities
in which the State and its political subdivisions may
participate .
To provide the State with the ability to respond rapidly and
effectively to potential or actual public health emergencies or
disaster emergencies.
Additionally ``The mission of the Rhode Island Emergency Management
Agency is to reduce the loss of life and property in natural and man-
made incidents by utilizing an all-hazards approach to prevention,
preparedness, response and recovery through a program of leadership and
expertise in comprehensive emergency management while providing
strategic partnerships, innovative programs, and coordination of State,
regional and Federal resources.''
The Emergency Management Agency provides this support to the
citizens of Rhode Island through the efforts of our 27 employees led by
its Director Major General Robert T. Bray, Adjutant General, Homeland
Security Advisor and Executive Director J. David Smith who is
responsible for day-to-day operations and agency coordination.
RHODE ISLAND'S HISTORY OF PREPAREDNESS
Prior to 2001, preparedness efforts in RI were focused in the
State's Emergency Management Agency. This work was limited to managing
the new Domestic Preparedness grant program activities and the
continuing mission to prepare for natural disasters. The events of
September 11, 2001, followed by the anthrax attacks in October 2001
catapulted public health into the preparedness arena and forced
cooperation with emergency managers and other first responders. The
Rhode Island Department of Health (HEALTH) was charged with managing
both the CDC's Bioterrorism Preparedness Program and HRSA's National
Hospital Bioterrorism Preparedness Program. With the implementation of
the preparedness grant programs, the State and HEALTH, in coordination
with Federal, regional, tribal, State, and local partner agencies, have
implemented many preparedness systems and response capabilities.
A CULTURE OF PREPAREDNESS
The strength of Rhode Island's preparedness efforts rests in the
ability of the Government, public, and private sectors to organize and
plan through multiple committees and working groups, all focused on the
primary goal of preparing Rhode Island for the worst, most probable
disaster. Rhode Island's small geographic size, diverse culture, lack
of county government and the close inter-working relationships are the
key ingredients that enable Rhode Island to have effective preparedness
planning program. At the core of Rhode Island's preparedness program is
the Emergency Management Advisory Council (EMAC). Chartered by statute,
this group advises the Governor on preparedness activities within the
State. EMAC is co-chaired by the Lieutenant Governor and the Adjutant
General, who also serves as the Homeland Security Advisor for Rhode
Island. The group has a total of 30 representatives from all sectors of
Rhode Island. The challenge encountered with the above described
committee is ensuring that all partners remain actively engaged in the
planning process.
INTERSTATE REGIONAL COORDINATION
Rhode Island has a strong relationship with our regional partners
at many working levels. Given current systems and Government
structures, these regional activities focus primarily on planning.
Because no overarching governmental system and therefore, no oversight,
exists at the regional level, there is great disparity in the types and
levels of planning that occur at the regional level. Despite this lack
of oversight, Rhode Island has forged forward to involve other New
England partners in building relationships and discussing response
mechanisms.
Current agency goals pertinent to this testimony include the
following:
Development of Situational Awareness (SA) tools and Common
Operating Picture (COP) solutions linking the State and local
agencies with RI Emergency Management.
Development of RI State-wide Communications Network (RISCON)
which is a border-to-border 800MHz Digital Radio System to
provide seamless digital voice communications to all
responders.
Grant management activities including the coordination of
more than 15 Federal grant programs and their reporting
requirements.
State-wide continuity of operations (COOP) planning
including the development of the State-wide pandemic flu plan
in cooperation with the Department of Health.
SITUATIONAL AWARENESS (SA) COMMON OPERATING PICTURE (COP)
Rhode Island's small geographic size, coupled with its ample supply
of critical energy and transportation infrastructure, suggests that the
State's first responders and public safety community would have
seamless and discreet interoperable capabilities second to none. Yet,
our 39 cities and towns, and a number of State agencies have fostered a
stovepipe mentality with limited guidance for implementation of
consistent and comprehensive technological systems and policies. To
date a number of systems both linked and disparate have been created to
enhance Rhode Island's operability and interoperability within the
technological environment of day-to-day operations as well as systems
designed to enhance emergency response capability. Examples include the
following:
Hospital Capacity System (HCS);
Web EOC;
Port Security Camera System;
Traffic Management System;
Mesh Network System.
Many of these systems serve useful purposes, however; there is
little integration of the systems currently in use in the State. RIEMA
is working to link the disparate systems into a consolidated
information hub to facilitate situational awareness and common
operating picture for all responders and policy decisionmakers.
RHODE ISLAND STATE-WIDE COMMUNICATIONS NETWORK (RISCON)
The vision of the RISCON project is to have interoperable
communications which will enable all public safety and first responder
agencies to communicate within and across departmental and
jurisdictional borders. The system is APCO 25 Compliant data capable
system. The current capabilities of RISCON include 11 sites in the
Washington County (southern) system and four in the North Providence
system and five in the Providence system with three in construction
stage and two in the site assessment stage. Over 2,500 subscriber units
have been purchased for local, State, and tribal agencies. Radios have
been purchased for each front line fire, police and EMS vehicle in the
State. Also, both U.S. Coast Guard Stations in Rhode Island, Capitol
Police, Regional Teams including the Urban Search & Rescue, Disaster
Medical Team, HazMat, Decon and Law Enforcement WMD teams and cabinet
level State agencies just to name a few have equipment and network
access enabling them to operate on the RISCON network. Current funding
will allow the system to expand to a total of 19 sites and provide 90+
percent coverage State-wide. The total users on the system will
increase to close to 4,000 by 2009. Additionally, a cache of radios and
repeaters are being developed.
GRANT MANAGEMENT AND FEDERAL REPORTING
RIEMA currently facilitates numerous grant programs, has an
established monitoring program and is able to assist sub-grantees with
questions regarding allocated funds and also with the grant application
process. Additionally, the agency is required to submit reports to
Federal agencies describing current programmatic activities.
As the State Administrative Agency (SAA) to over 15 grant programs
the small team that is currently managing these funds is not
sufficient. RIEMA aims to have a more robust grant management team who
can accurately and fastidiously award and monitor grant funding and
complete reporting requirements. Presently, we complete a number of
Federal reports, of which the purpose is not clear. We are told we are
completing them ``for Congress'', but are unsure if that is actually
the case. We seldom receive constructive feedback on the reports that
we submit, which would be helpful in evaluating our efforts and future
planning. The multiple grant programs, disparate timelines and numerous
reporting requirements detract from our programmatic preparedness
efforts. Locally, a larger grant management team would help, but
Federal support such as combining grants, multi-year funding and
alignment of program deadlines would allow for much more efficiency.
CONTINUITY OF OPERATIONS AND PANDEMIC PREPAREDNESS
Over the past few months, the State of Rhode Island took
unprecedented steps to enhance our pandemic flu preparedness. In
response to the Federal Guidance to Assist States in Improving State-
Level Pandemic Influenza Operating Plans, the Rhode Island Emergency
Management Agency and the Rhode Island Department of Health led a
collaborative effort to respond to this request for submission.
Under an unrealistic deadline, new partnerships were forged on the
State level. Non-traditional partners such as the Department of Labor
and Training, the Office of the General Treasurer, and the Department
of Education were included in the planning effort and provided
important insight on areas of responsibility which allowed them to
learn more about emergency management. The relationships that were
created have allowed for further offshoots of preparedness including
training State workers in Incident Command System (ICS) and a Pandemic
Flu/Continuity of Operations Working Group with the State's colleges
and universities. This effort served as an important gap analysis and
relationship builder. It now allows the State of Rhode Island to target
our planning efforts to specific areas which will bolster overall State
preparedness. Additionally, Rhode Island, along with many other States,
has begun to focus heavily on our ability to provide continuity of
operations (COOP) during a pandemic influenza event. This process has
allowed us to produce many COOP plans for our various State government
agencies and our critical infrastructure areas based on what appears to
be the worst-case scenario threat of pandemic influenza.
Despite the successes Rhode Island has enjoyed in State COOP and
pandemic planning, considerable work needs to be done. The challenges
include:
1. Training and Exercising existing COOP and Pandemic Plans.
2. Limited funding to purchase equipment needed to support COOP and
pandemic-related planning for information technology and
redundant systems.
3. Inadequate Department of Homeland Security support for Critical
Infrastructure Protection programs as it relates to COOP and
Pandemic Preparedness.
4. Guidance fails to take into account the unique organizational
environment found in States like Rhode Island.
Mr. Chairman, in addition to the responsibilities that my agency is
involved in, I also feel it is important to mention the following
preparedness efforts that I have been involved in over the past several
years.
MEDICAL SURGE CAPACITY EFFORTS
From the beginning of the implementation of the Health Resources
and Services Administration (HRSA) grant, surge capacity was identified
as a planning priority. In Rhode Island, the Station Nightclub fire
served as an important event highlighting the need for improved
coordination and management of surge capacity and patient management.
The Station Nightclub in West Warwick, RI caught fire at 11:12 p.m. on
February 20, 2003 with an estimated 400 persons attending a rock
concert. The fast-moving fire caused 96 immediate fatalities and
hundreds were sent to or self-transported to area hospitals. Four
victims subsequently died in hospitals making it the fourth-deadliest
fire in United States history.
The emergency planning community in Rhode Island continues to
revisit actions and lessons learned from this incident. The response of
the first responders and hospitals to the incident has provided Rhode
Island with a real-world exercise of the capabilities of the first-
responder community and hospitals to a mass casualty/fatality event.
RIEMA and HEALTH have worked with hospitals to establish procedures and
protocols for the activation of surge capacity plans in the event of a
similar incident. Over the last 5 years, the hospitals and health
centers have established and exercised their plans for a surge of
patients. HEALTH, in conjunction with RIEMA, has established
notification procedures and communications protocols to activate a Mass
Casualty Response. The Southern New England Mutual Aid Plan was
established with support of RIEMA to coordinate a response by first
responders to intra- and inter-State emergencies. A mutual aid
agreement amongst all hospitals within the State to share personnel,
supplies, and equipment during a public health emergency has been
implemented.
Pandemic flu planning has necessitated the expansion of hospital
surge capacity planning to surge management of the entire health care
system. HEALTH has established health care service regions to allow
hospitals to facilitate the management of resources within their
regions and to establish Alternative Care Sites (ACS).
RHODE ISLAND DISASTER MEDICAL RESPONSE TEAM (RI-1 DMAT)
The Rhode Island Disaster Medical Assistance Team (RI-1 DMAT) is a
Category One team of the National Disaster Medical System (NDMS). The
team consists of more than 250 medical professionals and support
personnel, supported by a cache of medical and logistical equipment and
is prepared to deploy anywhere in the country with only 6 hours notice.
In the event of a Federal deployment of the team, approximately 35
members would accompany the entire Federal cache for up to 2 weeks, and
provide medical care to patients without outside support for up to 72
hours. Until recently nearly all of the team's equipment was Federal
property and, as such, would not be available for use within the State
of Rhode Island if the team were deployed. This shortfall in equipment
would leave the un-deployed 200 members of the team without the
resources needed to care for patients within the State.
Through efforts led by Department of Health the State acquired a
comprehensive cache of medical and logistical equipment that will
enable RI-1 DMAT to provide care to patients within the State even if
the team has been deployed out-of-State with their Federal cache. The
team is also able to deploy its field hospital as an alternative care
site for a mass casualty incident, or situate it in the proximity of a
hospital emergency department to care for patient overflow. The
structure, its equipment and supplies could also be configured to serve
as a mass immunization or medication distribution facility almost
anywhere in the State or deployed through the emergency management
assistance compact to other States. The RI Medical Reserve Corps is a
Federal initiative which is managed in Rhode Island by the RI DMAT
team. The addition of this corps of volunteer healthcare providers has
had a positive impact on the team's ability to manage its mission in
Rhode Island in the wake of the removal of the RI team's Federal cache
and the current inability of HHS to enroll new members on the DMAT
teams.
Until recently, DMAT category one teams under the National Disaster
Medical System (NDMS) have been supplied with a cache of logistics and
medical equipment that they used to support the treatment of the
victims of disasters in the country. This cache, termed the ``Basic
Load'', was also available to be used by the teams to serve their local
communities, and there are many positive examples of this from around
the country.
NDMS leadership has recently decided to regionalize DMAT caches &
close multiple team warehouses throughout the country. The RI DMAT
cache was relocated to north of Boston at the end of June and their
warehouse was closed. This move effectively eliminates the ability of
the Rhode Island team to utilize their cache to serve their own
community during disasters, and denies them access to the equipment for
maintenance and training. This is of special concern to State planners
during a pandemic flu event when State borders are closed and movement
of materials is restricted.
While NDMS claims cost savings, in the case of the Rhode Island
team, there is a GSA lease that will have to be paid for the next 4\1/
2\ years for a now empty building. The total bill to the Government for
this lease will be more than $700,000, again, for an empty building.
Apparently GSA will be responsible for the rent, but NDMS will see a
positive impact on their budget. This development reinforces the
foresight of Rhode Island in developing and supporting their DMAT
team's local capability.
CONCLUSION
Efforts outlined in this testimony are just a snapshot of the
numerous programs and activities designed to enhance the preparedness
of Rhode Island. There are many agencies and individuals that work hard
each day to make Rhode Island a safer place to live and work.
It is important to mention that the ever-increasing number of grant
programs, reporting requirements and unfunded mandates all require
considerable planning time and utilization of resources in order to be
effective. In many cases, these resources are being stretched very
thin, both at the State and local level. It is critical that all
Federal preparedness grant programs be more closely aligned and
coordinated so that we at the State level can more effectively develop
an appropriate response to whatever emergency may occur.
Lastly, we cannot discuss local, State and national emergency
preparedness if we do not discuss the aggressive efforts needed to
impress upon the American people the need and critical requirement for
personal and family preparedness. I feel that personal and family
preparedness is an integral part of the overall preparedness continuum.
Mr. Chairman and Members of the committee, I thank you for the
opportunity to discuss these important issues with you this morning and
would be happy to answer any questions at this time.
Mr. Langevin. I thank you for your testimony. The Chair now
recognizes Peter Ginaitt for 5 minutes.
STATEMENT OF PETER T. GINAITT, DIRECTOR, EMERGENCY
PREPAREDNESS, LIFESPAN HOSPITAL NETWORK
Mr. Ginaitt. Thank you, Mr. Chairman and Members of the
committee. Thank you for the invitation to be here today. I
preface my remarks and I want to thank the Federal panel, the
group that was here. They have made a difference. I will tell
you, there's been an incredible difference that has been felt
in the State of Rhode Island and I'm sure across this Nation,
as well as my partners to the right. Our State agencies, the
RIEMA and the Guard, have made a tremendous impact on our
ability to respond.
I'm here today representing hospitals. Hospitals are our
lifeline within this country and there are many concerns out
there, especially when we deal with major events such as
pandemic influenza.
Here in Rhode Island, we've strived to develop an
integrated and coordinated system for the benefit of the public
health and for the health of our health care system. We have
worked toward a response to a pandemic influenza which has been
both enlightening and to a degree somewhat daunting. The
development of ten health care coordinating service regions in
the State, through the Department of Health have been
identified as an effective method of addressing the expected
influx of patients throughout the State of Rhode Island. These
hospitals would utilize the hospital incident command system
and would manage health care within a prescribed region of the
State. They would each report directly to the Department of
Health which would be the coordinating entity for all ESFA
activities.
In a planning phase for any hazard where a mass casualty
situation could exist it is imperative that the health care
system remain functional and that the ability to deliver
acceptable quality of care to preserve the greatest number of
lives be preserved. This philosophy is made more challenging
with the need to allocate scarce resources in a manner that
will optimize the saving of lives.
The challenge, however, is the allocation of these
resources in a fair, open, and transparent way while
maintaining a safe, infection-free environment for the delivery
of care. These challenges have been discussed throughout this
country and a solid understanding seems to be in place.
Hospitals willingly accept challenges every single day and even
more so as the impacts of reduced reimbursements affect
hospitals, increased uncompensated care requirements, impact
our community hospitals and our daily patient census numbers
hit record levels.
Rhode Island Hospital, just last week, had 355 patients
come through its emergency room in one 24-hour period. That is
an alarming number to manage. Granted, it's the largest
hospital within the State and it is a Level 1 trauma system,
but 355 patients and that is becoming a normal number.
Hospitals attempt to organize their care through the
sharing of resources and even attempt to merge operations in a
further attempt to maintain their high levels of quality care
through resource-sharing and functioning under economies of
scale.
It has been a practice to plan within a facility, but
further encouraged to integrate these facility level plans into
regional systems. The systems continue to build their plans
through an expanded involvement of private and public community
stakeholders and the need for a unified response continues to
be stressed, since individual preparedness will stress rapidly
during a major event. These plans must also be consistent with
all integrated--integrated into all Federal, State, and local
plans.
Rear Admiral Vanderwagen alluded to the intersectoral
interaction. It is very, very important that we regionalize all
of our efforts and I feel that in Rhode Island we've done a
very good job of that.
Altered standards of care need to also take into
consideration and recognition that a reduction in the work
force will further complicate and compound the stresses in
health care during major events. While identifying the needs of
hospitals and the expected volumes of patients in both the
clinical settings within the hospital, as well as the
activation of an alternate care site, personnel will play a
major role in the operational successes and/or failures of
these types of events. It is estimated that staff reductions
could reach upwards of 50+ percent in the case of pandemic
influenza.
This degree of clinical care reduction will further stress
the actual health care delivery system and will require that we
operate under different ratios to care for people. The
expectations for current standards of care, while we strive to
achieve these expected levels, will most likely be stretched
during these labor- and care-intensive periods while
experiencing large staff reductions and increased patient
numbers.
Hospitals face daily diversions of patients due to
increased volumes within their facilities. Managing these
influxes are extremely complicated while also maintaining the
quality of care within these facilities. With the addition of
alternate care sites, it is extremely difficult to predict the
actual impact that will be felt within the system.
Hospitals have experienced tragedies in the past and I can
assure you through planning and professional level of these
employees, responses have always been effective, well-
coordinated and resulted in good, patient care. However, the
unexpected event that stresses an entire health care system due
to sheer volume or resource limitations could be tantamount to
the proverbial house of cards. I can assure you that readiness
has been in the past effective. Readiness continues to be
imperative and again I thank this body for addressing that.
We must continue to build on these plans, but also the need
to address the needs of these patients. The simple stockpiling
of supplies needs to be further addressed by the Federal
Government. The hospitals simply cannot support stockpiling of
resources with limited storage as well as limited to no funding
to support these caches of pandemic and all-hazards supplies.
If these resources are identified as essential and I support
that premise, assistance must be given by other agencies to
purchase and support the delivery during a time of necessity
and guarantee a timely delivery of the same. We have
implemented the Chem Packs which is something that was exciting
to do because we're putting nerve agent antidotes right into
our backyards now, something the military has enjoyed for 30
years. But up until the last couple of years we're starting to
experience that.
Representative Pascrell, you talked about the increase of
antivirals. It is important that we have them within hospitals
and have more than a thousand courses within our hospital while
we're expected to deal with 150,000 patients in the city of
Providence alone.
We must move toward a clear and understandable goal within
the Federal Government and support that goal with a plan of
funding and implementation. Funding cycles must be beyond a
single year and progressive buildout of a system of resources
and staff support must be clearly delineated. While grant
funding is essential, working under unrealistic time parameters
with the hope of an extension or face loss of grant funding is
all too often counterproductive and often results in quick
fixes.
Multi-year funding, while federally problematic to manage
is the only real answer to build the structural framework for
system saving response. We clearly understand that the plans
will always be labeled with the word draft. As I talk to my
senior management and I tell them our plans are always going to
say the word draft, but that's because of the world that we're
in. We're constantly improving our plans so therefore to put
them back on the shelf and say that they're functionally
finished and can sit there for 2 or 3 years is the wrong thing
to do, so we're constantly working to improve.
We realistically also comprehend that any reliable plan of
action will take years to appropriately accomplish, but
building toward those goals through planning and implementation
is where we will succeed. I believe we are in that direction
and I have offered my full testimony for the committee and I'm
open to questions.
Thank you very much.
[The statement of Mr. Ginaitt follows:]
Prepared Statement of Peter T. Ginaitt
July 22, 2008
Mr. Chairman and Members of the committee, my name is Peter
Ginaitt, R.N., EMT-Cardiac. I serve as the Director of Emergency
Preparedness for the Lifespan Health System and recently retired as a
professional firefighter/EMT with the city of Warwick Fire Department
after 21 years of service. Also, I served in an elected position as a
State Representative from District 22 in Warwick for over 16 years
until retiring from public office to assume my current position at
Lifespan. My concentrations in public policy were both environmental
protection and health care.
I would like to thank you for inviting me to testify today to
discuss the challenges that lie ahead of health care in preparation for
the potential of emerging biological threats as well as the need to be
better prepared for the ``all-hazards'' approach of preparedness within
the health care community.
While I would like to report that I feel we as a country are
sufficiently prepared to handle a major biological outbreak, or even
further, are ready to handle the influx of victims if a catastrophic
event were to impact Rhode Island and Southern Massachusetts, I feel I
cannot report complete success. I do however feel strongly that we have
made major advancements in our levels of preparedness and are better
off today then ever in the past.
LIFESPAN
Lifespan, Rhode Island's first health system, was founded in 1994
by Rhode Island Hospital which includes its pediatric division Hasbro
Children's Hospital and The Miriam Hospital. A comprehensive,
integrated, academic health system, today Lifespan partners also
include Bradley Hospital and Newport Hospital.
As a not-for-profit organization, Lifespan is overseen by a board
of volunteer community leaders who are guided by its mission to improve
the health status of the people it serves in Rhode Island and Southern
New England. The mission of Lifespan is to improve the health status of
the people whom we serve in Rhode Island and New England through the
provision of customer-friendly, geographically accessible and high-
value services. We believe that this can best be accomplished within
the environment of a comprehensive, integrated, academic health system.
In September 2007, Lifespan President George Vecchione and senior
leaders recognized the need to be better prepared for any threat that
existed. The Office of Emergency Preparedness was developed and an
emergency preparedness council of CEO's and senior leaders was
developed. Preparedness within hospitals underwent a paradigm shift and
emergency preparedness and protection of our facilities to protect the
delivery of patient care became paramount. Recognizing the need to
assist and coordinate, the office of emergency preparedness continues
to develop its role of system support and resource building.
In my role as Director of Emergency Preparedness, I serve as the
Principal Investigator for a Hospital Preparedness and Healthcare
Facilities Emergency Care Partnership Grant through HHS and under the
Assistant Secretary for Preparedness and Response. The program
administered will better prepare our State in the event of a disaster
through the implementation of a robust patient tracking system that
will track all EMS patients every day from the scene to the hospital,
this program will be the first of its kind in the United States. The
need for patient tracking was identified after the Station Nightclub
fire on Feb. 20, 2003 in West Warwick, Rhode Island where over 400
people were attending a rock concert. A fast moving fire caused 96
immediate fatalities and hundreds were sent to or self transported to
area hospitals. Four victims subsequently died in hospitals making this
the fourth-deadliest fire in our country's history. The findings were
referenced in the After Action report assembled by the Titan
Corporation in the months following that deadly blaze and
recommendations made for the tracking of patients. The program will
also develop voice and data communications systems for health care and
proposed alternate care sites, a current system whose frailties were
evidenced during and after Hurricane Katrina when communications
failed. Last, the program will promote Incident Command adoption and
training to promote better unified responses within the State of Rhode
Island.
While pandemic planning continues to actively occur within all of
the State's hospitals, it does present an ongoing challenge that
requires constant planning and exercising in this and other areas. They
continue to be better prepared as the State and Federal Government have
requested but challenges are frequently discovered. The Lifespan system
hospitals take particular pride in the planning efforts given to
prepare for such an even as they work diligently to develop robust
plans to deal with any ``all-hazard'' event.
RHODE ISLAND
The successes to date in pandemic preparedness in Rhode Island have
been successful due to the partnerships and working relationships
within the State and the New England region. As partners here today at
this very table, I must acknowledge the hard work and efforts on behalf
of Dr. David Gifford, Director of the Rhode Island Department of
Health. Dr. Gifford has been challenged with the task of pandemic
preparedness and with the cooperation of the Center for Emergency
Preparedness and Response (CEPR) under his leadership, hospitals have
been provided an incredible amount of support through resource
allocations and pandemic cache development. On-going subcommittee work
dealing with all aspects of the pandemic influenza and our State's
response continue as plans develop.
Major General Robert T. Bray, the State's Adjutant General and
State Homeland Security Advisor continues to work diligently in the
development of plans to respond to catastrophic events within our
State, including the support for a pandemic outbreak. This agency has
made tremendous strides toward a robust response within this State to
an event under an ``all-hazards'' scenario utilizing resources within
our State military services and emergency management agency.
And also, Mr. Thomas Kilday, as outlined within his testimony, I am
sure you will notice that Mr. Kilday has assumed many roles which
include health care response prior to his emergency management career
as Homeland Security Program Manager. This broad knowledge provides a
clear and educated perspective to the very events we are here to
discuss today.
In Rhode Island, we have strived to develop an integrated and
coordinated system for the benefit of the public health and for the
health our health care system. We have worked toward a response to a
pandemic response which has been both enlightening and to a degree
somewhat daunting. The development of ten health care coordinating
service regions in the State through the Department of Health have been
identified as an effective method of addressing the expected influx of
patients throughout the State of Rhode Island. These hospitals would
utilize the Hospital Incident Command System and would manage health
care within a prescribed region of the State. They would each report
directly to the Department of Health which would be the coordinating
entity for all ESF-8 activities.
While these regional plans are aggressive and require us to utilize
all of the health care resources we as a State possess, we clearly
understand that the scope of response will most likely overwhelm us as
single facilities. We are better preparing by the use of shared
resources, but we also recognize that the available on-hand resources
may not be adequate if the event is as large as predicted. Many of the
challenges we predict we will experience include:
EMERGING ISSUES
As in any mass casualty, the ability to deliver customary care to
everyone is just not possible. Hospitals today face increased census
numbers and the availability of clinical space continues to be a
challenging issue. Our challenges to these extraordinary situations
should take into consideration our ability to:
Be compatible with day-to-day operations;
Be applicable to a broad spectrum of event types and
severities;
Be flexible through a graded response for the circumstances
faced with;
Be tested, to determine where gaps and improvements are
needed.
In the planning phase for any hazard where a mass casualty
situation could exist, it is imperative that the health care systems
remain functional and the ability to deliver acceptable quality of care
to preserve the greatest number of lives be preserved.
This philosophy is made more challenging with the need to allocate
scarce resources in a manner that will optimize the saving of lives.
The challenge, however, is the allocation of these resources in a fair,
open and transparent way while maintaining a safe, infection-free
environment for the delivery of care.
These challenges have been discussed throughout this country and a
solid understanding seems to be in place but no real tangible cure to
this challenge has been offered. Hospitals willingly accept challenges
every day and even more so as the impacts of reduced reimbursements
affect hospitals, increased uncompensated care requirements impact our
community hospitals and our daily patient census numbers hit record
levels. Hospitals attempt to optimize care through the sharing of
resources and even attempt to merge operations in a further attempt to
maintain their high levels of quality care through resource sharing and
functioning under economies of scale.
It has been a practice to plan within a facility but further
encouraged to integrate these facility level plans into regional
systems. The systems continue to build their plans through an expanded
involvement of private and public community stakeholders. The need for
a unified response continues to be stressed since individual
preparedness will stress rapidly during a major event. These plans must
also be consistent with and integrated into Federal, State and local
plans.
As with any major change in policy or practice, an adequate legal
framework must be further developed, endorsed and placed into action
due to the requests placed upon facilities when activating any regional
plan of care. These should include rapidly instituted executive orders
declaring a disaster with the enabling language to support altered
standards of care. These changes either through executive order or
statutory change must be clear and concise for ease of communication
and implementation and should further be free of confusion through
interpretation of meaning. As with any disaster, these directives
should also take into account the need to accommodate the demands of
varying sizes of events and should not be primarily based on
catastrophic levels of need.
These altered standards of care need to also take into
consideration that a reduction in the work force will further
complicate and compound the stresses in health care during major
events. While identifying the needs of hospitals and the expected
volumes of patients in both the clinical settings within the hospital
as well as the activation of an alternative care site, personnel will
play a major role in the operational successes and/or failures of these
types of events. Estimates vary around the 50 percent staff reduction
numbers. This degree of clinical care reduction will further stress the
actual health care delivery system and will require that we operate
under different ratios to care for people. The expectation for current
standards of care, while we will strive to achieve these expected
levels, will most likely be during these labor and care intensive
periods while experience large staff reductions and increased patient
numbers.
Hospitals face daily diversion of patients due to increased volumes
within their facilities. Managing these influxes are extremely
complicated while also maintaining the quality of care within each
facility. With the addition of alternate care sites, it is extremely
difficult to predict the actual impact that will be felt within the
system. While the State has adopted a memorandum of understanding
between all hospitals to share staff and resources, a State-wide or
regional event would render that agreement useless, not to mention that
the capacities of these other hospitals are already stressed with their
own patient census.
Hospitals have experienced tragedies in the past and through
planning and a professional level of employees, responses have always
been effective, well-coordinated and resulted in good patient care.
However, the unexpected event that stresses an entire health care
system do to sheer volume or resource limitations could be tantamount
to the proverbial ``house of cards''.
We must continue to build on these plans but also the need to
address the needs of these patients. The simple stockpiling of supplies
needs to be further addressed by the Federal Government. The hospitals
simply cannot support major stockpiling of resources with limited
storage as well as limited to no funding to support these caches of
pandemic and all-hazards supplies. If these resources are identified as
essential, and I support that premise, assistance must be given by
other agencies to purchase and support their delivery during a time of
necessity and guarantee timely delivery of the same. The following
continue to make planning problematic and they remain outstanding
challenges.
We must move toward a clear and understandable goal within the
Federal Government and support that goal with a plan of funding and
implementation. Funding cycles must be beyond a single year and
progressive build-out of a system of resource and staff support must be
clearly delineated. While grant funding is essential, working under
unrealistic time parameters with a hope of an extension or face loss of
grant funding is all-too-often counter-productive and often results in
quick fixes. Multi-year funding, while federally problematic to manage,
is the only real answer to building the structural framework for a
system saving response. We clearly understand that the plans will
always be labeled with the word ``draft'' since it will be a constantly
improving tool. We realistically also comprehend that any reliable plan
of action will take years to appropriately accomplish but building
toward those goals through planning and implementation is where we will
succeed.
Beyond funding, I would further recommend that the Federal
Government establish a smaller department within HHS or DHS to provide
hands-on technical support in each of the States and regions that have
realistic and attainable goals. I am not suggesting that this be the
solution, but any interaction beyond paid consultants will be
beneficial. Hospitals will respond well to systematic integration into
a well-formatted structure of needs. I see the need to have designated
Federal directors assisting the State governments and health care with
the guidance necessary to achieve our goals and objectives. I further
see the need for regular interaction with all regional partners while
these systems further develop. I understand that this is currently
being performed but see the need to better organize and deal with the
``All-Hazards'' response.
As stated earlier in this testimony, I feel strongly that the
Federal, State and local plans and responses are better than ever
before. Hospitals State-wide are better prepared and truly understand
the impact that could face them if a major event ever occurred. It is
further reinforced by The Joint Commission who accredits these
facilities through recurring surveys and new standards currently placed
in the survey tool. These new standards in place require increased
readiness compliance in 2008 and expected newer standards for January
2009 will only strengthen hospitals' preparedness and overall
responses.
Please accept my thanks for the opportunity to present this
testimony before this subcommittee and I remain available for
questions.
Mr. Langevin. Very good. Thank you, Mr. Ginaitt. With that,
I want to thank the panel for all of their individual
testimonies and we look forward to learning more on the full
testimony that you submitted for the record, but I just want to
remind Members we'll each have 5 minutes for questions and I'll
recognize myself for 5 minutes.
Dr. Gifford, let me start with you. With respect to public
health preparedness, being able to monitor day-to-day
activities and to obviously be well aware of emerging threats
that are actually occurring, in your opinion has bioterrorism
preparedness been integrated with pandemic influenza
preparedness and how have you been able to integrate these
activities into the existing framework in Rhode Island for
public health emergencies that occur more frequently or
currently. Can you give us a few examples of how you've done
that here in Rhode Island?
Dr. Gifford. I applaud, Mr. Chairman, your desire to try to
get us to integrate things in our daily activities and that
includes the theme of my presentation.
We have utilized some of the emergency preparedness
funding, as many States, to implement what's called the ROD
system which is a real time monitoring of diseases in the
emergency room. So we actually have a--as individuals are
registered in the emergency room for symptoms, we get actually
a real-time alert into a database. We actually have an
algorithm that screens that and looks for outlying events. When
we see a certain number of people coming in with respiratory
illness or high fever or diarrhea or some different symptoms,
it triggers us an alert. We look at the individuals to see if
they clustered by zip code. We look to see if they cluster by
town, gender, any aspects. We contact the hospitals and begin
to do a very quick investigation. I would say we get alerts
about every other day. It's diminishing as we build the
database and you get a better sense as to where they are, but
that helps us look at what's going on out there.
Some of that has actually helped us, in general public
health activities, identifying outbreaks of strep throat or
anything, a certain school district, so I think it not only
helps us from a biosurveillance standpoint, but it helps us
with our day-to-day activities.
We have currently for influenza we have sentinel physicians
that during the influenza season they report to us on the
number of people they're seeing that have influenza-like
illness and we're able to track and see when we need to put
alerts out to think about using antivirals or boosting up the
immunization rates as well as testing in our lab to see what
the strains are--did they match with the vaccines or not?
Those are some efforts that we have done. We can clearly do
a lot more. I mean with the advent of technology and health
information exchanges, we should be able to have a much better
surveillance process that's out there. Currently all the labs
report any incidents of any--about 85 different diseases. If
they culture any of it, it gets reported to us. Certainly all
the bioterrorism events are in that list, but we need a better
system for symptoms early on. I think as you heard from the
previous panel the exposure to these types of agents will not
manifest symptoms for anywhere from a few hours to several
days. It could be spread out and as we get the data
electronically, to be able to monitor that it will not only
help us with that bioterrorism, but will also help us in our
day-to-day activities as we go on.
Mr. Langevin. I couldn't agree more and the further out we
can push this in terms of being aware of an emerging threat
actually manifesting itself, the better we will be able to
respond.
Let me turn to you, Peter, on surge. You talked about that.
What are the hospital system's plans for surge in the event we
are overwhelmed?--and I recognize that on any good day a
hospital system, the emergency room, in particular, can easily
be overwhelmed with large numbers of patients, even just an
average flu season.
What are we doing in terms of being prepared for the
potential of thousands of people coming down with an illness,
whether man-made or natural disaster, and showing up at our
hospitals? I'm not talking about just a couple of hundred, I'm
talking about what if it were to occur in a thousand? How are
we going to deal with this? What are the contingency plans that
you're aware of in place and I also want to ask where the
majority of extra hospital supplies, where are they being
stored and are they being vendor-managed and do you think that
they should remain at this location or at the hospitals
themselves?
Mr. Ginaitt. Mr. Chairman, bear in mind we started to deal
with surge capacity back several years ago with the Department
of Health and with the Federal Government in our level of
preparedness and for the surge of people over and above our
normal, daily census. We're experiencing surge every day now.
We are actually actively going within surge capacity areas
drawing down on expanded places to give clinical care that
normally aren't being used and that's again a daunting task
when it comes to personnel issues and it comes to physical
space issues.
We were challenged several years ago to increase our
ability of surge for 500 people within 1 hour and we did that
very effectively. In the case of Rhode Island Hospital we
altered our surge capacity plan and identified 196 openings
within 1 hour that we could surge people into. Bear in mind
that means that we're not at capacity, that we're not drawing
down on those surge numbers and that we're able to effectively
deliver the same level of clinical care that's expected.
It's interesting, as I travel around the country and I hear
from other hospitals that have surge capacity plans and they're
very proud of the fact that they can take an additional 25
people in and I sit there and I look at the grand scene of what
a major event could do to this nature and I break out into a
cold sweat as far as where our pandemic plans are going. That's
why I'd like to really stress the all hazards. While we do talk
about pandemic influenza and we reference the 1918 pandemic
outbreak, I think our biggest threat is going to be from
something that will be--that will fall into the all-hazards.
Hospitals around the State have individually addressed
their surge capacity plans and have acknowledged that they
needed to build out additional resources. Call-back, we have a
new emergency notification system, thanks to the Department of
Health and Federal granting and our Hospital Association of
Rhode Island for rapid call-back of staff so that we can put
surge capacity areas into action.
So we're working very well with the increase, the influx of
people, whether it's into the thousands is another issue.
That's when we fall into an alternative care site. That's where
we're challenged with taking our in-house current staff and
deploying many of them into a free-standing alternative that in
many cases could be a school, could be a convention center and
dealing with those, the actual establishment of an alternative
care site is not all that difficult. The concept of a
freestanding hospital, but manning it, being able to deliver
care. Being able to run laboratory tests, manage reports,
manage the transfer of patients is the daunting task and again,
I credit the Department of Health for having an on-going ad hoc
committee through the hospital association also and identifying
these scarce resources and our needs.
We continue to work on that. I feel good about it. I cringe
a little bit about the word thousands, but it is something that
we're working toward.
Your second question: What is the management of supplies?
We've received tremendous number of supplies over the course of
the last few years to deal with hazardous materials and
decontamination. A lot of training. We do manage and do vendor
management to the best of our ability when we can do that. I
reference the fact that I have several hundred thousand doses
of ciprovoxin and doxycycline. We can't get rid of enough
doxycycline when you have 120,000 courses. We don't use it
enough. Luckily, it's a very inexpensive drug. So we try to--
many of the products that are costly, we try to do as much VMI
as we possibly can.
Mr. Langevin. Thank you. With that, I now recognize the
gentlelady from the Virgin Islands, Congresswoman Christensen
for 5 minutes.
Mrs. Christensen. Thank you, Mr. Chairman, and good
morning, and thank you for being here.
General Bray, I am in awe of how you manage four different
responsibilities, especially looking at how you direct the
local authority which is RIEMA and then the support authority,
the Guard, and how you keep those two operational and separate
is amazing.
I wanted to ask a question about the--your ability to--your
local response capacity. You say you're at 71 percent strength
as of July 15. The National Guard has set a standard of at
least 50 percent and you don't plan to call up your police,
your fire, your first responders if an event occurs that is a
disaster. Without calling up your first responders, can you be
at 50 percent strength?
Gen. Bray. Thank you for the question and I wear many hats.
We have a system, a tiered system of responsibilities and I
delegate a great deal of those authorities down to my
subordinates who are very competent. Let me just say again, the
Rhode Island National Guard is not the first responder in any
event.
Mrs. Christensen. Right.
Gen. Bray. So the first-tier response is always the first
response agencies, law enforcement, fire, emergency medical
services. So they will usually almost always be deployed prior
to the National Guard being called upon and then subsequently
deploying within the State as well.
So we will always augment those first responders in the
event of an incident.
The civil support team has a very close relationship and is
probably more likely to be deployed in a case of a biological
incident prior to the need for the total mobilization of the
Rhode Island National Guard, both Air and Army. So again, in a
tiered-level of response, we feel that we are more than able to
support any needs of the State.
Now I will tell you, that goes beyond that. We have the
Emergency Management Compact with the other States. We also
have a close regional relationship with the bordering States,
and then we have several other capabilities at the national
level that will augment the Rhode Island National Guard should
not only its personnel assets be exceeded or close to being
exceeded, but any other capability that might become a
shortfall. So on a regular basis and I mean daily, my staff
through our joint operations center senses that level of
capability in the State and whether or not we need to use those
other assets to support us.
Mrs. Christensen. Thank you. Mr. Kilday, stovepiping is not
unique to Rhode Island as I'm sure you have heard from some of
us. How long has RIEMA been working to integrate across
agencies and what are some of the barriers and when do you
think it will be accomplished?
Mr. Kilday. Over my years in the preparedness business here
in Rhode Island, I think very early on we recognized that there
was a great deal of stovepiping within agencies. It used to be
called turf and I found over my experience over the years
people have recognized that preparedness is important, that
they need to put aside those turf issues and work on
preparedness. It's about buy-in from the highest level down and
I think we've achieved that.
Unfortunately, we've achieved that at some level because of
some of the tragedies we've had in the State and some that
we've experienced nationally. It's unfortunate that it takes
that level of experience to create that buy-in.
I think in the State of Rhode Island what we've done is
recognize the small size of our State, our limited resources
and capabilities and forced a basis for regionalization. Most
of our capabilities, recognizing that one department or one
agency may be limited. We've regionalized those capabilities,
whether it be hazmat and decontamination teams, whether it be
urban search and rescue capabilities or the DMAT team.
We've focused these regional capabilities in linking with
emergency management and reaching out to these other agencies,
whether they be Department of Ed., Department of Labor,
training.
Mrs. Christensen. Is it working?
Mr. Kilday. I believe it is, ma'am.
Mrs. Christensen. Thank you. Dr. Gifford, I'm very
impressed with what you've been able to do based on your
written and your oral testimony and if we were to consider what
we have heard from you today, we probably wouldn't increase any
public funding for public health because you've done so well,
but as you interact with your counterparts across the country
are you hearing the same kinds of success stories or are you
hearing the need for more Federal funding?--and Director
Ginaitt, the same thing with respect to hospitals. I get the
sense that maybe public health funding is--it's not adequate, a
little closer to where it needs to be, but hospital funding for
preparedness is not. So if both of you could answer that.
Mr. Kilday. Well, I think it is always a shame when you
reward success by cutting funding.
Mrs. Christensen. We're not going to cut it.
Mr. Kilday. As you know from your public health background,
the greatest threat in public health is that when we start
making progress and we refocus elsewhere, we see many illness
reemerge. We've seen syphilis. We've seen TB come back in this
country, when we thought we were making progress on it because
we said we were doing so well, now let's focus somewhere else.
So I think that that is really, if we haven't learned from
history and we keep making the same mistakes, I would say shame
on us. I think that really applies to emergency preparedness.
I think we run the risk of saying okay, we planned for
pandemic. We stockpiled for it and we planned for bioterrorist
agents, okay, a new agent, we'll get ready for that. Then we
call it a day. I think that really underestimates the value
that this has had. While many of the events that we've had to
respond to, we had to respond to before 9/11, before anthrax,
we are now much better, we're better integrated with EMA. We're
better integrated with other agencies and we are much more
effective and efficient, frankly, at responding to those events
because of the emergency preparedness in those other areas.
I think that's what we're seeing across the country is the
whole incident command structure was foreign to the public
health sector until the emergency preparedness funds. Now you
have almost every State has been certified through the NIMS
system and ICS now utilizes it and while we used to respond to
disease outbreaks, infectious disease outbreaks with NICS, we
did okay. We're now much more effective because of that.
Now it also is clear that you need to integrate this to
train and support this and as I think Mr. Ginaitt recognized by
acknowledging that these plans are drafts, you need to always
be revising and continually planning your drafts. So I think
that there's a real need for it. As I meet with the other
health directors, as I've talked with them, I think you'll see
in my written testimony the many examples. Each of those
examples was not something that was directly related to prior
event, but it exercised a capacity or capability that was
directly related to pandemic flu and elsewhere. I will tell you
the first few times we stood up ICS in our department, it was
disastrous and you heard about people losing sleep, I lost
sleep saying oh my, if we had really had a pandemic, we're not
ready. That's why we lowered the threshold and utilized ICS at
a very low threshold in the department because we now have
everyone trained in ICS. One hundred percent of the staff were
trained in ICS. We utilize it all the time because we don't
know who is going to be sick and absent. I mean we had a
mycoplasma outbreak and I was on vacation in the Grand Canyon.
I ended up flying back here, but we utilized a lot of the
different aspects of it. But I think you need to have that
training and that on-going funding. My concern, I think I have
it in written testimony is you see a trending of the funding
going down and I think that that puts us at jeopardy of
watching some of the disease outbreaks coming back. So that's
the same story I hear.
All of us like to think we're unique. All of us have sicker
patients. All of us have more problems, but I will tell you,
everyone across the country whether it be California or Rhode
Island or the Virgin Islands or Hawaiian Islands, we all have
the same issues and concerns and I think really would benefit
from it. So I would hate to see us declare victory and go home
in this. I think we need, this is now a new way of responding,
not just to the threats, but to our day-to-day activities.
Mr. Langevin. Please be brief as possible, Peter.
Mr. Ginaitt. Absolutely, Mr. Chairman. Hospitals are
stressed. With all due respect, we do receive as much money as
we can. We're very grateful for the grant funding that we do
receive through the Federal Government and through the State,
however, we're faced with daily challenges in hospitals.
Emergency management is a new tool. As we all remember in
emergency management agency not that many years ago was called
civil defense and they bagged rivers when they were
overflowing. Now it's taken on a whole new meaning in this
Nation. Hospitals are taking it very, very seriously and we're
trying to deal with what funds we do have. We're grateful for
any of the funding that comes in. As an example, Rhode Island
Hospital is a recipient of one of the ASPR grants, one of the
five partnership grants to develop a patient tracking module
that can be used as a model throughout this Nation, as well as
a communication so that we can have sustainable communications
as we saw fail down in Louisiana after Hurricane Katrina. We do
try to manage those. We do try to take what money we can. It is
difficult at best. We will make anything work that heads our
way. However, we do need some, I think, some larger plans,
larger plans of attack with some grant funding that we can look
at through multi-year implementation.
Again, we're willing to work with our partners. We've done
a great job, but we also understand we have a daunting task
ahead of us.
Mrs. Christensen. Mr. Chairman, I'm going to probably leave
at this point so I want to thank you at this time for inviting
me to the hearing and for the opportunity to be here and be a
part of this.
Mr. Langevin. I'll see you tonight in Washington. Thank you
for your questions.
The Chair now recognizes the gentleman from New Jersey, Mr.
Pascrell, 5 minutes.
Mr. Pascrell. Thank you, Mr. Chairman. Mr. Ginaitt, you
talked about the hospital stress. Hospitals are closing and if
we're planning for huge service necessities, it would seem that
that's not a very good idea. But they close not because they
want to. They close because they don't--they can't pay their
bills. I'm sure that you've had closings in Rhode Island. So
that space, where the hospital sold it to some other entity or
not, that space could be much more valuable down the line and I
hope you've given thought to that.
Mr. Ginaitt. Representative, we have. Every morning I drive
down Warwick Avenue actually Representative Langevin's previous
legislative district and I drive by a Wal-Mart--not a Wal-Mart,
a drug store that formerly was a small community hospital that
no longer exists and it's disheartening to see what is actually
happening, the fleecing of the health care within the United
States and hospitals trying to sustain themselves through poor
economic times.
It is cyclical and we see that, but many of the smaller
community hospitals really do depend on those communities and
those communities depend on them. Trying to operate a major
initiative and controlling and being ready for emergency
preparedness while you're trying to pay for the very people
that keep the doors open in that hospital, again is a daunting
task.
Mr. Pascrell. Has anyone from the Homeland Security
Department ever reached out to you personally?
Mr. Ginaitt. No, other than through Homeland Security--
actually grants that we've dealt with, or the local. I will
say----
Mr. Pascrell. So no one has reached out to you?
Mr. Ginaitt. Directly, no.
Mr. Pascrell. How about you, Mr. Kilday?
Mr. Kilday. We speak to the Homeland Security folks daily.
Mr. Pascrell. I'm sorry?
Mr. Kilday. We work very closely with Homeland Security
from the Fed side on a daily basis for grant programs and other
activities.
Mr. Pascrell. Do you get the sense that they're attempting
a bottom-up kind of situation which is remove ourselves from
what we're doing 5, 6 years ago to now? You don't have that
feeling, do you?
Mr. Kilday. We've seen in the organization of DHS it's
shifted, clearly as was talked about earlier in the previous
panel over the years and we've seen from the top-down and now
we are working with the regional focus where the regional
planners are out in the community working with us out of FEMA
Region 1 specifically, although we are concerned that the
system will flex and change again and it takes a great deal of
staff time to flex with them and it takes away from program
activities.
Mr. Pascrell. Dr. Gifford.
Dr. Gifford. Most of our dealings are with the various
agencies within HHS, but we do do some with DHS. They've
reached out to----
Mr. Pascrell. I didn't ask you who you dealt with. I asked
you do they reach out to you?
Dr. Gifford. Yes. They've reached out to both me and my
staff. As we go forward, I would say there's been an evolution
over time from more of a top-down to much more of a partnership
activity. I think one would not want to see the pendulum swing
from either top-down or bottom-up. I think a partnership where
there's a co-working is better. I think as alluded to in the
previous panel, things have gotten better. Could they continue
to improve? I think we can always continue to strive to improve
and make it better.
Mr. Pascrell. All right.
Mr. Ginaitt. Representative, I just want to give some
clarification in my response. We do deal directly with our
State emergency management agency which are the program
managers for the Department of Health, Department of Homeland
Security, so we have been able to work very, very successfully
with the Emergency Notification System, the event calendar. We
have a tremendous number of things within our hospitals which
is directly related to Department of Homeland Security through
our State-wide providers.
Mr. Pascrell. Thank you. General Bray, you said you're at
71 percent capacity, if I heard you correctly.
Gen. Bray. Correct, sir.
Mr. Pascrell. How many guardsmen do you have?
Gen. Bray. We have just over 3,200. It varies on any given
day.
Mr. Pascrell. How many are deployed?
Gen. Bray. At the present time we have approximately 350.
Again, it varies every day. We try to maintain no more than
about 500 at any given time deployed both air and Army, but
again, depending on the mission, it varies on a regular basis.
Mr. Pascrell. Not every State has incorporated the National
Guard as you have here in Rhode Island into the emergency
management scheme. To what extent have you done that in Rhode
Island? Can you just briefly talk about that?
Gen. Bray. What we have attempted to do is build on the
relationship that the Rhode Island National Guard and Emergency
Management have had for some time. Rhode Island is very unique
in that there is no county government and so the default many
times from the local is directly to the State and oftentimes
the Rhode Island National Guard as well as the health
department becomes the next stop for the first responder. So it
has become absolutely essential that that relationship take
place on a regular basis.
So on a daily basis we have, as I mentioned, a joint
operation center staffed 24/7 by the military and on the other
side of my headquarters the State emergency operations center
which we have a 24/7 capability, but only staffed during
regular working hours and then a call waiting system after
that. My attempt is to merge that capability into one standing
joint interagency coordination center which I've been in
discussion with for a concept of operations with the National
Guard and try to work through the Title 32 issues that--and for
that matter the labor issues on the State side that apply in
that capability. That intent there is to give us full
situational awareness, develop a common operating picture so
that we can put critical assets at critical needs when we need
them, as opposed to reacting to situations that might develop.
Mr. Pascrell. Can you send me a summary of that operation?
I'm interested in that.
Gen. Bray. Yes, sir. I would just add that we have a great
collaboration within the region and also amongst the Adjutant
Generals, many of whom have the same dual hat capability that I
have to discuss these very matters. General Tim Lowenberg, the
Adjutant General for the State of Washington leads the
Governor's Homeland Security Advisory Council and is the lead
for much of that discussion. So a great deal of collaboration
takes place on a daily basis.
Mr. Pascrell. Thank you for your service to your country,
as all the gentlemen. Thank you for your service to Rhode
Island and the country, not just Rhode Island.
Mr. Langevin. I thank the gentleman. One final question
that I will pose to you, Mr. Kilday, since we're talking about
getting beyond getting ready and actually being prepared, have
the plans Rhode Island EMA produced been adequately tested and
evaluated? If so, how and if not, why not?
Mr. Kilday. Rhode Island maintains a comprehensive exercise
program that involves the local agencies as well as a number of
State agencies. We have a very small staff. We have a single
individual who manages our exercise program and they receive
support from other staff within the agency. Some of the
challenges are the requirements under the homeland security
exercise and evaluation program are quite arduous and the task
of completing after action reviews as well as other plans and
responses to preparedness.
I think that we have done a really good job with exercise
activities in the State in spite of our limited staff and
capability and I owe this to the local resources, specifically
the 39 local communities who often through their emergency
management programs which are either paid, volunteer, or are
part-time in some manner step to the plate, participate in the
exercise programs and support emergency management in our
efforts by participating in these exercises.
I think we could have a more robust exercise program and
hope to do that some day within the agency, but currently based
on funding, staff requirements, caps on hiring, we do not have
that.
Mr. Langevin. With that, I do want to thank all of you for
your testimony. I want to thank you for your service to the
State, to the country. The issue of emerging biological threats
is something we all take very seriously. It's a daunting task
to try to protect our citizens from every contingency. We
recognize perhaps that is not entirely possible, but to have
plans in place and a robust system of prevention, detection and
response is really the best strategy. Oversight sometimes is
obviously, it is difficult, painful sometimes for those on the
other side of the table to go through, but it's an important
part of being able to evaluate where we are and where we want
to get to. So I'm encouraged by what I've heard here today from
the things that Rhode Island is doing and perhaps because we
benefit always from being a small State, perhaps it's easier to
coordinate and I hope that what we're doing right here in the
State can serve as an example of what the rest of the country
can and should do to better protect the rest of our citizens.
Thank you all for your efforts and we stand ready to work
with you as we go forward in trying to better protect the
country from emerging biological threats and making sure that
we have the most robust, strongest system of public health
preparedness. So with that again I want to thank you all for
your testimony and your valuable insights that you've given us
today. Clearly, there are great challenges ahead. We're not
there yet and more work needs to be done, but thank you for the
work that you're doing.
With that, I want to thank you again, the witnesses, for
the valuable testimony, the Members for their questions. The
Members of the subcommittee may have additional questions for
the witnesses and we ask that you respond expeditiously in
writing to those questions.
Hearing no further business, this subcommittee stands
adjourned.
[Whereupon, at 1:04 p.m., the subcommittee was adjourned.]
A P P E N D I X
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Questions From Chairman James R. Langevin to Dr. Jeffrey W. Runge,
Assistant Secretary for Health Affairs and Chief Medical Officer,
Department of Homeland Security
Question 1. We know that you have considered the possibility and
impact of bioterrorism and an event such as pandemic influenza
occurring simultaneously or one right after another. This being the
case, some have suggested that medical and public health resources
should be held in reserve to address additional events. Do you think
this is even possible? How do you believe the multiplicative threat can
and should be handled?
Answer. In the Department's planning and preparedness efforts, we
have considered the potential impacts of both multiple and/or
simultaneous bioterrorism attacks and other catastrophic events. The
Department participates with its interagency, State and local partners
in the annual TOPOFF national-level exercises, which specifically
incorporate scenarios where multiple and/or simultaneous events occur.
In this year's TOPOFF-4 exercise, Federal, State and local officials
responded to three simultaneous Radiological Dispersal Device (RDD), or
``dirty bomb'' attacks, causing casualties and wide-spread
contamination in Guam and two U.S. cities. Given that virtually any
catastrophic event will almost certainly include medical and public
health consequences, we agree that medical and public health resources
should be held in reserve in the event that there are multiple and/or
simultaneous emergencies. The Department of Health and Human Services
(HHS) serves as the lead Federal entity for Emergency Support Function
8, Public Health and Medical Services: ``Public Health and Medical
Services provides the mechanism for coordinated Federal assistance to
supplement State, tribal, and local resources in response to a public
health and medical disaster, potential or actual incidents requiring a
coordinated Federal response, and/or during a developing potential
health and medical emergency.''\1\ Under ESF-8, HHS serves as the lead
Federal partner in ensuring that the Nation is maintaining appropriate
levels of medical surge capacity, which is a critical element of our
national, State and local resiliency. The Strategic National Stockpile
(SNS), which is managed and overseen by HHS, is an example of
maintaining a national stockpile, or reserve, of medical and public
health resources. HHS also oversees the Medical Reserve Corps, the
National Disaster Medical System, and other critical medical and public
health resources that can and are activated during catastrophic events.
DHS/OHA supports HHS's work with State and local governments to
maintain their enhanced medical surge capacity. There are a number of
ways to mitigate the risk of catastrophic outcomes resulting from
multiple and/or simultaneous biological events, including maintaining a
strong and well-trained cadre of medical first responders, developing
and exercising well-coordinated plans and mutual-aid agreements among
Federal, State and local governments, and establishing rapid
distribution and deployment strategies of medical countermeasures.
---------------------------------------------------------------------------
\1\ Emergency Support Function (ESF) 8: Public Health and Medical
Services; National Response Framework; January 2008.
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Question 2. Please provide information regarding the increased
efforts of Customs and Border Protection regarding identifying sick
persons crossing the U.S. borders, and sending them to secondary
screening.
Looking back on your time with the Department, starting out with
only yourself as Chief Medical Officer, and then growing the Office of
Health Affairs to the larger entity it is now, tell us what you have
learned and what you would have done differently in terms of helping
the Nation to prepare for emerging biological threats. What advice do
you have for your own Deputy, Dr. John Krohmer, who will be heading the
Office of Health Affairs through the transition to the new
administration, and for others that will be countering these threats?
Answer. As was described during the hearings last summer regarding
the procedures of CBP in the management of sick persons at borders and
ports-of-entry, the policies, legal authorities, and spirit of
cooperation between CBP and the Centers for Disease Control (Division
of Global Migration and Quarantine) are well-developed, supportive, and
appropriate. There were procedural issues, however, that produced sub-
optimal results. Specifically with regard to screening procedures
regarding anyone identified as being a possible public health concern,
CBP procedures and computerized screening support systems were modified
to require that anyone so identified at primary screening must be
referred to secondary screening for resolution of the issue. Using
well-established procedures, CBP works jointly with health authorities,
including CDC and the DHS Office of Health Affairs to get medically
valid advice regarding the health status of the individual in order to
reach a medically and legally valid determination on both admissibility
and any necessary medical/public health requirements.
Even prior to the incident of last summer, through a series of
interagency efforts particularly addressing pandemic influenza, we
learned that no one agency has the authorities, expertise, or
capabilities to fully counter natural or intentional biological threats
to the country. Such a proactive effort requires, for example, basic
sciences expertise resident in CDC, applied sciences tools resident
throughout HHS (especially the Office of the Assistant Secretary for
Preparedness and Response), research and development efforts by both
CDC and DHS Science and Technology, public health approaches involving
State, local, tribal, and Federal public health agencies, and law/
border security efforts by several agencies within DHS. Amongst the
most important lessons learned for the Office of Health Affairs is the
critical importance of taking the ``50,000 foot'' view to help
coordinate all of these efforts as there is no other office or agency
as well-positioned to take on this critical role. While DHS has the
overarching mission of coordinating preparedness and incident response,
in the specialized area of public health and medicine, the uniquely OHA
role has been to integrate understanding of the science of health and
medicine, including biological threats, with an understanding of law
and border enforcement, and applying this understanding to facilitate
the interagency coordination and cooperation required to successfully
prepare the Nation against biological threats.
Question 3a. Aside from the National Response Framework, the
Department of Homeland Security is responsible for creating operational
plans that delineate what the Federal Government is going to do if each
of the National Planning Scenarios were to occur. What is the status of
getting those plans done?
Answer. Planning to address Federal Incident Management activities
for each of the National Planning Scenarios is currently underway. The
effort, while coordinated through the Department of Homeland Security's
Office of Operations Coordination and Planning (OPS), is truly an
interagency effort.
The Hurricane KATRINA Lessons Learned \2\ report published in
February 2006 established the requirement for a permanent planning
element located within the Office of Operations Coordination's (OPS)
National Operations Center (NOC) and the need for a standardized
Federal planning process. As a result, OPS established the Incident
Management Planning Team (IMPT) \3\ in September 2006. The IMPT
developed the National Planning and Execution System (NPES) \4\ as an
interim process to standardize Federal planning as they developed
operational level concept plans (CONPLANS) based on the 15 National
Planning Scenarios (NPS). Over the next 16 months (SEP 06-DEC 07) the
IMPT developed six plans based on the NPS. These scenarios included:
Improvised Nuclear Device (IND), Radiological Dispersal Device (RDD),
Improvised Explosive Device (IED), Cyber Attack, Major Hurricane,
bioterrorism attack and Pandemic Influenza. In December 2007, the
President approved Annex I (National Planning), to Homeland Security
Presidential Directive 8 (HSPD-8). Annex I directed development of an
Integrated Planning System (IPS) which replaces NPES. IPS was approved
for interim Federal use in June 2008. [sic] edIn July 2008, the DHS
Office of Operations Coordination became the DHS Office of Operations
Coordination and Planning (DHS OPS).
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\2\ The Federal Response to Hurricane Katrina: Lessons Learned
(February, 2006).
\3\ The purpose of the Incident Management Planning Team (IMPT) is
to support a unified inter-agency planning effort for incidents
requiring a coordinated national response. The IMPT will support the
development of strategic guidance, concept development, plan
development, and plan refinement leading to publication of a series of
plans for actual or potential domestic incidents. IMPT Charter, August
21, 2006.
\4\ The NPES was aligned with the National Incident Management
System (NIMS) and the Department of Defense (DOD) Joint Operations
Planning and Execution System (JOPES).
---------------------------------------------------------------------------
[sic] was The planning process in IPS is based on best practices
from planning systems used in civilian and military communities. The
IPS calls for several layers of plans, each of which draws upon the
plan above it for guidance and direction:
FEDERAL INTERAGENCY PLANNING ARCHITECTURE
Interagency planning is ongoing on the 15 National Planning
Scenarios, which were compressed into 8 scenario sets and prioritized
by HSC Deputies. On 09 OCT 08, the Homeland Security Council requested
that by 20 JAN 08, the IMPT complete the Terrorist Use of Explosives
(TUE), Improvised Nuclear Device (IND), and Biological Attack (BIO)
Strategic Plans and begin work on the Radiological Dispersal Devices
(RDD) and Chemical Attack plans. Currently steady progress is underway
to meet this goal; the TUE is completed; the IND is in final
adjudication; and the BIO planning process is already underway.
While all interagency plans have not yet been produced under IPS,
it is important to note that there is a great deal of planning and
preparedness activities that addresses our readiness to address
threats. NIMS, NRF and incident annexes provide doctrine and a
framework for incident management, and Federal departments and agencies
have procedures and plans in place to execute legal and policy
responsibilities. As indicated in the chart below, the five biological
national planning scenarios have been compressed into two separate
scenario sets.
IPS PLAN DEVELOPMENT PRIORITY
Question 3b. In particular, have the material threat assessments
been completed for pandemic influenza and other biological threat, and
what is the status of the plans that addresses the pandemic influenza
planning scenario and other biological planning scenarios? Please send
us these material threat assessments, as well as the plans based on
them. If the plans are not yet complete, please forward the plans in
whatever draft state they are in now, and provide their expected
deadlines for completion.
Answer. (1) A Material Threat Assessment (MTA) has not been
performed on pandemic influenza. The MTA and Material Threat
Determination (MTD) process was established per the Project BioShield
Act of 2004 (Pub. L. 108-276) to inform medical countermeasure
requirements and acquisitions using the Special Reserve Fund for those
chemical, biological, radiological, and nuclear agents identified
through the MTD/MTA process. Funds to purchase medical countermeasures
for pandemic influenza are separate from the Project BioShield Special
Reserve Fund and thus pandemic influenza was not included in the MTD/
MTA process. MTAs have been completed on the following biological
threat agents:
Botulinum Toxin (Clostridium botulinum);
Plague (Yersinia pestis);
Anthrax (Bacillus anthracis);
Tularemia (Francisella tularensis);
Typhus (Rickettsia prowazekii);
Q-fever (Coxiella burnetti);
Rocky mountain spotted fever (Rickettsia rickettsii);
Glanders (Burkholderia mallei);
Melioidosis (Burkholderia pseudomallei); and,
Viral Hemorrhagic Fevers--Filovirus (Marburg, Ebola);
Arenavirus (Junin, Lassa, Machupo, Guanito); Flavivirus
(Dengue, Yellow, Kyasanur Forest, Omsk); Bunyavirus (Rift
Valley, Crimean-Congo, Hantaan).
These MTAs are classified at the SECRET level and are available
upon your request. To date, the anthrax MTA is the first scenario
established by the MTA process to be considered in facilitating the
Federal Government's planning activities per HSPD-8.
Question 4a. A strategy employed by many departments and agencies
for increasing efficiencies for public health and emergency
preparedness for emerging biological threats is to better align grants,
grant cycles, grant deadlines, etc.
Please describe the roles, responsibilities, and activities of the
Grants Coordination Division in the Office of Health Affairs. How much
progress has this Division made in better aligning grants, grant
cycles, grant deadlines, etc. in this regard?
Question 4b. It is possible for Federal Departments and agencies to
issue grants, contracts, and cooperative agreements that extend over
more than 1 year at a time. However, many grants, contracts, and
cooperative agreements issued by the Department of Homeland Security do
not cover multiple years. What do you think of the value and
feasibility of multi-year funding for activities that relate to public
health security and emergency preparedness for emerging biological
threats?
Answer. OHA leads the DHS effort to coordinate preparedness grants
that have a health and medical nexus. Efforts are underway to align
subject matter expertise in the synchronization of external grant
programs (i.e. HHS) and align those efforts to evolving Homeland
Security Presidential Directives; National Priorities; Target
Capabilities; Emergency Support Functions; and program guidance to
enhance national preparedness.
OHA has been intimately engaged with FEMA/GPD in ascertaining
health and medical readiness functions through guidance development
(State Homeland Security Grant Program (SHSGP)/Urban Area Security
Initiative (UASI)/Metropolitan Medical Response System (MMRS)). To that
end, OHA has made an increasingly positive impact by providing subject
matter expertise in the alignment of grant programs' health and medical
capabilities.
Currently, fiscal year 2009 grant guidance is in development and
pending release once appropriations are passed. Grant deadlines are
typically set through congressional appropriations and remain firm.
However, OHA has taken proactive efforts to work with the health and
medical community, professional organizations, and internal subject
matter experts in the guidance development ahead of appropriation
deadlines.
In coordination with the Grant Programs Directorate (GPD) within
FEMA, OHA communicates with stakeholders to enhance preparedness
efforts with specific attention to health and medical surge capacity,
response, and recovery. As a result of the Post Katrina Emergency
Management Reform Act of 2006 (PKEMRA), OHA is the principal agent for
all health and medical activities that affect our national ability to
prevent, prepare for, protect against, and respond to natural
disasters, acts of terrorism, and other manmade disasters. In this
role, we believe it is critical to ensure that our medical first
responders have the resources to respond to catastrophic incidents.
The period of performance for most homeland security grant
programs, including MMRS, is currently 36 months and extensions are
routinely granted as necessary. There is incredible value to multi-year
funding activities. As DHS/FEMA is actively promoting multi-agency as
well as multi-jurisdictional capabilities, multi-year funding for these
activities is paramount to meet the logistical challenges associated
with planning, organization, development, execution, and evaluation.
Activities relating to emerging biologic threats and public health
security may benefit from multi-year funding. OHA and FEMA/GPD are
working to prioritize grant funding for health and medical capabilities
planning.
Question 5. It has been stated that both the Secretary of Homeland
Security and the Secretary of Health and Human Services would be co-
leaders during an influenza pandemic. You, as well as your respective
secretaries, have also stated the same in previous testimony before
Congress. Please describe specifically how they will actually lead at
the same time. How do you see this working?
Answer. As stated in the National Response Framework, HSPD-5, and
other guiding documents, the Secretary of Homeland Security would serve
as the leader of the Federal response, coordinating activities of all
departments and agencies working through the ESF structure. DHS will
work closely with all Federal partners that have responsibilities in
preparing for and responding to a pandemic.
The Secretary of the Health and Human Services will fulfill the
major responsibility of overseeing the public health and medical
response. DHS is responsible for the coordination of the overall
Federal response during an influenza pandemic, including implementation
of policies that facilitate compliance with recommended social
distancing measures, development of a common operating picture for all
Federal departments and agencies, and ensuring the integrity of the
Nation's infrastructure, domestic security and entry and exit screening
for influenza at the borders.
DHS recognizes the key role of HHS in its responsibility to lead
the coordination of the public health and medical emergency response
activities during a pandemic under Emergency Support Function (ESF) 8,
including the deployment and distribution of vaccines, antivirals and
other life-saving medical countermeasures from the Strategic National
Stockpile. DHS also recognizes the Department of State's role to lead
the coordination of international efforts including U.S. engagement in
a broad range of bilateral and multilateral initiatives that build
cooperation and capacity to fight the spread of avian influenza and to
prepare for a possible pandemic. USDA conducts surveillance for
influenza in domestic animals and animal products, monitoring wildlife
in coordination with the Department of the Interior, and working to
ensure an effective veterinary response to a domestic animal outbreak
of highly pathogenic avian influenza.
Question 6. How has the Office of Health Affairs involved other
high-level decisionmakers at the Federal, State, territorial, tribal,
and local levels in planning efforts? How do you suggest that the
processes by which this should occur be improved?
Answer. The Office of Operations Coordination and Planning (OPS) is
tasked by the Secretary of the Department of Homeland Security to be
the lead for Federal Interagency Strategic Planning. The Deliberate
Plans Branch within OPS coordinates these planning activities, with
more than 53 Federal departments and agencies participating.
Additionally, FEMA is responsible for the development of Concept Plans
or CONPLANS that address interagency activities in greater detail. Each
Department and Agency is then responsible to develop their own agency
specific Operations Plan or OPLAN. Additionally coordination of
planning activities with State and local governments happens primarily
at the FEMA Region level. It is anticipated that regional plans will
also be produced through the IPS.
The Office of Health Affairs (OHA) is a very active partner in all
levels of planning at DHS. OHA provides expert advice and works with
subject matter experts at the Department of Health and Human Services
(HHS), the Department of Agriculture (USDA), and the Environmental
Protection Agency (EPA) to ensure that health and medical-related
content for these planning efforts has the most current information
available.
The required improvement to Federal, State, territorial, tribal and
local level planning is being addressed by the adoption of IPS. This
system is a major step in the improvement of planning processes across
the Federal Government. Additionally FEMA has recently released the
interim Comprehensive Preparedness Guide (CPG) 101, ``Producing
Emergency Plans: A Guide for All-Hazard Operations Planning for State,
Territorial, Local, and Tribal Governments'' which provides communities
with guidance for emergency operations planning. CPG-101 (interim) also
describes how the State and local planning process will vertically
integrate with the Federal Integrated Planning System. These two
planning documents that were developed with the assistance of multiple
departments and agencies at all levels of government have vastly
improved emergency planning activities across the spectrum of homeland
security.
OHA is an integral component in the development of each Federal
SGS, Federal Strategic Plans and Federal Concept Plans. Additionally,
OHA supported the development of content for the National Planning
Scenario No. 2: Biological Attack--Aerosol Anthrax.
Question 7. Do you believe that mobile hospital assets should be
deployed during an influenza pandemic? If so, how do you believe that
should occur--how would they be most useful?
Answer. The issue of providing care during a pandemic is a matter
of surge capacity. Surge care must be delineated from disaster care in
that it is not necessarily a space issue, but rather it is limited by
available human resources. While it is accurate that there will likely
be significant shortages of bed space in which to care for the
population, our ability to provide care will be limited by the number
of available health care providers. The deployment of mobile medical
facilities will assist with the surge only if we are able to staff
those beds. This differs from a disaster in that we generally have the
ability to mobilize providers from outside of the affected area to
bring in to staff a mobile medical facility. In the event of a pandemic
all available providers will likely be tied up providing care in their
normal institutions. It should also be understood that there will
likely be a shortage of available providers due to their inability to
report for duty due to illness. As such, we will be potentially facing
an overwhelming population of patients seeking care in traditional
hospitals while trying to maintain skeleton staffing due to health care
provider absence due to illness. Successful mass care during a pandemic
will be dependant upon creative use of limited human resources rather
than adding mobile beds which may be difficult, if not impossible, to
staff.
Question 8. What is the status of the pandemic influenza exercises
that were to be incorporated into the National Exercise Program? How
many have occurred to date, and how many will occur in the future? What
pandemic influenza exercises have you participated in or supported at
the Secretary, Assistant Secretary, and Deputy Assistant Secretary
levels (please provide dates and brief descriptions)? Are you satisfied
that during these exercises that lessons learned are being adequately
communicated and applied to bioterrorism preparedness?
Answer. DHS participated in PLE 1-08, an Assistant Secretary level
exercise conducted in Washington, DC on February 20, 2008. Assistant
secretaries met to examine the Federal Government response to an
influenza pandemic and consider 3 specific modules: Screening of
inbound air travelers, distribution of anti-viral medications, Federal
Government options if communities fail to implement effective
mitigation strategies. The exercise also focused on effective
communication strategies during a pandemic. An exercise covering
communications coordination during a pandemic was conducted in November
2007. This exercise included the pre-designated National PFO and
Regional PFO Pandemic Influenza/Biological Threat Response teams, HHS
and representatives from the Homeland Security Council. More exercises
for the PFO Pandemic Influenza/Biological Threat Response teams are
planned for 2009. DHS has an intradepartmental PI exercise scheduled
for Oct 2008 that will primarily cover the specific roles and
responsibilities of the DHS component agencies during a pandemic and
will review and exercise parts of the DHS pandemic plan and specific
DHS component PI plans. DHS is satisfied that lessons learned from all
these exercises are being effectively implemented in guiding future
policies and programs regarding pandemic and bio-terrorism scenarios.
Question 9. GAO recently released a report on State and local
pandemic planning and exercising, and recommended that the Secretaries
of the Department of Homeland Security and the Department of Health and
Human Services, in coordination with other agencies, convene additional
meetings with the States and territories in the five Federal influenza
pandemic regions to help them address identified gaps in their pandemic
planning. We have heard that previously held meetings were of limited
value to both the Federal and non-Federal Governments. Do you think
that have additional meetings would be useful? Are you planning on
holding additional regional meetings on pandemic influenza, and for
what purposes?
Answer. Additional regional workshops will have to be coordinated
by DHS and HHS at some time after the current State plan review process
has been completed. DHS concurs with HHS, that it would be impractical
in the short term because of each department's current involvement in
the update of the States' pandemic plans. The current timeline to have
all of the updated reviews done, reconciled with States, and analysis
of gaps will not likely occur until December 2008 or January 2009 at
the earliest. It should be noted that the State plan review effort has
also allowed DHS and HHS get a better understanding of what issues the
States would like addressed and has provided us with an opportunity to
make direct contact with States.
Question 10. There has been a lot of discussion regarding altered
standards of care, including in a recent GAO report on medical surge.
You have said that the standard care always remains the same, but in
the case when resources are limited, the type or amount of care may
have to change. Please elaborate. How would you recommend that States
and territories address this difficult issue?
Answer. The most common legal definition of standard of care is how
similarly qualified practitioners would have managed the patient's care
under the same or similar circumstances; hence our comment that the
standard of care would not change but rather would be evaluated in the
context of the situation or circumstances. A mass casualty event
involving thousands or tens of thousands, of injured or ill victims
will require health care systems to quickly shift from routine
operating practices to processes, procedures, and practices that can
best support the additional emergent and urgent demand. When feasible,
resources (people, equipment, space, supplies, etc.) used to provide
certain types of care (e.g. preventive, screening, or elective) may
need to be shifted to support the increased demands for emergent and
urgent care. Another shift might incorporate the use of non-traditional
providers to provide care for those with chronic conditions (e.g.
hypertension and diabetes mellitus) that left untended could become
urgent or emergent or the ``worried well.'' Examples of this might
include:
Shifting the resources that produce the 183,000,000 visits
to physician offices and hospital Out Patient Departments and
Emergency Departments for non-illness or non-injury conditions
(source: 2006 National Ambulatory Medical Care Survey (NAMCS)
and National Hospital Ambulatory Medical Care Survey (NHAMCS)).
Shifting the resources used to provide the 1,615,100
screening colonoscopies performed annually (source: National
Cancer Institute Survey of Colorectal Cancer Screening
Practices).
Having processes in place to effectively optimize the
expertise of other non-traditional medical disciplines:
Approximately 161,000 and 95,000 medical, dental, and
ophthalmic laboratory technicians (U.S. Department of
Labor, Occupational Outlook Handbook, 2008-09 Edition).
Approximately 62,000 veterinarians and 71,000 veterinarian
technicians and technologists (U.S. Department of Labor,
Occupational Outlook Handbook, 2008-09 Edition).
To address this difficult issue, our recommendations to the States
and territories would be to:
Use data-driven processes, specific to the State or
territory, to understand their unique set of existing
requirements and capabilities.
Support, facilitate, and fund coordination and collaboration
at the community, regional, and inter-State level.
Provide information to the Department of Health and Human
Services to support its role in coordinating public health
emergency preparedness and response information.
Question 11. In your position as Assistant Secretary for Health
Affairs, it is often not as challenging to partner with another health
entity such as the Assistant Secretary for Preparedness and Response at
the Department of Health and Human Services, as it is with non-health
entities within the Department of Homeland Security itself. How have
you overcome these challenges, and what lessons have you learned that
you would pass on to those that need to partner across sectors to
prepare for emerging biological threats?
Answer. Coordination within the Department of Homeland Security, as
well as with other Federal partners is extremely important to ensure a
cross-share of information and integration of resources and expertise
on both health and non-health issues. A cross-sharing and integration
of information and resources is critical because there are overlapping
requirements and authorities that must be coordinated in response
efforts. Without ongoing collaboration, information is not easily
accessible and additional time may be necessary to obtain complete
situational awareness. As with many other types of threats,
bioterrorism can have wide-ranging consequences and require a multitude
of response capabilities and expertise, including health, emergency
management, law enforcement, intelligence and critical infrastructure/
key resources protection. As such, in the event of a biological attack,
many components of DHS would play critical roles in a response.
The Office of Health Affairs (OHA) regularly participates in
working groups, strategic planning initiatives, training and exercises
and other preparedness and response activities with other Department
components to develop coordinated approaches to the various
preparedness and response planning initiatives. As an example, the
National Biosurveillance Integration Center (NBIC) coordinates and
integrates situational awareness information within DHS and with
Federal partners. During the recent salmonella saintpaul outbreak, NBIC
participated with Federal partners to maintain current situational
awareness of the disease outbreak trends. The salmonella saintpaul
event is an example of the importance of collaboration by addressing
potential issues, including economic effects, international relations,
and border screening. In addition, the NBIS Interagency Working Group
(NIWG) and sub-working groups meet on a regular basis to participate in
biosurveillance conferences to address a broad range of interagency
requirements and collaboration issues.
Question 12. Please give us the status of the Department of
Homeland Security's own pandemic influenza plan. Has this plan been
finalized? If so, when--and how have they been circulated throughout
the Department and the Executive branch? Please provide a copy of this
plan and any other relevant plans regarding pandemic influenza and
other biological threats that the Office of Health Affairs has
developed.
Answer. The DHS pandemic influenza (PI) plan will be revised during
interagency planning under the IPS. DHS OPS intends to leverage the
extensive previous pandemic planning efforts (which include a Federal
Pandemic Influenza Concept Plan, a Federal Pandemic Influenza Border
Management Plan and a DHS Pandemic Influenza Plan) to expedite the
revision of the DHS PI plan. Current estimate for the completion of
these revisions is early in 2009.
Question 13. We have a lot of biosurveillance efforts going on
throughout the Nation. The National Biosurveillance Integration Center,
BioSense, BioFusion, the National Medical Intelligence Center are only
a few of the many activities occurring in this arena. In your opinion,
how do you think these efforts should be integrated?
Answer. The mission of the National Biosurveillance Integration
Center (NBIC) is to provide senior leaders and National Biosurveillance
Integration System (NBIS) Member Agencies (NMAs) early cueing and
increased situational awareness of biological events across all the
biological domains.
NBIS provides a collection backbone that supports cross-domain
integration, unique analysis of information, and collaboration between
the agencies. Through NBIS, NMAs and participating agencies can
provide, share and receive early biological event cueing and bio-
situational awareness across all of the biological domains. NBIC serves
as the operational hub for this community of member and participating
agencies that leverages and integrates the various bio-surveillance
efforts in support of the NBIC and NMAs missions. The expectation is
that agencies will continue to collect their agency specific
information, such as CDC using BioSense, will conduct their own data
analysis of this information such as CDC intends to perform within
BioPhusion, and then share this information with the NBIC. This is the
same functional relationship being established between NBIC and the
National Center for Medical Intelligence (NCMI). The NBIC provides the
functional capability to collect bio-informational data, integrate
those data via collaboration with the member and participating
agencies, thus producing various NBIS products to provide early cueing
and bio-situational awareness.
For example, during the recent salmonella event, the NBIC provided
inter-agency information integration, sharing, and awareness in support
of the Food and Drug Administration (FDA). Additionally, the NBIC team
is working closely with the CDC as it develops the National Bio-
Surveillance Strategy for Human Health and serves to facilitate the
interagency and cross-domain collaboration for this important strategy
effort.
As mandated in Public Law, the various biosurveillance and
intelligence data streams should be integrated leveraging the NBIS with
the NBIC providing the keystone.
Questions From Chairman James R. Langevin to Rear Admiral W. Craig
Vanderwagen, MD, Assistant Secretary for Preparedness and Response,
Department of Health and Human Services
Question 1. We know that you have considered the possibility and
impact of bioterrorism and an event such as pandemic influenza
occurring simultaneously or one right after another. This being the
case, some have suggested that medical and public health resources
should be held in reserve to address additional events. Do you think
this is even possible? How do you believe the multiplicative threat can
and should be handled?
Answer. Response was not provided at the time of publication.
Question 2. Beginning in fiscal year 2009, the Pandemic and All-
Hazards Preparedness Act (PAHPA) of 2006 requires the Secretary of the
Department of Health and Human Services to withhold some grant and
cooperative agreement funding where a State has failed to develop an
influenza pandemic plan that is consistent certain criteria,
benchmarks, and standards established by the Department of Health and
Human Services. Have the criteria, benchmarks, and standards been
established by the Department of Health and Human Services? If so,
when? What is the status of the Departmental review of State plans
required by PAHPA to ensure that certain criteria are being met?
Answer. Response was not provided at the time of publication.
Question 3a. A strategy employed by many departments and agencies
for increasing efficiencies for public health and emergency
preparedness for emerging biological threats is to better align grants,
grant cycles, grant deadlines, etc.
Please describe the roles, responsibilities, and activities of
those grant-making agencies and offices at the headquarters level of
the Department of Health and Human Services, and at its subordinate
agencies regarding grants alignment with those put out by other
departments and agencies. How much progress has the Department of
Health and Human Services made in better aligning grants, grant cycles,
grant deadlines, etc. in this regard?
Answer. Response was not provided at the time of publication.
Question 3b. It is possible for Federal departments and agencies to
issue grants, contracts, and cooperative agreements that extend over
more than 1 year at a time. However, many grants, contracts, and
cooperative agreements issued by the Department of Health and Human
Services and its subordinate agencies do not cover multiple years. What
do you think of the value and feasibility of multi-year funding for
activities that relate to public health security and emergency
preparedness for emerging biological threats?
Answer. Response was not provided at the time of publication.
Question 4. It has been stated that both the Secretary of Homeland
Security, and the Secretary of Health and Human Services would be co-
leaders during an influenza pandemic. You, as well as your respective
secretaries, have also stated the same in previous testimony before
Congress. Please describe how they will actually lead at the same time.
How do you see this working?
Answer. Response was not provided at the time of publication.
Question 5. How have you involved other high level decisionmakers
at the Federal, State, territorial, tribal, and local levels personally
in planning efforts? How would you improve the processes by which this
should occur?
Answer. Response was not provided at the time of publication.
Question 6. Do you believe that mobile hospital assets should be
deployed during an influenza pandemic? If so, how do you believe that
should occur--how would they be most useful?
Answer. Response was not provided at the time of publication.
Question 7. The Assistant Secretary for Preparedness and Response
has a unit that deals with exercises. Previous, your office reached out
to the Department of Homeland Security regarding the use of the Lessons
Learned Information Sharing system. Is the Department of Health and
Human Services using the system yet? How are personnel in your office
working with those in the Office of Health Affairs, the National
Exercise Program, etc., to combine efforts and data?
Answer. Response was not provided at the time of publication.
Question 8. GAO recently released a report on State and local
pandemic planning and exercising, and recommended that the secretaries
of DHS and HHS, in coordination with other agencies, convene additional
meetings with the States and territories in the five Federal influenza
pandemic regions to help them address identified gaps in their pandemic
planning. We have heard that previously-held meetings were of limited
value to both the Federal and non-Federal governments. Do you think
that have additional meetings would be useful? Are you planning on
holding additional regional meetings on pandemic influenza, and for
what purposes?
Answer. Response was not provided at the time of publication.
Question 9. There has been a lot of discussion regarding altered
standards of care, including in a recent GAO report on medical surge.
In this report, GAO recommended that the Department of Health and Human
Services establish a clearinghouse for States and territories to share
information regarding their current approaches to addressing this issue
of altered standards of care. According to GAO, the Department of
Health and Human Services was silent on that recommendation, although
the Department did agree with GAO's findings. Why was the Department of
Health and Human Services silent on that recommendation? How would you
recommend that States and territories address this difficult issue?
Answer. Response was not provided at the time of publication.
Question 10. Please provide information regarding the consensus
meeting run by the Department of Health and Human Services in
Indianapolis regarding medical surge requirements.
Answer. Response was not provided at the time of publication.
Question 11. What has the Department of Health and Human Services
done to examine what happened to the hospitals in the Gulf Coast during
Hurricane Katrina, and how the Department of Homeland Security
communicated that information to hospitals throughout the country?
Answer. Response was not provided at the time of publication.
Question 12. What types of assistance has the office of the
Assistant Secretary for Preparedness and Response offered or is it
planning to provide to the States, territories, tribes, and localities
to help them in planning, exercising, and general preparedness for an
influenza pandemic? Has the office of the Assistant Secretary for
Preparedness and Response systematically asked the States, territories,
tribes, and localities what type of assistance would be most helpful to
them? If so, what did they say and what has been done to address their
needs?
Answer. Response was not provided at the time of publication.
Question 13. Since pandemic-specific funding to the States and
certain localities will be ending this year, and pandemic ``fatigue''
is setting, are you concerned about how the States, territories,
tribes, and localities will maintain continuity in their pandemic
preparedness? If so, is the Department of Health and Human Services
taking any specific actions to help maintain this focus into the next
administration and over the long-term?
Answer. Response was not provided at the time of publication.
Question 14. Are there any plans to provide additional pandemic-
specific funding to the States and certain localities for pandemic
efforts?
Answer. Response was not provided at the time of publication.
Questions From Chairman James R. Langevin to Dr. Daniel M. Sosin,
Director, Biosurveillance Coordination Unit, and Associate Director for
Science, Coordinating Office for Terrorism Preparedness and Emergency
Response, Centers for Disease Control and Prevention
Question 1. We have a lot of biosurveillance efforts going on
throughout the Nation. The National Biosurveillance Integration Center,
BioSense, BioFusion, the National Medical Intelligence Center are only
a few of the many activities occurring in this arena. In your opinion,
how do you think these efforts should be integrated?
Answer. The United States is confronted by an array of threats with
natural, accidental and intentional origins. Numerous domestic and
global biosurveillance capabilities exist across the human, plant,
animal and environmental domains; these capabilities are distributed
across levels of government and the private sector but are inadequately
coordinated. Integrating biosurveillance capabilities requires
investment in:
A comprehensive Nation-wide focus embracing centralized and
collaborative planning and achievable standards while allowing
decentralized execution at all levels of government;
Enabling existing systems and people to connect across
multiple platforms--a single infrastructure is not a viable
option;
Building transparent communication and information-sharing
systems that balance interests of stakeholders at all levels of
government and distribute and receive information for
decisionmakers simply and comprehensively.
Ultimately, biosurveillance addresses the management of an
information supply chain for the control of acute health events of
national interest through early detection and characterization for
intervention.
The National Biosurveillance Integration System (NBIS) has been
established to integrate biosurveillance information from all available
sources, including public and private entities and NBIS member
agencies. NBIS is chartered to analyze the information, from a
national/homeland security perspective, and to share and disseminate
information and finished products to senior governmental leaders and
contributing partner agencies. HSPD-21 directs the Centers for Disease
Control and Prevention (CDC) to collect, assess, and share human health
biosurveillance information with all levels of government and with the
private sector. Similarly, other domain-specific agencies collect,
process, and share biosurveillance information that is gathered from a
broad array of domestic and global biosurveillance information sources
across a range of biological domains, including food, wildlife, and
domestic animals.
NBIS provides a single point within the Federal Government for the
integration of these agency-specific biosurveillance reporting streams.
NBIS also provides the capability for the acquisition, integration,
assessment, and sharing of biosurveillance-related data from
intelligence, nongovernment, and other open source reporting systems
across each of the domains, as well as those within the public health,
food and agriculture, chemical, energy, transportation, and financial
infrastructures. The National Biosurveillance Integration Center
(NBIC), housed within DHS, provides NBIS community members with a
unique environment for interagency cross-domain event cueing and
situational awareness.
The following graphic depicts the life cycle of biosurveillance for
human health for CDC. The various health and health-related data and
information resources from State, local, tribal, and territorial
jurisdictions, and other national, Federal, and international
biosurveillance entities are reflected at the base of the graphic.
These resources may feed data through biosurveillance systems (e.g.,
BioSense) or through programs and people in search of information to
guide actions. In the ideal State, each of these entry points to the
agency is tightly linked for information exchange with the others and
the BioPHusion program serves both to integrate information from the
multiple streams and to improve cross-agency networking for information
exchange. Fused information products, including electronic health data
from direct clinical connections such as BioSense, national
surveillance systems like NNDSS and LRN, and condition-specific
surveillance conducted by prevention and control programs, are
disseminated by BioPHusion back to providers to close the information
loop and to customers of human health biosurveillance at the national
and global levels (e.g., NBIS, WHO).
The life-cycle of collection management, analysis, interpretation,
and dissemination requires multiple systems and reciprocal
relationships with all levels of government. Key functions of CDC's
biosurveillance management depicted in this graphic are noted below:
Human health.--CDC is responsible for leading
biosurveillance efforts for human health and providing a common
operating picture for human health to national and
international biosurveillance organizations.
Reciprocal relationships.--CDC receives and disseminates
information to local, State, tribal, territorial, Federal and
global entities. Mutual benefit must be achieved wherein
national visibility and multi-sectoral context enhances
information value.
Horizontal relationships.--Key biosurveillance activities at
CDC work collaboratively to integrate subject matter expertise
and information gathered from surveillance systems.
Just as CDC's BioPHusion activity utilizes information from across
formal and informal sources to combine and communicate this information
for situation awareness for human health, the National Center for
Medical Intelligence (NCMI), is a DOD/DIA organization serving to fuse
classified medical intelligence. NCMI produces medical intelligence
assessments, forecasts and databases on foreign military and civilian
health care including worldwide infectious disease risks and global
environmental health risks. CDC maintains public health liaison staff
with the NCMI and the National Biosurveillance Integration Center
(NBIC).
CDC is a consumer of credible and coherent medical intelligence and
not a source of this type of information. Through CDC's Office of
Security and Emergency Preparedness (OSEP) information from the
intelligence community is identified, acquired, and channeled
appropriately to components of CDC that will benefit from the
information.
The primary objective of BioSense is to create a real-time picture
of the health of Americans as seen through the lens of America's acute
health care system, allowing decisionmakers to assess how well that
system is performing in response to the challenges posed by an acute
health emergency, to characterize evolving threats, to plan responses
to threats and assess their impact. The information gathered through
BioSense can provide complementary information to CDC programs, such as
the Nationally Notifiable Disease Surveillance System or the National
Healthcare Safety Network, and contributes to the daily situation
awareness report produced by the BioPHusion Program.
Question 2. Please describe the two CDC programs--BioSense and
BioFusion. How are they similar and how do they differ? How do or will
these programs interface and provide inputs into other agencies'
programs, such as the National Medical Intelligence Center, the
National Biosurveillance Integration Center, etc.?
Answer. The need to develop and share critical information for
decisionmaking within public health has increased markedly over the
last few years. The ability to share this information, however, has
decreased due to the proliferation of multiple data systems and
fragmented knowledge exchange. CDC's BioPHusion program was formed in
order to exploit the agency's unique information repositories and
health-related subject matter capabilities and to allow the routine
collection, monitoring, and synthesis of hundreds of disparate
information sources to create actionable knowledge. BioPHusion, an
analytic unit, merges information from a variety of sources, such as
other Federal agency, media-related, non-governmental organizations and
social network sources, and draws on these multiple data streams to
produce an integrated view of health threats and events--in effect, the
daily situational awareness needed for public health action. Since
August 2008, BioPHusion has produced a preliminary daily public health
situation awareness report.
BioSense, a surveillance data system, collects de-identified health
record level data from enrolled hospitals and health information
exchanges across the Nation to identify anomalies in patterns of
hospital visits and detect outbreaks of disease and maintain public
health situation awareness.
BioSense will include:
Sensitive and timely detection of PH events through
monitoring of electronic data streams from emergency
departments, primary care, poison control centers, and other
data sources;
Regional coordination of investigation of aberrancies in
real-time data and response through data sharing and electronic
communications;
Electronic death notification and monitoring;
Electronic case reporting and investigation;
Tracking of outbreaks and forecasting of size, magnitude and
location of future spread of disease;
Support of innovation, research and development to improve
the Nation's real time biosurveillance capabilities and work
force capacity development.
Data received in the BioSense system are available simultaneously
to State and local health departments, participating hospitals and CDC
through a web-based application that is accessed through the CDC Secure
Data Network. The BioSense application has over 800 users in 124 State
and local public health jurisdictions. BioSense receives real-time data
from over 570 non-Federal hospitals and batched data from over 1,200
DoD and Veteran Affairs medical facilities. BioPHusion receives
information about the anomalies in patterns of health visits detected
by BioSense and incorporates this information into a common picture
that contains information from other CDC surveillance systems and
sources, such as news reports about disease outbreaks.
CDC maintains public health liaison staff with other agencies'
programs such as the National Center for Medical Intelligence (NCMI),
formerly called the Armed Forces Medical Intelligence Center, and the
National Biosurveillance Integration Center (NBIC). CDC liaisons sit in
different programmatic areas of CDC but serve as CDC-wide resources for
interfacing with the programs of other agencies. In this emerging and
evolving role as a liaison, experts have provided epidemiologic
expertise in the interpretation and analysis of health-related
information for the NBIS daily report, served as a resource to DHS on
the status of CDC surveillance systems, and consulted on medical and
medical policy issues to prevent or address the exposure of Department
of State employees and their families stationed overseas to infectious
diseases, to name just a few examples.
Question 3. We know that assays for avian influenza were put
through the Laboratory Response Network for Bioterrorism (LRN). Why was
this done, considering avian influenza is not an agent of biological
terrorism? What other assays for non-bioterrorism agents have been put
through the LRN? Is it the intention of CDC to put more assays for
disease agents that are not agents of biological terrorism through this
Network? Please explain the reasoning for these decisions.
Answer. Assays for avian influenza were put through the LRN because
of the need by the Department of Health and Human Service (HHS), DoD
and Homeland Security Council to have a standardized assay deployed as
soon as possible in support of coordinated preparedness and integrated
response plans. The LRN was used because of its:
Dual mission (i.e., high priority bioterrorism threat agents
as well as other high priority biological threats to public
health mandated by emergency preparedness or rapid response
needs);
Efficacy of using the established LRN national and
international infrastructure asset to ensure standardization of
detection and response communications (i.e. notification and
lab result reporting);
Unique capability of CDC collaborators to develop a high
quality test, expeditiously deploy the test reagents with
controls and ensure performance readiness through an ongoing
proficiency testing program.
Planning to rapidly identify an emerging influenza pandemic is a
public health priority and is a principle goal necessary for successful
implementation of programs to mitigate a pandemic's impact. In a
pandemic, all aspects of society will be affected, such as the public's
health and economy, in addition to the possible security implications
of widespread illness and work absenteeism in the population. Capacity
for rapid detection of new pandemic strains in the LRN laboratories,
with one or more laboratories in each State, is a critical component of
U.S. pandemic planning. The LRN was also used for emergency response to
SARS Coronavirus. CDC will include more assays for disease agents that
are not agents of biological terrorism through the network only when
emergency preparedness and response exigencies require it.
Question 4. What can the Federal Government do to assist State,
territorial, tribal, and local public health personnel strengthen and
coordinate biosurveillance for emerging biological threats (including
emerging and re-emerging infectious diseases, as well as bioterrorism)
at those levels? How do you see information from localities throughout
the country rolling up into a cohesive real-time disease surveillance
picture?
Answer. There will always be a need for hypothesis-driven analysis,
human insights, and judgment in situational awareness activities.
Professionals from diverse disciplines provide a range of skills
necessary for the components of a biosurveillance system to work
effectively to protect the Nation's health. Current and projected
shortages in work force skills and capacities in addition to a dearth
of trained workers and the inability of government to provide
competitive salaries and benefits present serious challenges.
A focus on the public health work force is part of CDC's mission;
efforts to sustain and enhance biosurveillance capacity at the State,
territorial, tribal and local levels must include support and funding
for CDC's biosurveillance work force initiatives. These initiatives
include:
Developing public health workers who serve all levels of
government through fellowships and training programs;
Defining the biosurveillance-related competencies and
integrating into health curricula;
Placing CDC staff in the field to build biosurveillance
capacity at the State, local, tribal and territorial levels;
and
Collaborating with partners to improve links between the
Nation's public health and clinical health care systems.
The solutions to these challenges must create job opportunities and
viable career paths for health professionals. A comprehensive Federal
approach will ensure a prepared, diverse, and sustainable health work
force--with the right number, mix, and disciplines--capable of meeting
the challenges ahead, such as enhancing timely reporting from clinical
settings to health departments and helping to ensure that information
from localities can roll up into a cohesive, real-time disease-
surveillance picture.
Additional strategies for enhancing the exchange of disease
surveillance information include the following:
Electronic Health Information Exchange.--While
biosurveillance encompasses many types of data, health care
data provide the most specific and direct representation of the
health of communities. The electronic health data-sharing
environment should allow appropriate access to health
information when it is needed, automated analyses that support
notifiable disease detection and outbreak cues, the ability to
query systems for addition investigation when warranted, and
feedback loops to validate findings and enact countermeasures.
Access to data will be increased through the development of
regional cooperatives, linkages with health information
exchanges and enhancing incentives for clinical providers to
transmit data to public health. Regional cooperatives will also
promote data sharing among States. Support for these systems,
combined with investments for a trained and competent work
force having outbreak detection and response skills, will
enhance real-time disease surveillance for rapid identification
of emerging threats.
Electronic Laboratory Information Exchange.--The public
health laboratory remains an important agent for improvement in
public health practice. Rapid assays and genotypic/phenotypic
characterization have allowed public health experts to identify
subtle threats and respond more quickly, efficiently, and
effectively than has ever been possible before. Increasing the
connectivity of laboratories (public health, clinical, and
research) and their analysts through standards and technology
will also yield rapid and significant benefits in improved
biosurveillance.
Unstructured Data and Data Mining.--Material obtained from
media, Internet, and informal communication sources is showing
promise as a valuable complement to more direct measures of
population health and is an underutilized resource. Successful
methods have been developed for aggregating and analyzing these
unstructured data so that they can be incorporated today as a
complementary health security resource for detecting potential
incidents that warrant investigation. Significant opportunities
to improve these data through rigorous research and experience
should be leveraged.
Integrated Biosurveillance Information.--A commitment is
needed to develop tools, methods, and analyst capabilities, to
appropriately integrate information from multiple sources, and
to create more actionable information than is otherwise
available from individual sources and current information
products. The fusion model should address notification
protocols and effective communication of findings.
Global Disease Detection and Collaboration.--Visibility of
emerging health threats around the world is contingent on the
local capability to detect and investigate and our connection
to the health work force. Developing international capability
through work force and infrastructure improvements will
increase global health awareness and our connection to it.
Question 5. Please describe how you envision epidemiological
investigations taking place when hospitals and other health care
establishments are completely overwhelmed by a biological threat that
sweeps the Nation, since we know that they will not have time for to
use standard reporting mechanisms. What will CDC be able to do to help?
How will we be able to get an accurate picture of what is happening
with the disease?
Answer. In the unfortunate circumstances of a significant
biological event sweeping across the country, CDC will lead and support
epidemiological investigation and response at all levels of government
by focusing on the following activities:
Preparedness.--As much as possible, CDC is working to
automate aspects of health information exchange. This is an
evolutionary process and we will have more automated electronic
resources next year than we have this year and more still in 5
years. Our preparedness goal is to prioritize and expedite the
implementation of automated resources and lessen the burden of
a pandemic when it arrives. The national planning effort of the
National Biosurveillance Strategy for Human Health is helping
to identify the priority targets for investment across the
Nation and program initiatives such as those sponsored by the
Office of the National Coordinator for Health Information
Technology, HHS (e.g., National Health Information Network) and
the National Center for Public Health Informatics, CDC, HHS
(e.g., BioSense) expedite implementation.
Adaptation.--When collection cannot be automated, CDC will
adapt and scale back information requirements to those that are
most vital for saving lives and protecting health. For
instance, confirming a case at the onset of a pandemic will
require more specificity and rigorous validation, but as a
confirmed pandemic evolves the requirements can be simplified
(e.g., influenza-like illness counts).
Investigation.--CDC will bring more public health expertise
directly to the clinical community. CDC will provide support to
State and local jurisdictions through the services of the
epidemiologic work force, such as members of the Epidemic
Intelligence Service and the Career Epidemiology Field
Officers. Through the provision of a surge work force, CDC
staff will assist with the information gathering,
identification of outbreaks, and inform the response planning
and implementation.
Response Management.--CDC will serve a central role in
supporting the management of complex, distributed health
systems. CDC will utilize existing programs and relationships
with governmental entities to receive and disseminate
information. Key systems such as the Health Alert Network (HAN)
and Epidemic Information Exchange (Epi-X) provide CDC two tools
to disseminate information quickly to decisionmakers. HAN
includes a web-based connectivity and rapid communications
capability among CDC and local and State health departments and
health care providers. HAN has demonstrated effectiveness for
communicating urgent public health messages to the health care
community. Epi-X provides secure web-based communication
regarding outbreak and other acute or emerging health events
among public health officials from CDC, State, and local health
departments, and the military. Additionally, CDC will apply
information technology tools to the management of the response
as appropriate.
Gathering Health-related Information.--Information sources
outside the clinical community will provide complementary
information. CDC will also have experts in the field conducting
various assessment activities, including environmental
monitoring and tracking patterns in vector-borne diseases.
Through the implementation of these complementary efforts,
decisionmakers will be able to ascertain an accurate picture of the
health event.
Questions From Chairman James R. Langevin to Dr. David R. Gifford,
Director of Health, Department of Health, State of Rhode Island
Question 1. One of the emerging biological threats of current
interest is Methicillin-resistant Staphylococcus Aureus (MRSA). We
understand that we now have both institutional and community-based MRSA
here in Rhode Island. Describe the steps you have taken to address this
threat. What resources and guidance do you need to help you combat this
threat?
Answer. MRSA is a growing threat in communities and in health care
settings, and it represents an enormous health and economic impact in
the United States. It is estimated that MRSA is responsible for 19,000
deaths per year; 4.5 out of every 100 hospital visits results in an
infection and one study estimated that each infection costs an
additional $37,000 per hospital stay.
State health departments need increased funding to combat health
care-acquired infections and decrease this burden. Increased resources
would enable States to:
fund programs to educate health care practitioners on
methods to decrease antimicrobial resistance and implement
better infection control measures;
conduct surveillance; and,
investigate and respond to outbreaks in hospitals, schools,
and other settings.
In Rhode Island, we have been focusing on MRSA for the past couple
of years which has included the following:
In collaboration with hospital infection control
professionals we facilitated the development of infection
control best practice guidelines and standards for hospitals.
These 2001 published guidelines have received national acclaim
and have been a model for other States to adapt. The guidelines
were published in the national trade journal in 2002: Arnold
MS, Dempsey JM, Fishman, M, McAuley PJ, Tibert C, Vallande NC.
The Best Hospital Practices For Controlling Methicillin-
Resistant Staphylococcus Aureus: On the Cutting Edge. Infect
Control Hosp Epidemiol 2002;3(2):69-76. They are currently
being implemented in Rhode Island. Individual hospitals track
their performance with success with implementing guidelines.
When uncontrolled outbreaks in hospitals occur they are
reportable to the Health Dept. None have been reported. Recent
surveys indicate hospital acquired MRSA rates in Rhode Island
are stable and nor growing.
In collaboration with representatives from nursing home
(long-term care) infection control professionals we have
developed guidelines for the management of MRSA in Rhode Island
nursing homes (attached). The LTC surveyors use these
guidelines to review for deficiencies at LTC.
In 2005 we sent an informational advisory on community
acquired MRSA to all Rhode Island physicians (content is
current and valid): See http://www.health.ri.gov/disease/
communicable/providers_mrsa060705.php.
We maintain a 24-hour on-call system to provide expert
consultation, assess needs and make recommendations to
institutions, facilities and professionals related to
prevention and control measures, as well as public risk
assessment and risk communications for various MRSA-related
issues, especially clusters--outbreaks or sustained
transmission. We provide such consultations on average once a
month.
We have an active collaboration with the Rhode Island Dept.
of Corrections and have provided on-site consultations and
review of prevention and control measures at the ACI (adult
correctional institution).
Our public health nurses are available to provide
information and guidance to members of the public by phone
(222-2577) daily. The office receives at least one or two calls
a day on this subject.
We maintain an informational web page on the subject: http:/
/www.health.ri.gov/topics/mrsa.php.
Question 2. In your opinion, has bioterrorism preparedness been
integrated with pandemic influenza preparedness? How have you been able
to integrate these activities into the existing framework in Rhode
Island for public health emergencies that occur more frequently or
currently? Can you give us a few examples of how you have done that in
Rhode Island?
Answer. The bioterrorism Cooperative Agreement activities have
prepared us well to meeting the planning challenges for pandemic flu
head-on. In Rhode Island, the Cooperative Agreements led to the
development of public health adopting the ICS structure, the
construction of a Departmental Operations Center (DOC), the
strengthening of disease outbreak protocols, and successful real-life
responses to incidents that required isolation, mass vaccinations,
medication distribution, medical surge, strong interagency
interoperable communication, and large public information campaigns.
For example, we were able to apply these new resources and training to
situations related to:
a case of active TB in Central Falls high school resulting
in over 500 students and teachers getting TB skin tests on a
single day;
distribution of Hepatitis A vaccine to over 500 restaurant
workers as a result of exposure from a co-worker; and,
closing of three school districts from a community outbreak
of Mycoplasma Pneumonia, which included the distribution of
antibiotics over the New Year's Day weekend to nearly 300
families.
Question 3. What is your opinion of Federal regional offices of all
types? Do you think that regionalization is a good model for Rhode
Island?
Answer. Regional collaborations and standing relationships clearly
enhance multi-jurisdictional communications, planning and response
capabilities. This is especially true as it pertains to mutual aid,
whether it is between individual States or through a national system
such as the Emergency Management Assistance Compact of which Rhode
Island is a member.
Traditionally, federally organized regional planning and
coordination emanated from the Office of the Regional Health
Administrator of the Department of Health and Human Services (we are in
Region I which is headquartered in Boston). In recent years, and driven
in large part by our shared mission to better prepare for public health
emergencies, there has been a growing Federal presence in the regions
not only as part of HHS (e.g. Regional Emergency Coordinators) but also
from the Department of Homeland Security, such as the pandemic
influenza pre-designated Principal Federal Official. Conceptually, this
construct has great merit in that it provides direct linkages between
States and key Federal agencies and a ready resource to support States
without having to go directly to agency headquarters as long as they
are informed and empowered to provide the necessary assistance and
support.
The recent consolidation and standardization of policy, program
design and oversight to central Federal agencies has changed the role
of Federal Regional Offices. The challenge is to manage the growing
pains by clearly defining roles, responsibilities, and agency
``lanes''; maintain open communications; and establish lines of
reporting, to name a few. In the Northeast, with small States and
frequent cross-border issues, efforts to coordinate regional activities
and responses will be helpful. However, the current regional leadership
could be more active in facilitating these discussions across State
lines.
Question 4a. DHS and HHS recently led a series of five workshops
for States in the five Federal influenza pandemic regions primarily to
discuss the current update of State and territorial pandemic plans. A
Regional Principal Federal Official (PFO) and Federal Coordinating
Officer (FCO) for pandemic influenza are pre-designated for each of
these five pandemic regions.
What was your impression of the DHS/HHS led workshop held in
January 2007 for pandemic Region A? Did you find it helpful in planning
for a pandemic? Should more regional meetings of State and Federal
officials be held on pandemic influenza? How could they be made more
useful?
Answer. A half-day regional briefing was conducted to discuss the
draft State Pandemic Influenza Operational Planning Guidance. It
provided an opportunity for a cursory high-level discussion on the
expected process for plan development and submission. Having the draft
guidance well in advance of the meeting would have provided an
opportunity for more substantive discussion on many of the key planning
elements. We did appreciate the opportunity to submit follow-up
comments and questions as the guidance was being finalized. Many of the
States' concerns and comments were considered, making the final version
more useful.
Additionally, I think that regional meetings are helpful to bring
together State teams to interact and learn from each other. However,
many of the regional meetings do not provide enough opportunity for
interaction and learning from our counterparts. Regional meetings that
principally utilize PowerPoint presentations to convey information
either by experts or by teams does not provide the opportunity for more
meaningful interaction between State team members. I think regional
meetings should be held but need to spend less time on transfer of
factual issues more on regional planning between State teams.
Question 4b. How has the regional PFO assisted with your pandemic
preparedness efforts?
Answer. The regional PFO has reached out to us to ask about our
current process and has offered to bring State teams together.
Question 5. What additional resources are needed for you to address
emerging biological threats--including pandemic influenza,
bioterrorism, etc.?
Answer. Every year CDC State and local preparedness grant funding
is reduced. States need a sustained commitment of Federal funds to
recruit and retain highly qualified public health professionals to
continue preparedness exercises, planning and other important
activities. Reductions in the ASPR hospital preparedness grants are a
major concern to State health officials.
Emerging biological threats are also addressed through Epidemiology
and Laboratory Capacity grants, which require continued support. For
example:
CDC funding for Epidemiology and Laboratory Capacity
decreased since 2002 from $78.5 million to $61 million in 2007.
Epidemiology and Laboratory Capacity (ELC) is a funding
mechanism intended to address emerging threats by enhancing
investigation/surveillance capabilities and laboratory capacity
at State and local health departments.
CDC's West Nile, Antimicrobial Resistance, Influenza and
Emerging Infections programs also support work at the State and
local level.
ELC funding is declining because of budget cuts at CDC
making it harder for State and local health departments to
respond to new disease threats.
Emerging biological threats are also addressed through Emerging
Infections Programs, which require continued support. For example:
There are 10 Emerging Infections Programs throughout the
Nation that collaborate among public health, academia and
clinical institutions to provide rapid and flexible response to
emerging disease threats.
Although Rhode Island is not an EIP site, these programs
provide vital surveillance information about food-borne
infectious diseases, information about Creutzfeldt-Jakob
disease, and collected the data for the most recent study on
the burden of MRSA in the United States.
Question 6. What problems do you face in spending Federal dollars?
Is the Rhode Island State Budget cycle in synch with those of the
Federal Departments and agencies?
Answer. The Rhode Island State Budget cycle is not in synch with
Federal grant years, which makes contracting more difficult, as well as
having to close grants and the State budget 6 weeks apart. Also, each
State has to follow its purchasing rules even for Federal funds. Thus,
spending funds takes some time. Delays in the release of Federal
Cooperative Agreement guidances, awards, and redirect request approvals
therefore often hinder the timely spending of Federal funds at the
State level.
The other problem facing Rhode Island and many other States are
hiring or spending freezes due to State budget issues as well as FTE
caps. These ``freezes'' and CAPs are usually applied to all sources of
funding including Federal sources. This then makes expending Federal
funds in a defined budget cycle difficult.
In addition, the fiscal year 2009 Hospital Preparedness report
language and CDC State and local grant preparedness language proposed
by the House Appropriations Subcommittee on Labor, Health and Human
Services, Education, and Related Agencies that provides funding for ``a
full year of grants rather than 9 months and 3 weeks of grants as
proposed by the administration'' would be helpful.
Question 7. Please provide your perspective on training and
exercising. Do you believe your organization is training the way it
fights (i.e., the way it would need to in order to respond to
biological threats)?
Answer. I could not agree more with the concept of ``training the
way you fight''. Nationally, State health agencies participated in more
than 700 exercises of all types in 2007 and many more took place at the
local level. Exercises require significant time and effort to plan and
execute. Most States faced at least one major emergency response in
2007, and only 11 percent of States had no major emergency that
required their response.
We at the Rhode Island Dept. of Health have a low threshold to
utilize ICS for many real-life incidents facing the Department. This
helps us both better respond to these incidents but also serves as a
real-life training opportunity for both primary and secondary staff
within the Department. We have found that this is more helpful than
some of the simulation exercises. Nonetheless, more mock exercises
would also be helpful, especially when the simulations are treated not
as exercise but a real-life response.
In addition to training and exercising, States learn how to improve
their systems through response to real-life events. These events offer
opportunities for program improvement that are comparable to exercises.
For example, in 2006, the Rhode Island Department of Health exercised
the same capabilities that would be needed in a bioterrorism incident
by successfully delivering antibiotics to 275 families following a
mycoplasma outbreak.
Question 8. The best preparation for public health emergencies
involves public health workers who plan and exercise their plans for
emergency response jointly with local elected officials, police and
fire departments, emergency managers, the National Guard, hospitals,
physicians, schools, businesses, and other community partners. Please
describe how this has occurred in Rhode Island regarding emerging
biological threats like pandemic influenza and bioterrorism.
Answer. While all response planning in the State requires joint
planning with partners and the Rhode Island Department of Health serves
as the ESF-8 lead for State-wide planning, many of the Cooperative
Agreement requirements have facilitated this process. Because Rhode
Island has no local health departments, in order to meet the
requirements of the SNS/CRI program, the Rhode Island Department of
Health engages in contracts with each municipality in the State for
SNS/CRI planning. This program has been the source of a tremendous
amount of relationship building with emergency management directors,
and police, fire, and EMS staff. This has proven to be a successful
venture when real-life events occur and these plans must be called into
action because the relationships and planning foundations are already
in place.
In addition, because the Rhode Island Department of Health acts as
both a local and State health department for all jurisdictions in the
State, it would become quickly overwhelmed in a pandemic situation. In
order to appropriately plan for a pandemic, ten acute care hospitals
have been deputized to serve as local health departments within the
State during a pandemic, allowing them the authority to direct all
public health and medical activities within their regions. Each of
these healthcare service regions has a planning committee, comprised of
hospitals, health centers, first responders, and community partners to
address the utilization of medical and non-medical assets within the
region.
Question 9a. Recently, GAO released a report on the status of State
and local planning and exercising for an influenza pandemic. GAO found
that while all 50 States have developed an influenza pandemic plan in
accordance with Federal pandemic funding requirements, a review
conducted by the Department of Health and Human Services concluded that
these plans had ``many major gaps'' in 16 of 22 priority areas, such as
the policy process for school closures and communications, community
containment and medical surge capacity. GAO also found that all States
and localities that had received pandemic funds met the requirements to
conduct a pandemic exercise to test their plans. We know updated plans
were due in July for a second round of reviews led by the Department of
Health and Human Services.
What is the current status of planning and exercising for an
influenza pandemic in Rhode Island?
Answer. As referenced in your question, every State and territory
was recently required to submit comprehensive details of their Pandemic
Influenza Operations Plans for U.S. Government review. The Federal
planning guidance was released on March 11 and identified three
strategic goals:
(1) Ensuring Continuity of Operation of State Agencies and
Continuity of State Government;
(2) Protect Citizens; and,
(3) Sustain/Support 17 Critical Infrastructure and Key Resource
Sectors.
It contained over 400 operating objectives and sub-objectives to be
in one way covered or addressed in the State Plans. Rhode Island filed
its submission on time. The plan was more detailed and advanced
compared to the first round of plan reviews referenced in the question,
and we await the preliminary assessment that we believe will be
available in the next couple of months.
Question 9b. What were the identified gaps in Rhode Island's
pandemic plan from the HHS-led interagency review conducted in 2007?
How did you address those gaps in the current update to your State plan
and how do you plan to address them in the future?
Answer. For Rhode Island, the HHS-related issues, which required an
additional response, were in the areas of COOP and Community
Containment. While HEALTH still awaits feedback on these resubmissions,
the requirements for the 2008 State Pan Flu Operations Plan led to
further development of the Department's COOP and has helped facilitate
COOP planning State-wide, since many of the gaps in the Department's
plan were due to lack of policy decisions at a higher level than
individual departments. This process is ongoing.
HEALTH's Community Containment plan was modified to include the
guidance from ``Community Strategy for Pandemic Influenza Mitigation''.
HEALTH is currently working to continue improvement on this plan
through work with the Department of Education, and is also preparing a
regional survey that would develop triggers for the region as to when
certain non-pharmaceutical interventions should be implemented.
Question 9c. Please describe the pandemic exercises that Rhode
Island has held or participated in and whether any changes were made to
the State's pandemic planning as a result of these exercises. Do you
plan to hold any pandemic exercises in the future at the State and/or
local levels? If yes, please describe the exercises you have planned.
Answer. Five of the ten health care service regions have conducted
functional and/or full-scale alternate care site exercises. The
remaining five regions will conduct their alternate care site exercises
within the current grant year. In order to fully examine the capacity
to track and provide vaccine during a pandemic, three municipalities
conducted combined CRI/CRA POD exercises utilizing seasonal flu vaccine
during the last flu season. State-wide tabletop exercises on antiviral
distribution and community containment have been conducted.
Question 10a. While the Federal Government has provided pandemic
influenza guidance to the non-Federal public and private sectors, non-
Federal officials have told GAO that they would welcome additional
guidance from the Federal Government in a number of areas to help
better plan and exercise for pandemic influenza.
What Federal assistance have you asked for, or do you need, to
address the identified gaps in Rhode Island's pandemic plan?
Answer. Rhode Island has asked for clearer guidance and additional
planning support regarding Public Health COOP, prioritization of
antivirals during a pandemic (and whether or not antivirals can/should
be used for prophylaxis vs. treatment), the use of masks, triggers for
the use of non-pharmaceutical interventions, especially school closures
and social distancing.
Question 10b. What other planning guidance do you need?
Answer. There are three guidance documents currently in Federal
clearance, which, when released, will provide important planning
assistance to the States. The pending documents are:
Proposed Guidance on Antiviral Drug Prophylaxis during an
Influenza Pandemic;
Proposed Considerations for Antiviral Drug Stockpiling by
Employers in Preparation for an Influenza Pandemic; and,
Proposed Guidance on Workplace Stockpiling of Respirators
and Facemasks for Pandemic Influenza.
There has been a strong emphasis on planning for stockpiling,
distribution and administration of pharmaceutical countermeasures for
pandemic flu (vaccines and antivirals). While these interventions are
an important defense against a pandemic threat, States would benefit
from additional focus on non-pharmaceutical countermeasures. The
document released in February 2007, Interim Pre-Pandemic Planning
Guidance: Community Strategy for Pandemic Influenza Mitigation in the
United States, was an excellent starting point for planning in this
area. States would benefit from further discussion on some key points
such as school closures and social distancing, and the intricacies of
avoiding unintended consequences from these control measures. Examples
include optimal methods for providing meals when schools are closed to
children who depend on subsidized school lunch programs and providing
guidance to the public on home care of sick individuals (when to seek
care, proper infection control practices, etc.).
It should be noted, however, that sustained funding to support
State pandemic planning will be necessary to operationalize existing
and new guidance documents.
Question 11. According to the Implementation Plan for the National
Strategy for Pandemic Influenza, ``State, local, and tribal law
enforcement agencies should coordinate with appropriate medical
facilities and countermeasure distribution centers in their
jurisdictions to coordinate security matters, within 6 months'' of when
the Plan was released--so the deadline would have been October 2005. To
your knowledge, has this coordination taken place? If so, how, and if
not, how would you recommend this happen?
Answer. Yes, we have done some coordination has taken place but the
process is ongoing. Rhode Island plans and responds in accordance with
the National Response Framework's Emergency Support Function (ESF)
structure. The State Police lead ESF-13 and provide assistance in
planning with local law enforcement agencies. Through the SNS/CRI
program, the Rhode Island Department of Health has engaged in contracts
with each municipality in the State for SNS/CRI planning. The security
issues faced at the local level are addressed by the State Police in
coordination with HEALTH. Currently, plans are available for 37 of the
State's 39 municipalities. These plans would be used in coordination
with the health care service regions' plans for countermeasure
distribution.
Each of these health care service regions has a planning committee,
comprised of hospitals, health centers, first responders, and community
partners to address the utilization of medical and non-medical assets
within the region.
Question 12. The Implementation Plan for the National Strategy for
Pandemic Influenza provided this task, ``All Federal, State, local,
tribal, and private sector medical facilities should ensure that
protocols for transporting influenza specimens to appropriate reference
laboratories are in place within 3 months''--which would have been July
2006. Are these protocols in place in Rhode Island? What challenges did
you face in executing this task?
Answer. Yes, these protocols are in place. We have an established
courier system to deliver influenza specimens to the State Health
Laboratory, which is the only reference laboratory in the State. Given
the small geographic area involved and the concentration of the
majority of facilities submitting specimens in relatively close
proximity to the lab, there have not been any particular challenges
associated with implementing this plan.
Question 13. What is your opinion of the decision to centralize
Disaster Medical Assistance Team assets in your region? What problems
do you see with this approach; especially in the context of a
biological threat that sweeps the entire region?
Answer. The National Disaster Medical System (NDMS) and one of its
components parts, DMAT, is a cornerstone of our country's mass casualty
system. The public health community supported the decision to return
management and oversight responsibilities of the NDMS to the Department
Health and Human Services and commends HHS's efforts to systematically
identify and address gaps. Regarding centralization, the challenge is
to strike the careful balance between bringing about material
management and human capital efficiencies that may come about with
centralized services with the assurance of State partnership and ready
availability of the assets when needed. We cannot afford unintended
consequences that could possibly delay response time and effectiveness.
Rhode Island has a particularly strong DMAT and the regionalization
has stripped the RI-1 DMAT of independent funding, causing them to lose
the space that NDMS paid to have refurbished as a warehouse, training,
and administrative space. The RI-1 DMAT was deployed in two teams
during the recent hurricanes and was faced with the inability to
utilize their own cache, which was designed, organized, and trained
with to meet the needs of the team specifically. These changes impact
not only the RI-1 DMAT's ability to respond efficiently and effectively
in a Federal deployment, but also in their ability to provide medical
assets within the State during a local/State emergency.
Question 14. It is clear that we need to increase efficiencies in
public health preparedness. How do you suggest that be done?
Answer. Within Rhode Island efficiency can be gained through
continued efforts to support the intrastate regional team models. Rhode
Island has organized a robust hazardous materials and decontamination
team capability. Additionally, Rhode Island has used this same model to
support law enforcement WMD tactical teams, Urban Search and Rescue and
Disaster Medical Response resources. The in-State regionalization
provides an efficient platform for use of grant funds, it provides for
standardized equipment and model training programs while avoiding
duplication of effort across multiple jurisdictions.
Question 15. Do you think that the Federal Regional Planning/
Coordinating Committee meetings are useful? If not, why not?
Answer. Conceptually, yes, but they have yet to be executed in a
manner that allows for useful collaboration throughout the region.
Question 16. As you know, public health has been identified as one
of the critical infrastructures of our Nation. Have you been included
in the planning undertaken by the Department of Homeland Security to
protect the public health infrastructure? From what you know about this
work, how does it affect what you are trying to accomplish in your
position? What more do you think needs to be done in this regard,
especially in advance of an influenza pandemic?
Answer.
Homeland Security Presidential Directive 7 (HSPD-7) and the
National Infrastructure Protection Plan (NIPP) provide the
overarching framework for a structured partnership between
Government and the private sector for protection of Critical
Infrastructure and Key Resources (CI/KR).
The Healthcare and Public Health (HPH) Government
Coordinating Council (GCC) brings together Federal, State,
local, tribal and territorial interests to identify and develop
collaborative strategies that advance critical infrastructure
protection. The overall vision of the HPH Sector is to prevent
or minimize damage to, or destruction of, the Nation's health
care and public health infrastructure.
The private sector members comprise the Healthcare and
Public Health Sector Coordinating Council (SCC), while the
public sector comprises the GCC. The lead for the HPH
Sector is the Department of Health and Human Services
(HHS), serving as the Sector-Specific Agency (SSA).
Current State health agencies serving on the GCC on behalf
of ASTHO: the Alaska Department of Health and Social
Services, Michigan Department of Community Health, and the
Washington State Department of Health. Members from these
State health agencies provide the State perspective on
issues related to health care and public health in relation
to CI/KR. These members also sit on workgroups associated
with the GCC to identify core metrics to measure critical
infrastructure and key resource capabilities as well as
research and development initiatives. Participation is
mainly through conference calls either on a monthly or
quarterly basis, and possibly one in-person meeting.
Goals of the Sector specific to Public Health include
Workforce Sustainability, Physical Security, Cyber Security,
and Service Continuity.
Path Forward: Moving forward, the Healthcare and Public
Health Sector will focus on:
Assessing procedures for collecting, validating and
updating CI/KR protection and preparedness-related data to
assure that the processes are cost-effective, meet HSPD-7
needs, and are not burdensome.
Identifying a process for coordinating with other sectors
to implement cross-sector programs.
Developing a methodology to measure and assess the
effectiveness of the HPH Sector's preparedness and response
capabilities to various threat scenarios or real events.
Unfortunately, due to staffing shortages, the Rhode Island
Emergency Management Agency does not currently have an individual
supporting DHS's Critical Infrastructure/Key Resources planning. While
public health is invited to the planning and response table, we have
yet to begin working with our partners who manage the State's Homeland
Security Grant on the steps to be taken to protect the public health
infrastructure.
Question 17. From the public health perspective, there are certain
similarities and differences between disasters and pandemics. Can you
describe a few of both, and talk about the implications you see for
Federal support from both DHS and HHS?
Answer. Pandemics are widespread epidemics affecting large
populations throughout the world. Disasters (such as hurricanes or
release of an infectious agent in a jurisdiction) and pandemics have
impacts on health, critical infrastructure, the economy, and
(potentially) national security. In most localized disasters, resources
can be redirected from non-affected areas to affected areas, including
first responders (through mechanisms such as EMAC), countermeasures and
medical supplies, and other infrastructure-related support. The
availability of this support enhances the response and often speeds up
the recovery process.
A pandemic is a worldwide outbreak of an infectious disease that
will have broader and potentially longer term impacts on health,
critical infrastructure, the economy, and national security. In the
case of an influenza pandemic, all jurisdictions will be affected
within a relatively short time frame making it difficult to share
resources. As a result, systems will become progressively overwhelmed
for longer periods of time. There may also be increased absenteeism,
from critical infrastructure and response-related jobs, due to fear of
the virus or the need to care for a loved one who cannot obtain care in
a traditional medical setting. The Federal Government has been clear
that States and local areas should not anticipate receiving Federal
support during a pandemic, as it is not possible to provide support to
all States at the same time.
It is important for DHS and HHS to provide sustained funding to
States to build response capabilities, conduct exercises and then
refine pandemic influenza and all-hazards preparedness plans. These
capabilities will enable States to better respond on their own when a
pandemic strikes.
DHS and HHS should also provide guidance on whether and how
reimbursement may be available through the Stafford Act for infectious
disease-related response activities.
Questions From Chairman James R. Langevin to Major General Robert T.
Bray, Adjutant General, State of Rhode Island; Commanding General,
Rhode Island National Guard; Director, Rhode Island Emergency
Management; and Homeland Security Advisor, State of Rhode Island
Question 1. As a military officer, you are well aware of the
military approach to planning. Given all of your experience with
operating in the civilian context, though, you are also well aware that
most civilians, including the Federal Government, do not use the
military approach. What advice would you give your civilian
counterparts? How have you been able to get other civilian agencies
here in the State to come on board?
Answer. The Military Decision Making Process (MDMP) provides a
formal, interactive and dynamic way to generate feasible, acceptable
and supportable courses of action to solve problems, but it is not
unlike other methods used by other entities. When developing a plan to
adequately accomplish a goal or solve a problem, the process matters
more than the model used. An effective planning model must contain
processes that facilitate the examination of all factors that will or
may affect an organization's attempt to solve a problem.
The Rhode Island Emergency Management Agency (RIEMA) offers and
conducts numerous courses on the Incident Command System (ICS) to
educate responders and response agencies on the methodology for an
organized and coordinated response to emergencies. Additionally, RIEMA
engages agencies and stakeholders through participation in numerous
committee meetings. Education and consensus building is our primary
tool for gaining cooperation and coordination toward integrated
emergency management.
Question 2. Describe the challenges of being triple-hatted as the
Adjutant General, EMA Director, and Homeland Security Director. How do
you think holding these and other positions simultaneously has helped
you to address threats to the State and its citizens?
Answer. There are many challenges associated with being triple-
hatted but they are not uncharacteristic of a chief executive's
position. In Rhode Island form fits function due to the inter- and
intra-agency connection, as well as the common strategic nature of
emergency management. In order to effectively meet these challenges, it
is essential to have a competent staff and a solid adherence to core
organizational competencies relating to span of control, chain of
command, and unity of command.
The ability of the Adjutant General as a federally recognized
General Officer of the United States military to function in several
authoritative statuses (Title 32, Title 10, State Active Duty, and as a
State employee) provides and allows for bridging requirements and
institutions in the interest of responsive emergency management. An
Adjutant General with Emergency Management experience may be the only
official who can effectively communicate strategically with Federal
agencies such as, USNORTHCOM, USARMYNORTH, NGB, DHS, and FEMA.
Question 3. Not every State has incorporated the National Guard,
emergency management, and homeland security to the extent that you have
here in Rhode Island. Please explain how this works in the State of
Rhode Island. Is this something that you would recommend all States
doing? If so, why, and if not, why not?
Answer. The incorporation of the agencies is statutory according to
Rhode Island State law. Approximately 12 other States incorporated the
responsibility for these agencies under their Adjutant General. While
many Federal laws apply to provide a measure of continuity, the
uniqueness of each State's laws provides significant diversity.
Integration of the agencies for emergency response, which includes
training, planning, and preparation, is what may be most unique. It has
been my initiative to merge agency capabilities as much as regulations
will allow. The challenges to that initiative have been internal
personalities and turf, labor laws, Federal regulations and not
surprisingly, paradigms. Integration of capabilities between the
agencies make sense corporately, reduces duplication of effort,
increases efficiency, maximizes resources and streamlines the process
of delivering limited resources in a timely manner, where and when they
are needed. Consequently, I highly recommend incorporation as an
organizational format. Essential, however is the need for statutory
authority as well as responsibility. The incorporated agency must have
the statutory authority to affect and ensure coordination, cooperation,
and compliance within the agency as well as among the multiple agencies
and jurisdictions receiving support.
Question 4. Do you believe that the Rhode Island Emergency
Management Agency has enough funding to cover planning efforts? How
much more funding do you think is necessary? What other planning
resources do you need?
Answer. The RIEMA does not have sufficient funds to accomplish its
statutory obligations because of the Federal grant process and State
budget deficit. The FMA/DHS grant application process and format does
not adequately provide for a uniquely governed State, like Rhode
Island, to promote its hazards and infrastructure to compete for
funding. Additionally, the percentage share of the grant funding that
the State is eligible for limits the agencies' performance. Second, the
budget deficit in Rhode Island limits the amount of funds available to
the agencies. Therefore, support for both the dollar and ``in-kind''
funding required to match and fully utilize Federal grant dollars is
limited.
Question 5. What additional resources are needed for you to address
emerging biological threats--including pandemic influenza,
bioterrorism, etc.?
Answer. Effectively addressing emerging threats within the full
spectrum of CBRNE, including biological threats, requires adequate
situational awareness (SA) and the ability to work within a common
operating picture (COP). In order to obtain SA and COP, personnel,
funding, knowledge, authority, equipment, and logistical support are
essential. The best way to address emerging biological threats is to
prevent them from happening. A proactive approach requires an inter-
agency fusion cell, intelligence, communication, a well-trained staff
capable of processing SA into a COP which facilitates mitigation. In
order for Rhode Island to achieve that level of capability, the RIEMA
needs additional trained personnel, better two-way intelligence sharing
between State and Federal agencies, statutory enforcement authority for
local inter-agency cooperation, and the equipment and statutory
authority to support a joint inter-agency coordination center.
Question 6. What problems do you face in spending Federal dollars?
Is the Rhode Island State Budget cycle in synch with those of the
Federal Departments and agencies?
Answer. There are two primary problems in spending Federal dollars.
The first is the ability of the municipalities supported by RIEMA to
both appropriately spend their grant funds and execute their grant
funds in a timely manner. Some local agencies have limited accounting
ability to execute large sums of Federal grant dollars within the
specified time once a project is approved limit. The second problem is
the ability to produce either the dollar or in-kind State match, given
both the nature of the State budget and the unique local government
dependence upon State support. The State of Rhode Island's budget cycle
differs from the Federal Government's by beginning on July 1 instead of
October 1.
Question 7. How has the State Fusion Center assisted in State
efforts to address emerging biological threats?
Answer. The State Fusion Center works well with other law
enforcement agencies, local and Federal, to address potential or
emerging threats. The State Fusion Cell coordinates and communicates
across State lines for SA. The State Fusion Center is law enforcement-
centric.
Question 8. Please provide your perspective on training and
exercising. Do you believe your organization is training the way it
fights (i.e., the way it would need to in order to respond to
biological threats)?
Answer. There are several levels of competency for emergency
response and degrees with each of them. The RIEMA provides training and
exercises, as well as support to local and Federal agencies in the
conduct of training and exercises. The RIEMA supports a robust training
and exercise regimen, which is necessary to accommodate new
initiatives, as well as to train a constantly rotating response force.
First responders are very competent at the tactical level.
Question 9. The best preparation for public health emergencies
involves public health workers who plan and exercise their plans for
emergency response jointly with local elected officials, police and
fire departments, emergency managers, the National Guard, hospitals,
physicians, schools, businesses, and other community partners. Please
describe how this has occurred in Rhode Island regarding emerging
biological threats like pandemic influenza and bioterrorism.
Answer. The Rhode Island Department of Health serves as the State
lead agency for all matter of emergency planning relating to threats
that may result in a public health emergency. Most notable is their
membership in the Emergency Management Advisory Committee. Dr Gifford
and I co-chaired the recent State multi-agency effort to complete the
State's Pandemic Influenza plan, which focused on the continuity of
government through the COOP site. The State Health Department has
involved all public and private health agencies in National Incident
Management System Incident Command training. They are a model agency
for preparation and support.
Question 10a. Recently, GAO released a report on the status of
State and local planning and exercising for an influenza pandemic. GAO
found that while all 50 States have developed an influenza pandemic
plan in accordance with Federal pandemic funding requirements, a review
conducted by the Department of Health and Human Services concluded that
these plans had ``many major gaps'' in 16 of 22 priority areas, such as
the policy process for school closures and communications, community
containment and medical surge capacity. GAO also found that all States
and localities that had received pandemic funds met the requirements to
conduct a pandemic exercise to test their plans. We know updated plans
were due in July for a second round of reviews led by the Department of
Health and Human Services.
What is the current status of planning and exercising for an
influenza pandemic in Rhode Island?
Answer. The Office of the Adjutant General, including the Rhode
Island Emergency Management Agency and the Rhode Island National Guard
is the lead coordinating agency for emergency planning, preparation and
response to emergencies and disasters of all types in the State of
Rhode Island. With respect to the remaining questions, the Adjutant
General is not the subject matter expert or lead technical agency. The
Rhode Island Department of Health is the primary subject matter expert
for matters of health, including the DMAT and the Pandemic Influenza.
Therefore the remaining questions are respectfully deferred to the
Rhode Island Department of Health.
Question 10b. What were the identified gaps in Rhode Island's
pandemic plan from the HHS-led interagency review conducted in 2007?
How did you address those gaps in the current update to your State plan
and how do you plan to address them in the future?
Answer. The Office of the Adjutant General, including the Rhode
Island Emergency Management Agency and the Rhode Island National Guard
is the lead coordinating agency for emergency planning, preparation and
response to emergencies and disasters of all types in the State of
Rhode Island. With respect to the remaining questions, the Adjutant
General is not the subject matter expert or lead technical agency. The
Rhode Island Department of Health is the primary subject matter expert
for matters of health, including the DMAT and the Pandemic Influenza.
Therefore the remaining questions are respectfully deferred to the
Rhode Island Department of Health.
Question 10c. Please describe the pandemic exercises that Rhode
Island has held or participated in and whether any changes were made to
the State's pandemic planning as a result of these exercises. Do you
plan to hold any pandemic exercises in the future at the State and/or
local levels? If yes, please describe the exercises you have planned.
Answer. The Office of the Adjutant General, including the Rhode
Island Emergency Management Agency and the Rhode Island National Guard
is the lead coordinating agency for emergency planning, preparation and
response to emergencies and disasters of all types in the State of
Rhode Island. With respect to the remaining questions, the Adjutant
General is not the subject matter expert or lead technical agency. The
Rhode Island Department of Health is the primary subject matter expert
for matters of health, including the DMAT and the Pandemic Influenza.
Therefore the remaining questions are respectfully deferred to the
Rhode Island Department of Health.
Question 11a. While the Federal Government has provided pandemic
influenza guidance to the non-Federal public and private sectors, non-
Federal officials have told GAO that they would welcome additional
guidance from the Federal Government in a number of areas to help
better plan and exercise for pandemic influenza.
What Federal assistance have you asked for, or do you need, to
address the identified gaps in Rhode Island's pandemic plan?
Answer. The Office of the Adjutant General, including the Rhode
Island Emergency Management Agency and the Rhode Island National Guard
is the lead coordinating agency for emergency planning, preparation and
response to emergencies and disasters of all types in the State of
Rhode Island. With respect to the remaining questions, the Adjutant
General is not the subject matter expert or lead technical agency. The
Rhode Island Department of Health is the primary subject matter expert
for matters of health, including the DMAT and the Pandemic Influenza.
Therefore the remaining questions are respectfully deferred to the
Rhode Island Department of Health.
Question 11b. What other planning guidance do you need?
Answer. The Office of the Adjutant General, including the Rhode
Island Emergency Management Agency and the Rhode Island National Guard
is the lead coordinating agency for emergency planning, preparation and
response to emergencies and disasters of all types in the State of
Rhode Island. With respect to the remaining questions, the Adjutant
General is not the subject matter expert or lead technical agency. The
Rhode Island Department of Health is the primary subject matter expert
for matters of health, including the DMAT and the Pandemic Influenza.
Therefore the remaining questions are respectfully deferred to the
Rhode Island Department of Health.
Question 12. According to the Implementation Plan for the National
Strategy for Pandemic Influenza, ``State, local, and tribal law
enforcement agencies should coordinate with appropriate medical
facilities and countermeasure distribution centers in their
jurisdictions to coordinate security matters, within 6 months'' of when
the Plan was released--so the deadline would have been October 2005. To
your knowledge, has this coordination taken place? If so, how, and if
not, how would you recommend this happen?
Answer. The Office of the Adjutant General, including the Rhode
Island Emergency Management Agency and the Rhode Island National Guard
is the lead coordinating agency for emergency planning, preparation and
response to emergencies and disasters of all types in the State of
Rhode Island. With respect to the remaining questions, the Adjutant
General is not the subject matter expert or lead technical agency. The
Rhode Island Department of Health is the primary subject matter expert
for matters of health, including the DMAT and the Pandemic Influenza.
Therefore the remaining questions are respectfully deferred to the
Rhode Island Department of Health.
Question 13. What is your opinion of the decision to centralize
Disaster Medical Assistance Team assets in your region? What problems
do you see with this approach, especially in the context of a
biological threat that sweeps the entire region?
Answer. The Office of the Adjutant General, including the Rhode
Island Emergency Management Agency and the Rhode Island National Guard
is the lead coordinating agency for emergency planning, preparation and
response to emergencies and disasters of all types in the State of
Rhode Island. With respect to the remaining questions, the Adjutant
General is not the subject matter expert or lead technical agency. The
Rhode Island Department of Health is the primary subject matter expert
for matters of health, including the DMAT and the Pandemic Influenza.
Therefore the remaining questions are respectfully deferred to the
Rhode Island Department of Health.
Questions From Chairman James R. Langevin to Mr. Thomas J. Kilday, Jr.,
Homeland Security Program Manager, Rhode Island Emergency Management
Agency
Question 1. What is your opinion of Federal regional offices of all
types? Do you think that regionalization is a good model for Rhode
Island?
Answer. In my opinion the Federal Regional offices provide a
valuable link for Rhode Island Emergency Management Agency and other
State agencies to seek advice, work on planning issues and coordinate
grant activities. A regional office understands the local challenges
unique to the region in question rather than viewing each State as just
another State from the national level. Additionally, the regional
office understands the Federal policies and the State polices for their
constituent States; this knowledge allows the regional offices to help
States interpret policy. Often the regional office serves as a mediator
on issues that require further clarification with the Federal offices.
The only gap lies in the area of funding and planning actions.
Currently the funding is provided at the Federal, State, and local
level. There is not a mechanism to ensure regionally based program
funding and these programs are often the first programs cut during a
budget crunch or a department re-organization. During my time serving
the State I have personally seen the Federal regional model bear the
effects of budget constraints and reorganization.
Question 2a. DHS and HHS recently led a series of five workshops
for States in the five Federal influenza pandemic regions primarily to
discuss the current update of State and Territorial pandemic plans. A
Regional Principal Federal Official (PFO) and Federal Coordinating
Officer (FCO) for pandemic influenza are pre-designated for each of
these five pandemic regions.
What was your impression of the DHS/HHS led workshop held in
January 2007 for pandemic Region A? Did you find it helpful in planning
for a pandemic? Should more regional meetings of State and Federal
officials be held on pandemic influenza? How could they be made more
useful?
Question 2b. How has the regional PFO assisted with your pandemic
preparedness efforts?
Answer. The answer to question No. 2 part A & B will be provided by
Dr. Gifford from the Rhode Island Department of Health. Rhode Island
Emergency Management has partnered with Rhode Island Health Department
on pandemic planning over the years and has collaborated on the answers
to the pandemic questions related to this testimony.
Question 3. How would you recommend that entities within the
Federal Government better align and coordinate the grants that they put
out to the States and territories?
Answer. The Federal Government could improve the grant process by
aligning programs and requirements across Federal departments and
agencies. In Rhode Island we establish stakeholder committees to
facilitate the planning and grant processes to ensure alignment with
programs ongoing in the State. This coordination is required within the
grant guidance for each Federal program whether it is a DHS or DHHS
program. I find it interesting the States are required to plan with
intra- and inter-State stakeholders although we often find that this is
not the case with the Federal departments. There are conflicting
timelines, program requirements and duplication of programs across a
number of Federal agencies often with extremely compressed timelines.
Question 4. Given the decision to centralize the DMAT in the
region, what do you think needs to be done? Do you think that the State
needs to develop its own disaster medical assistance assets?
Answer. I feel that this decision by the ASPR validates Rhode
Island's decision more than 5 years ago to go forward with plans to
build a cache of response equipment and capacity to stand up a Field
Hospital and other response capabilities independent of the team's
Federal Cache. With more than 200 RI DMAT members, and more than 400
Medical Reserve Corps members, the RI DMAT Team has depth in every
position on the team. They have demonstrated many times that they can
deploy assets on both Federal deployments and calls for assistance from
Rhode Island public health and emergency management officials for in-
State needs. The team now has a substantial cache of equipment and
mechanisms in place to train and deploy credential-verified volunteer
health care providers and support personnel to respond to extraordinary
medical needs. Other States that have come to depend upon the National
Disaster Medical System (NDMS) DMAT teams should look to Rhode Island's
model in this area.
Question 5. How do you think decisions will be made when medical
professionals are in the National Guard, and would need to be called up
for Guard service and medical service simultaneously?
Answer. The question may be moot in the sense that when the
National Guard deploys any of its assets, the members have no choice
when it comes to deploying. They are obligated to go. This has resulted
in medical personnel shortages in every State as National Guard and
Reservists have been deployed to the wars in Iraq and Afghanistan.
Health care providers at many levels are already in short supply, and
their deployment will only make adequate staffing more difficult.
Recruiting health care providers for volunteer service from non-acute
care facilities is one answer as to how to fill vacancies left by
deployments of the Guard and Reserve. The Medical Reserve Corps is an
ideal organization to provide this recruitment and training, as has
been demonstrated in Rhode Island.
Question 6. Is there funding provided to the Rhode Island EMA to do
critical infrastructure and/or continuity of operations planning?
Answer. Critical infrastructure planning in Rhode Island is
considered one of the responsibilities of the Homeland Security Program
Manager and other staff. There is not anyone specifically tasked to
work on critical infrastructure planning at this time. The funding is
provided in part through the Department of Homeland Security grant
program funds that Rhode Island receives. Ideally Rhode Island would
have a single individual working on critical infrastructure planning
and Continuity of Operations Planning but budget constraints and
resource allocation has not allowed this to happen. There are programs
such as the Buffer Zone Protection Program that provide funding to
support critical infrastructure efforts although this funding goes
directly to the critical infrastructure owner to provide for protective
measures against attacks.
Question 7. What do you think can be done to increase efficiencies
in emergency preparedness?
Answer. Within Rhode Island efficiency can be gained through
continued efforts to support the intra-State regional team models.
Rhode Island has organized a robust hazardous materials and
decontamination team capability. Additionally, Rhode Island has used
this same model to support law enforcement WMD tactical teams, Urban
Search and Rescue and Disaster Medical Response resources. The in-State
regionalization provides an efficient platform for use of grant funds,
it provides for standardized equipment and model training programs
while avoiding duplication of effort across multiple jurisdictions.
Questions From Chairman James R. Langevin to Peter T. Ginaitt,
Director, Emergency Preparedness, Lifespan Hospital Network
Question 1. What is your opinion of Federal regional offices of all
types? Do you think that regionalization is a good model for Rhode
Island?
Answer. Response was not provided at the time of publication.
Question 2a. DHS and HHS recently led a series of five workshops
for States in the five Federal influenza pandemic regions primarily to
discuss the current update of State and territorial pandemic plans. A
Regional Principal Federal Official (PFO) and Federal Coordinating
Officer (FCO) for pandemic influenza are pre-designated for each of
these five pandemic regions.
What was your impression of the DHS/HHS led workshop held in
January 2007 for pandemic Region A? Did you find it helpful in planning
for a pandemic? Should more regional meetings of State and Federal
officials be held on pandemic influenza? How could they be made more
useful?
Answer. Response was not provided at the time of publication.
Question 2b. How has the regional PFO assisted with your pandemic
preparedness efforts?
Answer. Response was not provided at the time of publication.
Question 3. We understand that a decision has been made that for
mass casualties, the hospitals will take over the Convention Center.
What happens when this private sector entity wants and needs its asset
back to start their business enterprise again?
Answer. Response was not provided at the time of publication.
Question 4. Please give us your perspective on altered standards of
care. How do you recommend that the necessary discussions take place
and difficult decisions be made--in the State of Rhode Island and
throughout the Nation?
Answer. Response was not provided at the time of publication.
Question 5. What additional guidance do you think the Federal
Government still needs to provide to the States and territories--
regarding altered standards of care, pandemic influenza, emerging
biological threats, bioterrorism, etc.?
Answer. Response was not provided at the time of publication.
Question 6. What additional resources are needed for the hospital
network in Rhode Island to address emerging biological threats--
including pandemic influenza, bioterrorism, etc.?
Answer. Response was not provided at the time of publication.
Question 7. What problems does the hospital network in Rhode Island
face in spending Federal dollars? Is the Rhode Island State budget
cycle in synch with those of the Federal departments and agencies?
Answer. Response was not provided at the time of publication.
Question 8. Please provide your perspective on training and
exercising. Do you believe your organization is training the way it
fights (i.e., the way it would need to in order to respond to
biological threats)?
Answer. Response was not provided at the time of publication.
Question 9. The best preparation for public health emergencies
involves public health workers who plan and exercise their plans for
emergency response jointly with local elected officials, police and
fire departments, emergency managers, the National Guard, hospitals,
physicians, schools, businesses, and other community partners. Please
describe how this has occurred in Rhode Island regarding emerging
biological threats like pandemic influenza and bioterrorism.
Answer. Response was not provided at the time of publication.
Question 10. According to the Implementation Plan for the National
Strategy for Pandemic Influenza, ``State, local, and tribal law
enforcement agencies should coordinate with appropriate medical
facilities and countermeasure distribution centers in their
jurisdictions to coordinate security matters, within 6 months'' of when
the Plan was released--so the deadline would have been October 2005. To
your knowledge, has this coordination taken place? If so, how, and if
not, how would you recommend this happen?
Answer. Response was not provided at the time of publication.
Question 11. The Implementation Plan for the National Strategy for
Pandemic Influenza states that, ``All health care facilities should
develop, test, and be prepared to implement infection control campaigns
for pandemic influenza, within 6 months'' of when the Plan was
released--so the deadline was October 2006. Hospitals and other health
care facilities in Rhode Island are more than familiar with infection
control measures. Can you describe the specific challenges in
identifying and implementing infection control measures for pandemic
influenza?
Answer. Response was not provided at the time of publication.
Question 12. What is your opinion of the decision to centralize
Disaster Medical Assistance Team assets in your region? What problems
do you see with this approach, especially in the context of a
biological threat that sweeps the entire region? Or will having those
assets centralized help with a widespread biological event? If so, how?
Answer. Response was not provided at the time of publication.