Testimony

Statement by
Julie L.  Gerberding, M.D., M.P.H., 
Director
Centers for Disease Control and Prevention
U.S. Department of Health and Human Services

on
Avian Influenza: Pandemic Influenza: Progress Made and Challenges Ahead 

before
Committee on Appropriations
Subcommittee on Labor, Health and Human Services, Education and Related Agencies
United States Senate

Wednesday, January 24, 2007

Mr. Chairman and members of the Subcommittee, I am pleased to be here today to provide an update on cross-cutting preparations the Centers for Disease Control and Prevention (CDC) and our many partners, collaborators, and other organizations are undertaking for the next influenza pandemic. Secretary Michael O. Leavitt, Secretary of the Department of Health and Human Services (HHS), is strongly committed to preparing for a pandemic. An influenza pandemic would have a profound impact on almost every sector of society, both in the United States and globally. I would like to emphasize the importance of this consolidated approach not only within the realm of public health but across all sectors of society in readiness for the next influenza pandemic. CDC is committed to improving the health of our Nation and the world. Our longstanding emphasis on cooperative action has allowed the public health community to accomplish a great deal since I testified before the Subcommittee last January, and much more needs to be done. I will focus my testimony today on three areas: ongoing domestic and international surveillance, other preparedness initiatives in 2006, and examples of CDC actions planned for 2007 and beyond. I will also describe the agency's progress towards the President's National Strategy for Pandemic Influenza.

Before continuing my testimony, I would like to thank this Subcommittee and the Congress for providing Fiscal Year 2006 Emergency Supplemental funding for pandemic preparedness.

CDC recognizes the continuing threat of avian influenza A/H5N1 as well as other influenza strains that could evolve into a pandemic, and we are committed to take steps necessary for effective preparedness and response. Work clearly must continue to ensure sustained actions that will minimize the morbidity, mortality, economic burden, and social disruption that an influenza pandemic could cause. To put this imperative into perspective, I'd like to share a few comparisons between 2005 and today.

In January 2005, 10 countries that had reported detection of highly pathogenic avian influenza A (H5N1) viruses in wild birds or domestic poultry to World Organization for Animal Health (OIE) (including both China and the Hong Kong Special Administrative Region of China). By January 22, 2007, 56 countries had reported H5N1 in birds had grown to 56 (including both China and the Hong Kong Special Administrative Region of China). In January 2005, the World Health Organization (WHO) confirmed 47 human cases with 34 fatalities in two countries. As of January 22, 2007, WHO had confirmed 269 human cases with 163 fatalities in 10 countries.

Ongoing International and Domestic Surveillance
One of CDC's most important roles in protecting the nation's health is to provide an ongoing assessment of the threat of an influenza pandemic. We collect and disseminate surveillance information for influenza strains circulating throughout the world, including those with a high possibility of evolving into an influenza pandemic. As one of four World Health Organization Global Collaborating Centers for Influenza, CDC is responsible for detecting and reporting predominant influenza strains and coordinating development of annual influenza vaccines for the Northern and Southern Hemispheres.

Our agency is especially focused on monitoring changes in the avian influenza A/H5N1 virus. We are carefully monitoring changes in the H5N1 virus that might allow it to evolve into a strain that could result in a pandemic. Our work in this area is highly collaborative, involving global and regional non-governmental organizations, ministries of health in countries across the world, CDC offices in selected countries, and other United States Government agencies such as Naval Medical Research Units (NAMRU). This extensive surveillance network has made it possible for CDC to closely track the geographic spread of the H5N1 viruses in 2006 and to identify and analyze several subtle changes in the virus. Fortunately, at present, these changes do not appear to have increased the virus' capability for efficient human-to-human transmission. CDC also has been able to identify changes in the composition of H5N1 virus samples that could affect its susceptibility to antiviral medications. A recent example appeared in an H5N1 virus sample from Egypt, initially indicating a change in susceptibility to oseltamivir, better known as Tamiflu™. As WHO has stated, at this time there is no indication that oseltamivir resistance is widespread in Egypt or elsewhere.

Influenza surveillance within the United States is closely linked with seasonal influenza activities. The established domestic surveillance network provides a solid foundation on which CDC and our partners are building the real-time human surveillance that will be vital when an influenza pandemic appears in the United States. We also are working closely with agencies such as the U.S. Geological Survey and the United States Department of Agriculture (USDA) to maintain integrated surveillance of animals infected by avian influenza strains. CDC is cooperating with public and private organizations to monitor migratory wild birds that carry numerous strains of avian influenza. We have strengthened agreements with our neighbors in Canada and Mexico to identify highly pathogenic H5N1 and other potential pandemic strains quickly.

International and domestic surveillance is vital if the United States is to contain viruses that cause influenza pandemics and slow the spread of infection to allow the most time possible for development and dissemination of a pandemic vaccine. If an influenza pandemic expands in the United States, CDC's surveillance efforts will shift focus to supplying the necessary data to track the extent and severity of infection and inform response and recovery efforts.

Other Preparedness Initiatives in 2006
CDC's preparedness initiatives can be grouped under the agency's Health Preparedness Goals. Many of the agency's accomplishments in 2006 bridge these goals, including the completion and implementation of a comprehensive Pandemic Influenza Operations Plan, an examination by nationally recognized ethicists of ethical issues in the decisions that must be made to achieve preparedness for an influenza pandemic, and the implementation of a cross-cutting Pandemic Influenza Task Force that is focusing on CDC's responsibilities related to the President's Pandemic Influenza National Response Plan.

Prevention
In 2006, CDC completed several important preparedness actions related to prevention, in cooperation with parts of the HHS and other organizations.

• CDC played a lead role in most State Influenza Summits coordinated by HHS and has continued follow-up with the States.
• CDC has prepared and disseminated guidance, recommendations and initial funding to 62 States, localities, territories, and tribal nations that are receiving HHS funding for pandemic influenza preparedness. This guidance included templates for operational drills of influenza immunization clinics and table-top exercises for community-based school-closing decision processes as well a model contract for engaging pertinent private-sector entities in receipt, storage and emergency intra-state distribution of antiviral drugs when an influenza pandemic seems imminent.
• To strengthen seasonal vaccination and prepare a foundation for promotion and distribution of a pandemic influenza vaccine upon availability, CDC held two National Vaccine Summits with partners in 2006 and conducted the first National Influenza Vaccination Week.
• CDC completed its Pandemic Influenza Operations Plan in 2006 and began implementing the plan. As part of this initiative, the agency has begun a systematic series of preparedness exercises.
• CDC and other WHO Global Collaborating Reference Laboratories isolated and characterized strains of avian influenza and with this information recommended representative strains for use in avian influenza vaccines.
• CDC laboratories employed reverse genetics methods to rapidly develop safer strains of newly identified avian influenza viruses for use in vaccine production.
• CDC's 2006 research on the deadly 1918 pandemic influenza increased understanding about the challenges in preventing or minimizing the impact of pandemics.
• As part of United States global cooperation, CDC in collaboration with other parts of HHS, had worked with other agencies to pre-position antiviral regimens overseas to support international containment efforts. This activity is closely coordinated with WHO.

Detection and Reporting
In 2006, CDC made considerable progress in its detection and reporting goals related to pandemic influenza preparedness.

• CDC awarded four contracts to biotechnology companies to develop easy to use rapid diagnostic tests for detecting avian influenza. These tests can diagnose influenza within 30 minutes and will be used at the point of care such as in doctor's offices, in emergency rooms, or at ports of entry.
• Research accomplishments ranged from development, production and dissemination of new rapid diagnostic tests to development of tests to distinguish H5 viruses from other strains, which now are being used by 113 certified laboratories in the Laboratory Response Network (LRN). These labs have reagents on hand to perform the H5N1 test (assay). Of these, 107 are domestic labs and six are international labs. CDC also conducted extensive research on viral samples to identify changes in the structure of H5N1 subtypes that might indicate greater ability for person-to-person transmission or increased severity of infection.
• To help ensure the prompt identification and containment of people infected by H5N1 and other viruses that could result in an influenza pandemic, CDC and the Council for State and Territorial Epidemiologists (CSTE) continued our cooperative work to make all laboratory-confirmed influenza hospitalizations notifiable. In addition, CSTE recently has recommended that infection with novel influenza viruses be nationally reportable.

Timeliness and Accuracy of Communications
Risk communication planning is critical to pandemic influenza preparedness and response. HHS and CDC are committed to the scientifically validated tenets of outbreak risk communication: comprehensive information shared across diverse audiences, information tailored according to need, and information that is consistent, frank, transparent, and timely.