<DOC>
[105 Senate Hearings]
[From the U.S. Government Printing Office via GPO Access]
[DOCID: f:50023.wais]
S. Hrg. 105-630
PREPAREDNESS FOR EPIDEMICS AND BIOTERRORISM
=======================================================================
HEARING
before a
SUBCOMMITTEE OF THE
COMMITTEE ON APPROPRIATIONS UNITED STATES SENATE
ONE HUNDRED FIFTH CONGRESS
SECOND SESSION
__________
SPECIAL HEARING
__________
Printed for the use of the Committee on Appropriations
Available via the World Wide Web: http://www.access.gpo.gov/congress/
senate
______
50-023 cc U.S. GOVERNMENT PRINTING OFFICE
WASHINGTON : 1998
_______________________________________________________________________
For sale by the U.S. Government Printing Office
Superintendent of Documents, Congressional Sales Office, Washington, DC
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ISBN 0-16-057529-X
COMMITTEE ON APPROPRIATIONS
TED STEVENS, Alaska, Chairman
THAD COCHRAN, Mississippi ROBERT C. BYRD, West Virginia
ARLEN SPECTER, Pennsylvania DANIEL K. INOUYE, Hawaii
PETE V. DOMENICI, New Mexico ERNEST F. HOLLINGS, South Carolina
CHRISTOPHER S. BOND, Missouri PATRICK J. LEAHY, Vermont
SLADE GORTON, Washington DALE BUMPERS, Arkansas
MITCH McCONNELL, Kentucky FRANK R. LAUTENBERG, New Jersey
CONRAD BURNS, Montana TOM HARKIN, Iowa
RICHARD C. SHELBY, Alabama BARBARA A. MIKULSKI, Maryland
JUDD GREGG, New Hampshire HARRY REID, Nevada
ROBERT F. BENNETT, Utah HERB KOHL, Wisconsin
BEN NIGHTHORSE CAMPBELL, Colorado PATTY MURRAY, Washington
LARRY CRAIG, Idaho BYRON DORGAN, North Dakota
LAUCH FAIRCLOTH, North Carolina BARBARA BOXER, California
KAY BAILEY HUTCHISON, Texas
Steven J. Cortese, Staff Director
Lisa Sutherland, Deputy Staff Director
James H. English, Minority Staff Director
------
Subcommittee on Departments of Labor, Health and Human Services, and
Education, and Related Agencies
ARLEN SPECTER, Pennsylvania, Chairman
THAD COCHRAN, Mississippi TOM HARKIN, Iowa
SLADE GORTON, Washington ERNEST F. HOLLINGS, South Carolina
CHRISTOPHER S. BOND, Missouri DANIEL K. INOUYE, Hawaii
JUDD GREGG, New Hampshire DALE BUMPERS, Arkansas
LAUCH FAIRCLOTH, North Carolina HARRY REID, Nevada
LARRY E. CRAIG, Idaho HERB KOHL, Wisconsin
KAY BAILEY HUTCHISON, Texas PATTY MURRAY, Washington
TED STEVENS, Alaska ROBERT C. BYRD, West Virginia
(Ex officio) (Ex officio)
Majority Professional Staff
Bettilou Taylor
Minority Professional Staff
Marsha Simon
Administrative Support
Jim Sourwine and Jennifer Stiefel
C O N T E N T S
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Page
Opening remarks of Senator Lauch Faircloth....................... 1
Statement of Luther L. Fincher, Jr., fire chief, city of
Charlotte, NC.................................................. 2
Prepared statement........................................... 5
Statement of Robert Knouss, M.D., Director, Office of Emergency
Preparedness, U.S. Department of Health and Human Services..... 8
Prepared statement........................................... 10
Statement of James M. Hughes, M.D., Director, National Center for
Infectious Diseases, Centers for Disease Control and
Prevention, U.S. Department of Health and Human Services....... 12
Prepared statement........................................... 14
Statement of Richard Jackson, M.D., M.P.H., Director, National
Center for Environmental Health, Centers for Disease Control
and Prevention, U.S. Department of Health and Human Services... 18
Prepared statement........................................... 19
Potential problems............................................... 22
Prepared statement of Dr. David L. Heymann on behalf of the World
Health Organization............................................ 30
Statement of Michael Osterholm, Ph.D., chair, Committee on Public
Health, Public and Scientific Affairs Board, American Society
for Microbiology............................................... 32
Prepared statement........................................... 35
Statement of Edgar Thompson, M.D., M.P.H., chair, government
relations, Association of State and Territorial Health
Officials...................................................... 40
Prepared statement........................................... 42
Statement of Ralph D. Morris, M.D., M.P.H., president, National
Association of County and City Health Officials................ 48
Prepared statement........................................... 51
PREPAREDNESS FOR EPIDEMICS AND BIOTERRORISM
----------
TUESDAY, JUNE 2, 1998
U.S. Senate,
Subcommittee on Labor, Health and Human
Services, and Education, and Related Agencies,
Committee on Appropriations,
Washington, DC.
The subcommittee met at 2:14 p.m., in room SD-138, Dirksen
Senate Office Building, Hon. Lauch Faircloth, presiding.
Present: Senator Faircloth.
NONDEPARTMENTAL WITNESS
STATEMENT OF LUTHER L. FINCHER, JR., FIRE CHIEF, CITY
OF CHARLOTTE, NC
OPENING REMARKS OF SENATOR FAIRCLOTH
Senator Faircloth. The subcommittee will come to order.
Today the panel will discuss our Nation's preparedness for
epidemics and bioterrorism.
As some of you may know, Senator Specter, who had certainly
planned to be with us, very successfully underwent heart bypass
surgery and is going to be in the hospital for 5 or 6 days. The
doctors tell us he is expected to make a full and complete
recovery and will be back to his normal activities quickly.
Knowing Arlen and the speed with which he does everything else,
I would think he would handle this quickly too. But our
thoughts and prayers are with him, and we wish him and his
family a speedy recovery.
I would like to welcome everyone here today to discuss the
growing problems of epidemics and bioterrorism. I am not a
scientist but I am a pretty good reader, and a book I read
recently called the ``Hot Zone'' by Richard Preston got me to
thinking about what we are going to be talking about today. It
got me to thinking how long viruses have been around and how
difficult it is to protect ourselves from them. I have also
learned about bacteria and how quickly they have become
resistant to antibiotics which has very important implications
for both human and animal medicine.
I am sure everyone here is aware that people are using
germs and chemicals to try to hurt other people, not in a
distant war, but right here in the United States. An incident
recently occurred in my home State of North Carolina. And as I
learn more about the growing problems of epidemics and
bioterrorism, I'm concerned about our ability to protect people
from these threats.
When bioterrorism is discussed, most people think of a
military or law enforcement response. Those answers are
obviously important, but today we want to focus on the public
health response because I don't think we have devoted the
resources and attention needed to assure sufficient protection.
Attorney General Janet Reno and FBI Director Louis Freeh
share my concerns. During a recent congressional hearing,
Attorney General Reno said she believes the Centers for Disease
Control does not have adequate resources to deal with
bioterrorism. Now this is coming from the U.S. Attorney
General.
FBI Director Freeh then added that the Centers for Disease
Control almost shipped a dangerous biological agent to an
individual who had created a false identity using a stolen
letterhead. I mean, the very idea that this potentially very,
very dangerous material which could have devastated hundreds
and thousands of people almost was released simply because the
Centers for Disease Control did not have the resources to
perform an onsite inspection of the address they were shipping
the substance to.
Most of us believe our public health system has adequate
resources to provide the network needed to protect us from the
dangers of epidemics and terrorism. This simply is not true.
Most people would be shocked to learn that less than 40 percent
of our health departments can connect online to the command
center at the Centers for Disease Control or to their own State
health departments because they simply do not have computers.
Some 20 percent of our health departments are still using
rotary dial telephones.
For those who feel we should just ignore the public health
folks and let law enforcement or the military take charge, I
suggest you think again.
The first sign of a deadly new epidemic or serious
terrorist attack is not going to be announced on the evening
news. We're not going to see a battleship pull up to our shores
and offload a microbe army. It will simply start with a large
number of people falling ill and going to the doctor or
emergency rooms in the area.
We are going to hear today from folks who have experienced
these situations firsthand and can show us all of its vital
importance to provide more resources to the Centers for Disease
Control, the Public Health Service, and our State and local
public health departments.
SUMMARY STATEMENT OF LUTHER FINCHER, JR.
Our first witness today will be Luther Fincher who is chief
of the Charlotte Fire Department, needless to say, Charlotte,
NC. [Laughter.]
Chief Fincher played a major role in responding to a recent
incident that occurred in Charlotte.
He also serves as vice president of the International
Association of Fire Chiefs and will become their president in
the year 2000. I wish all politics was as certain as becoming
president of the fire chiefs, Luther. [Laughter.]
Chief Fincher is a former Marine and attended the Kennedy
School of Government at Harvard. His son Luther is also a
member of the Charlotte Fire Department.
Chief Fincher, you may begin.
Mr. Fincher. Thank you, sir.
Good afternoon, Mr. Chairman. I am Luther Fincher, chief of
the Charlotte Fire Department in North Carolina. Thank you for
this opportunity to speak and to provide input from an
emergency services perspective to this committee.
As the fire chief of the city of Charlotte and vice
president of the International Association of Fire Chiefs, I
will briefly talk about domestic terrorism in our country, the
first responders' role, and the public health.
On the morning of February 5, 1998, at approximately 10
a.m., a subject entered the front doors of our county court
located just five blocks from the center of Charlotte. Upon
entering the security checkpoint, he informed sheriff's
deputies that he had an explosive device containing a chemical
that, if released, would hurt a lot of people.
X rays at the checkpoint revealed that the device was real.
It was detonated by bomb technicians 17 hours later when they
determined that it did not contain chemical or biological
agents. Fortunately for Charlotte, this incident had a positive
outcome, but it was a wake-up call for us.
Charlotte lacks sufficient resources and training to deal
with urban terrorism. The emergency services community is
neither prepared nor adequately trained to mitigate incidents
which involve weapons of mass destruction and chemical or
biological agents. The threat of contamination is an important
complicating factor. We do not have the means to make sure that
we can mitigate an incident effectively, treat the victims
without preventing secondary contamination of emergency
personnel.
There are three areas where we must have clear
understanding and Federal support.
First is the role of the first responders and Federal
responders. When an act of terrorism occurs, only local
emergency responders will provide the first and immediate
mitigation of the incident. The work accomplished by these
first responders in the first 2 to 3 hours will likely
determine the number of lives saved and the ultimate outcome of
the operation. Without proper training and equipment, first
responders can take what may be normally considered an everyday
emergency incident and create a disaster.
At this point public health is most vulnerable. The local
health care system must treat patients while ensuring that
first responders and its own workers do not become victims.
Public health systems must be prepared to react immediately and
with the correct information for first responders and our
citizens. Decontamination procedures and facilities must be
available, along with sufficient supplies of drugs and
antidotes for whatever agent is present. The need and the
challenge are enormous.
In almost all cases, Federal resources will not arrive for
6 to 8 hours. When they do arrive, the critical period is long
past. As the terrorism response time line shows, the local
first responders are unassisted for the most critical hours.
Following notification of a terrorist act is an intense and
vivid period when local first responders cope alone with the
aftermath of these incidents.
The National Guard has been designated to work with
Federal, State, and local officials. The Federal Government
must acknowledge the role of the National Guard and other
Federal resources when assimilated into the existing incident
command system.
The Bureau of Justice Assistance training materials have
been successful because they were developed with the National
Fire Academy. The National Fire Academy's role in preparing
fire and emergency service leaders for response to terrorism
must be recognized and enhanced.
There is also the need for training assistance beyond the
120 most populous jurisdictions targeted by the Department of
Justice [DOJ] and the Department of Defense [DOD]. Strategic
and critical U.S. infrastructures are often located outside
metropolitan areas. These areas are protected by volunteer
departments. Congressional mandate must direct that Federal
training reach fire and emergency services nationwide. The
resident and nonresident programs of the National Fire Academy
offer an excellent delivery system that should be utilized to
the maximum extent possible.
Second is the incident command system. When Federal
resources arrive, the incident command system will already be
in place. The incident commander will plug Federal resources
into the system. There is an urgent need for all Federal
agencies which respond to emergencies to understand and adopt
the incident command system.
Third is hospital capability. Any large scale incident
involving weapons of mass destruction or chemical, biological,
or nuclear agents will sorely test even the largest community's
ability to deal with mass casualties. Congress needs to examine
the ability of the hospitals to deal with victims at community
hospitals or trauma centers under these conditions. Plans must
be in place to protect local first responders as they mitigate
incidents before the Federal resources arrive. The need for
drug and antidote caches, decontamination facilities should be
a focus of Congress. The Veterans Administration hospitals
should be considered for an important role.
In conclusion, I would like to leave you with several
thoughts and recommendations. The fire and emergency services
need assistance from the Federal Government in the areas of
training, detection equipment, personnel protective clothing,
and mass decontamination capabilities.
No. 2, the Federal Government must organize its various
missions and objectives with the clear understanding that once
a terrorist incident occurs, the local first responder will be
on the scene and operating within 6 minutes while Federal
resources will not arrive for 6 hours. The Federal Government
must understand its supportive and important role when plugged
into the incident command system.
No. 3, Federal departments and agencies must involve fire
and emergency services in conception, design, and review of all
Federal plans relating to response to terrorist incidents. We
strongly encourage FEMA support for the National Fire Academy's
involvement with the Department of Justice and the Department
of Defense on training issues.
PREPARED STATEMENT
I appreciate the opportunity to appear before you today and
will be pleased to respond to any questions you may have.
Senator Faircloth. Thank you, Chief Fincher, and we will
get to the questions later.
[The statement follows:]
Prepared Statement of Luther L. Fincher, Jr.
STRENGTHENING THE LOCAL RESPONSE TO DOMESTIC TERRORISM
Good morning, Mr. Chairman. I am Luther Fincher, Chief of the
Charlotte Fire Department in North Carolina. I am appearing today as
second vice president of the International Association of Fire Chiefs.
We greatly appreciate the opportunity to be here.
As we look forward to the twenty-first century, we see that the
emergency services community faces new and difficult threats and
challenges. These new hazards include many threats that have not been
adequately dealt with in the past, including domestic terrorism.
The emergency services community must face the fact that American
security, intelligence, and law enforcement will not always
successfully prevent terrorist attacks. Therefore, the emergency
services must be available when terrorist incidents occur. We must
understand the ramifications or responding to terrorist incidents,
which are totally different from traditional large-scale emergencies.
The safety of emergency service providers will be at stake and must be
an early consideration. The media will also take an active interest in
incidents, from start to finish. Our customers have very high
expectations of government in terrorist situations, and they demand
extraordinary effort.
The federal government depends directly on local emergency service
providers and their actions during the initial emergency phase of a
terrorist incident. There are many eyes watching. Emergency managers,
law enforcement personnel, firefighters, and emergency medical
providers should be aware and prepared for this.
The role of first responders
When an act of terrorism occurs, the local fire and emergency
service organizations alone respond immediately to deal with the
incident and begin mitigation. Their operations in the first two or
three hours will largely determine the number of lives saved and the
eventual outcome of the incident. Congress and the federal government
must clearly understand the role of the local responder. In almost all
cases, the federal assets responding to an incident will not arrive
until six to eight hours have passed, well after the most critical
period. For the record, the International Association of Fire Chief's
terrorism response timeline shows the anticipated response of emergency
forces. It clearly demonstrates that local first responders are
unassisted for the most critical hours.
This is the point at which public health is most vulnerable. The
local healthcare system must respond to treat patients while ensuring
that first responders and its own workers do not become victims as
well. Time will be of the essence; public health systems must be
prepared to react without outside assistance. Decontamination policies,
procedures, and facilities must be available, along with sufficient
supplies of drugs and antidotes for whatever nuclear, biological, or
chemical agent is present. The need and challenge is enormous.
Federal response plans regarding terrorism usually describe two
roles--crisis management and consequence management. Crisis management
deals with the enormous task of trying to prevent an incident from
occurring. Consequence management concerns with planning for an
incident before it occurs, then for recovery and rehabilitation after
the event.
Let me point out a third area--the area called ``local emergency
response'' immediately after the event. ``Local emergency response''
fits between crisis and consequence management. It begins at the point
immediately following notification of the terrorist act. ``Local
emergency response'' is that intense and vivid period of several hours
when local first responders cope with the aftermath of a major
incident. It is that time when local first responders work alone.
The role of Federal responders
In 1996, Congress passed two laws regarding acts of terrorism: The
Antiterrorism and Effective Death Penalty Act and the Nunn-Lugar-
Domenici provisions of the Department of Defense Authorization. Both
these important laws contain provision designed to help prepare local
fire and emergency response organizations to deal with acts of
terrorism. My testimony will focus on the policy issues which Congress
must address to ensure that the administration delivers what is truly
needed by American's fire and emergency services.
Department of Defense
In November 1997, Secretary of Defense William Cohen announced he
was significantly enhancing the role of the National Guard to work with
other federal agencies and state and local officials. He recently
announced establishment of the Consequence Management Program
Integration Office to oversee the activities of the National Guard and
reserve components. We welcome this news, as the National Guard, while
military, is controlled by state government and accessible at the local
level. In planning a role for the National Guard and the reserve
component, the federal government must acknowledge that the military
will be a supportive asset for the incident commander, who most likely
will be the municipal or volunteer fire chief. We applaud the National
Guard for its continuing effort to work closely in the IAFC and the
fire service as it enhances its mission for maximum effectiveness at
the local level. However, federal assets--military, law enforcement,
emergency management--must understand that they will necessarily be in
a support role.
We request that the authority enhancing the current role of the
National Guard to support local first responders be clearly defined. We
need a ``wiring diagram'' of how federal assets are requested. What is
the federal 911 number?'' How is it activated? Who determines what
assets will be sent? What are the defined roles for each federal agency
dispatched? Do they understand that they will report to the local
incident commander for assignment? The answers to these questions must
be understood and agreed upon by all parties. There can be no
hesitation or confusion about any of this after an incident occurs.
Department of Justice
The IAFC has a close relationship with the Bureau of Justice
Assistance (BJA) and the FBI. Nancy Gist, Butch Straub, and Andy
Mitchell of BJA have done an excellent job working with the fire
service to produce excellent training materials. First was an awareness
training package which has already trained 8,000 firefighters. 68,000
are expected to be trained by June 1999. Additionally, more than 80,000
videotapes warning first responders about the dangers of secondary
bombs have been distributed to fire, police, and EMS organizations, The
BJA program has been so successful because it was developed in close
cooperation with the National Fire Academy (NFA) to ensure its
acceptance by the fire service. The key role of the National Fire
Academy in preparing fire and emergency service leaders to respond to
terrorism must be recognized and enhanced to increase its capability.
The IAFC has also found the FBI to be most helpful to the fire
service as we prepare for terrorism. Specifically, we have excellent
communication links with Bob Blitzer, Rinaldo Campana, and Barbara
Martinez of the Domestic Terrorism and WMD Sections. We enjoy a high
level of responsiveness and a willingness to work together in
coordination of our efforts, and we plan to enhance this relationship
in the future.
The incident command system
To quote from the report prepared by the DOD Tiger Team dated
January 1998, ``Local response to an emergency situation uses the
Incident Command System (ICS) to ensure that all responders and their
support assets are coordinated for an effective and efficient response.
The Incident commander is normally the senior responder of the
organization with the preponderance of responsibility for the event
(e.g., fire chief, police chief, or emergency medical).'' That is an
excellent explanation. When federal assets arrive, ICS will be in
place. They will be plugged into that system by the Incident Commander.
Therefore, there is an urgent need for all federal agencies which
respond to emergencies to adopt the National Fire Academy's Incident
Command System.
Training and equipment
Both the Antiterrorism and Effective Death Penalty Act and Nunn-
Lugar-Domenici contain provisions for training and equipping first
responders. Congress has identified these as the two key roles for the
federal government in assisting first responders to deal with acts of
terrorism. Indeed, they are the two crucial elements for which the fire
and emergency services look to the federal government for assistance.
Both programs are important, necessary, and beneficial, but both can be
improved. There needs to be better coordination between the Department
of Justice and the Department of Defense and the Federal Emergency
Management Agency (FEMA). Congressional oversight is required.
A national domestic preparedness consortium has been formed to
provide operational training, exercises, tests, and evaluation for
first responders and municipal leaders. This consortium consists of the
National Exercise Test and Training Center--Nevada Test Site, the
National Emergency Response and Rescue Training Center--Texas A&M
University, the National Center for Domestic Preparedness--Ft.
McCellan, AL, National Center for Bio-Med Research and Training--
Louisiana State University, and the National Energetic Materials
Research and Testing Center--New Mexico Institute of Mining and
Technology. These training and exercise areas and supporting
organizations are important in preparing first responders to deal with
acts of terrorism. The IAFC endorses the consortium and recommends
continuing support from Congress as a matter of policy.
Training must be expanded beyond the 120 most populous
jurisdictions targeted by DOJ and DOD. Strategic and critical American
infrastructure--such as water, electric power, and telecommunications
sites--are often located outside major metropolitan areas. These areas
are protected by combination career and volunteer departments and by
all-volunteer departments. Congressional mandate must direct that
federal training reach the fire and emergency services nationwide. The
resident and non-resident programs of the National Fire Administration
offer an excellent existing delivery system that can and should be
utilized to the maximum extent possible.
On the equipment issue, there is a clear and demonstrated need for
sophisticated detection equipment. Firefighters need to know what they
are facing--what chemical or biological agent. First, this information
is necessary to protect ourselves and, second, to determine the correct
strategy and tactics to deal with the incident. When such equipment is
made available to first responders, provision must be made for training
on its use, maintenance, spare parts, and future upgrades. This cannot
be a one-shot deal but rather a continuing partnership between the
federal government local fire and emergency responders.
There is also a need to assist local response agencies acquire
appropriate personal protective equipment. Local fire departments
simply do not have the resources to purchase all the protective
equipment necessary to deal with a large-scale chemical or biological
attack. Federal assistance is vital.
Another essential equipment need is the ability to engage in a
large-scale decontamination effort. Some federal organizations, such as
the Marine Corps' Chemical Biological Response Force, have some
decontamination capabilities. However, they can only be effective when
pre-positioned in anticipation of a specific event. The effectiveness
of the capabilities are greatly diminished when geography dictates a
response time of six to eight hours. Therefore, local first responders
and public health providers must have policies, procedures, and
facilities in place to deal with any nuclear, biological, or chemical
agent that may be used.
Hospital capability
In a terrorist incident, the fire and emergency services will be
responsible for triage, emergency medical treatment, and transportation
of the sick and wounded. A large-scale WMD incident will sorely test
even the largest community's ability to deal with mass casualties.
Congress needs to closely examine the ability of hospitals to deal with
large numbers of victims. Drug and antidote caches, decontamination
facilities, and hospital pre-plans must be a focus of congressional
inquiry and policy. Veterans Administration Hospitals should be
considered for an important role.
Wireless radio communications
In 1996, the Public Safety Wireless Advisory Committee submitted
its report to the Federal Communications Commission. One of its key
recommendations was that the FCC set aside 2.5 MHZ of spectrum for
interoperability. We need Congress to push for the policy to direct the
FCC to establish several frequency ranges for interoperability
purposes. In the World Trade Center and Oklahoma City incidents, the
inability of the first responder agencies to communicate with each
other and then with other levels of government severely hampered
effective operations. This problem must be corrected.
CONCLUSION
In conclusion, I would like to leave you with several
recommendations.
--The fire and emergency services need assistance from the federal
government in the areas of training, detection equipment,
personal protective equipment, and mass decontamination
capabilities.
--Congress must recognize and direct federal agencies to organize
their various missions and objectives with the clear
understanding that, once a terrorist event occurs, the local
first responders will be on the scene and operating in six
minutes while federal assets will not arrive for six hours. The
federal government must understand completely its supplemental,
supportive role to the local incident commander.
--Fire and emergency services must be involved in the conception,
design, and review of all federal plans relating to response to
terrorist incidents. We currently work with the Bureau of
Justice Assistance, Federal Bureau of Investigation, and the
National Guard. These relationships should continue and should
be a matter of congressional policy. We also strongly encourage
FEMA support for the National Fire Academy's involvement with
DOJ and DOD on fire service training issues.
Thank you for the opportunity to appear before you today. I will be
pleased to respond to any questions you may have.
STATEMENT OF ROBERT KNOUSS, M.D., DIRECTOR, OFFICE OF
EMERGENCY PREPAREDNESS, U.S. DEPARTMENT OF
HEALTH AND HUMAN SERVICES
Senator Faircloth. Our second witness will be Dr. Robert
Knouss.
Dr. Knouss, is the Director of the Office of Emergency
Preparedness in the Department of Health and Human Services.
Dr. Knouss is a graduate of the University of Pennsylvania
School of Medicine and has served in the Public Health Service
in positions at the National Institute of Health and the Office
of Refugee Health.
Dr. Knouss served as a Deputy Director of the Pan-American
Health Organization for 10 years before returning to the
Department of Health and Human Services.
Dr. Knouss also served as staff for the Senate Labor and
Human Resources Committee.
Thank you, Dr. Knouss, and welcome.
Dr. Knouss. Thank you very much, Senator.
As you mentioned, my name is Dr. Robert Knouss. I am
Director of the Office of Emergency Preparedness, and I am
pleased to have this opportunity to comment and testify before
you today.
The Office of Emergency Preparedness is responsible for
coordinating HHS' continuity of Government, continuity of
operations, and the provision of public health and medical
services following emergencies and disasters that sufficiently
degrade local capacity as to require national assistance. In
this role we also work with other Federal agencies and the
private sector to develop capabilities and capacities for
responding to the health and medical needs of affected
populations.
HHS is actively participating in the Department of Justice
led effort to develop a 5-year interagency counterterrorism and
technology plan, and that is a mouthful. This effort will
address specific strategies and requirements for all agencies
involved in the counterterrorism effort.
I am also the Director of the National Disaster Medical
System, which is a partnership between the Department of
Defense, the Department of Veterans Affairs, Federal Emergency
Management Agency, and our own Department, as well as the
private sector. This system can provide medical response to an
affected area, evacuate patients, and provide definitive care
if local and State resources are overtaxed. Under the Federal
response plan, the National Disaster Medical System [NDMS],
assets are incorporated into Emergency Support Function No. 8,
Health and Medical Services, and have been deployed to a wide
variety of emergencies, such as natural disasters, plane
crashes, and terrorist incidents.
The Sarin gas attack on the Tokyo subway system and the
Oklahoma City bombing of the Alfred P. Murrah Federal Building
left the world shocked by these senseless and horrific acts of
terrorism. One of our greatest challenges is addressing the
complex preparedness issues posed by a terrorist use of a
weapon of mass destruction on civilian populations. The human
health impact of such a release or detonation is the primary
consequence of such an attack.
HHS is taking a systems approach to building response
capability and capacity at the local, State, and Federal
levels. Our counterterrorism strategy includes the following
key elements: Enhancing local resources because disaster
response in this country begins at the local level, as the
chief has just indicated; developing partnerships to improve
local and State health and medical system coordination and
capability to respond effectively; and improving Federal health
and medical capability to rapidly augment State and local
responses. Our resources include those of the National Disaster
Medical System.
As part of this system, we have developed specialized
national medical response teams located in Washington, DC,
Winston-Salem, Denver, and Los Angeles that can augment local
resources in the event of a WMD threat or event. Instances
where these teams have been used include in response to the
bombing in Centennial Olympic Park, prepositioned to respond if
needed during the Summit of the Eight last year in Denver,
during the inauguration in 1997 here in Washington, DC, and in
the Capitol here in this area during the State of the Union
Address this year. It was also one of these teams, the one in
Winston-Salem, that responded under State auspices to the event
that occurred earlier this year in Charlotte, NC.
In creating these resources, we have not been alone. Some
of the key HHS agencies with which we have been working very
closely to address counterterrorism include the Centers for
Disease Control and Prevention, the Agency for Toxic Substances
and Disease Registry, FDA, and the NIH. External to HHS, we
have been working with other Federal departments and agencies,
the National Academy of Sciences, and local and State
governments, as well as with nationally recognized individual
experts.
We have also supported 27 major metropolitan areas for the
development of local metropolitan medical strike team systems.
These enhancements to existing local response systems are
designed to provide initial onsite response and provide for
safe patient transportation to hospital emergency rooms for
treatment in the event of a WMD terrorist attack. These systems
are characterized by specially trained responders for on-site
triage and initial medical treatment, specialized
pharmaceuticals and decontamination equipment, enhanced
emergency medical transportation, definitive hospital care, and
the provision of assistance from the National Disaster Medical
System, if needed. Our plans are to continue developing local
MMST systems in conjunction with the Domestic Preparedness
Program's 120-city initiative. Further system development is
necessary to assure adequate surveillance, laboratory support,
and pharmaceutical distribution systems in the event of a
biological weapon release.
The program of enhanced preparedness that the President
called for in his Naval Academy commencement speech on May 22
and his recent signing of Presidential Decision Directive No.
62 will strengthen our Nation's defenses against the growing
threat of unconventional attacks against the people of the
United States. This directive designates HHS as the lead
Federal agency in support of FEMA to plan and prepare a
national response to medical emergencies arising from the
terrorist use of weapons of mass destruction. We will be
supported by other Federal agencies in this effort, and
together we plan to continue to provide enhanced local response
through the strengthening of local systems and the provision of
Federal supporting teams, if necessary, for the prevention,
detection, identification, and public health response to the
release of a weapon of mass destruction.
Of significant concern is how best to protect our civilian
population from biological weapons. In response to the
President's directive, our Department is exploring a range of
approaches for upgrading our public health systems for
detection and warning and for providing medical care for
massive numbers of affected people. We are examining a broad
spectrum of needs that includes research and development,
pharmaceutical stockpiles, public health surveillance, and
response capabilities.
PREPARED STATEMENT
Secretary Shalala has recently requested that the Assistant
Secretary for Planning and Evaluation convene a working group
to develop an HHS strategic plan for strengthening and
expanding our role in the Governmentwide bioterrorism effort.
Implementation of the plan and oversight of the resulting
activities will be the responsibility of the Assistant
Secretary for Health and the Surgeon General.
I want to thank you very much, Senator, for this
opportunity to appear before you today on this very important
issue, and I would be glad to eventually answer any questions
you may have.
Senator Faircloth. Thank you, Dr. Knouss.
[The statement follows:]
Prepared Statement of Robert Knouss
Good afternoon. I am Dr. Robert Knouss, Director of the
Office of Emergency Preparedness in the Department of Health
and Human Services (HHS). I am pleased to have the opportunity
to appear before the Senate Appropriations Subcommittee on
Labor, Health and Human Services and Education on the very
important topic of the Nation's Public Health Infrastructure
Regarding Epidemics and Bioterrorism.
The Office of Emergency Preparedness is responsible for
coordinating HHS' continuity of government, continuity of
operations, and the provision of public health and medical
services following emergencies and disasters that sufficiently
degrade local capacity as to require national assistance. In
this role we also work with other federal agencies and the
private sector to develop capabilities and capacities for
responding to the health and medical needs of affected
populations.
HHS is actively participating in the Department of Justice
led effort to develop a Five-Year Inter-Agency Counter-
terrorism and Technology Plan. This effort will address
specific strategies and requirements for all agencies involved
in the counter-terrorism effort.
I am also the Director of the National Disaster Medical
System (NDMS) which is a partnership between the Department of
Defense, the Department of Veterans Affairs, the Federal
Emergency Management Agency, HHS and the private sector. This
system can provide medical response to an affected area,
evacuate patients, and provide definitive care if local and
state resources are overtaxed. Under the Federal Response Plan,
NDMS assets are incorporated into Emergency Support Function
No. 8, Health and Medical Services, and have been deployed to a
wide variety of emergencies such as natural disasters, plane
crashes, and terrorist incidents.
The Sarin gas attack on the Tokyo subway system and the
Oklahoma City bombing of the Alfred P. Murrah Federal Building
left the world shocked by these senseless and horrific acts of
terrorism. One of our greatest challenges is addressing the
complex preparedness issues posed by a terrorist use of a WMD
on civilian populations. The human health impact of such a
release or detonation is the primary consequence of such an
attack.
HHS is taking a ``systems'' approach to building response
capability and capacity at the local, state and federal levels.
Our counter-terrorism strategy includes the following key
elements: Enhancing local resources because disaster response
in this country begins at the local level; developing
partnerships to improve local and state health and medical
system coordination and capability to respond effectively; and
improving federal health and medical capability to rapidly
augment state and local responses. Our resources include those
of the National Disaster Medical System.
As part of this system, we have developed specialized
national medical response teams (located in Washington, D.C.,
Winston-Salem, Denver, and Los Angeles) that can augment local
resources in the event of a WMD threat or event. Instances
where these teams have been used include: (1) in response to
the bombing in Centennial Olympic Park; (2) pre-positioned to
respond if needed during the Summit of the Eight last year in
Denver; (3) during the Inauguration in 1997; and (4) in the
Capitol during the State of the Union Address this year. It was
also one of these teams, the one in Winston-Salem, that
responded under State auspices, to the event that occurred
earlier this year in Charlotte, North Carolina.
In creating these resources, we have not been alone. Some
of the key HHS agencies with which we have been working very
closely to address counter-terrorism issues include the Centers
for Disease Control and Prevention, the Agency for Toxic
Substances and Disease Registry, the Food and Drug
Administration, and the National Institutes of Health. External
to HHS we have been working with other federal departments and
agencies, the National Academy of Science's Institute of
Medicine, and local and state governments, as well as with
nationally recognized individual experts.
We have also supported 27 major metropolitan areas for the
development of local Metropolitan Medical Strike Team Systems.
These enhancements to existing local response systems are
designed to provide initial on-site response and provide for
safe patient transportation to hospital emergency rooms for
treatment in the event of a WMD terrorist attack. These MMST
Systems are characterized by specially trained responders for
on-site triage and initial medical treatment; specialized
pharmaceuticals and decontamination equipment; enhanced
emergency medical transportation; definitive hospital care; and
the provision of assistance from the National Disaster Medical
System, if needed. Our plans are to continue developing local
MMST Systems in conjunction with the Domestic Preparedness
Program's 120-city initiative. Further system development is
necessary to assure adequate surveillance, laboratory support
and pharmaceutical distribution systems in the event of a
biological weapon release.
The program of enhanced preparedness that the President
called for in his Naval Academy commencement speech on May
22nd, and his recent signing of Presidential Decision Directive
62, will strengthen our nation's defenses against the growing
threat of unconventional attacks against the people of the
United States. This directive designates HHS as the lead
Federal agency, in support of FEMA, to plan and prepare a
national response to medical emergencies arising from the
terrorist use of weapons of mass destruction. We will be
supported by other Federal agencies in this effort. Together we
plan to continue to provide enhanced local response through the
strengthening of local systems and the provision of Federal
supporting teams, if necessary--for the prevention, detection,
identification and public health response to the release of a
weapon of mass destruction.
Of significant concern is how best to protect our civilian
population from biological weapons. In response to the
President's directive, HHS is exploring a range of approaches
for upgrading our public health systems for detection and
warning and for providing medical care for massive numbers of
affected people. We are examining a broad spectrum of needs
that includes research and development, pharmaceutical
stockpiles, public health surveillance, and response
capabilities.
Secretary Shalala recently requested that the Assistant
Secretary for Planning and Evaluation convene a working group
to develop a HHS strategic plan for strengthening and expanding
our role in the Government-wide bioterrorism effort.
Implementation of the plan and oversight of the resulting
activities will be the responsibility of the Assistant
Secretary for Health and Surgeon General.
Thank you for this opportunity to discuss our counter-
terrorism initiatives with you. I would be glad to answer any
questions.
STATEMENT OF JAMES M. HUGHES, M.D., DIRECTOR, NATIONAL
CENTER FOR INFECTIOUS DISEASES, CENTERS FOR
DISEASE CONTROL AND PREVENTION, U.S.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Senator Faircloth. Our third witness will be Dr. James
Hughes. Dr. Hughes is Assistant Surgeon General and Director of
the National Center for Infectious Diseases at the Centers for
Disease Control. Dr. Hughes is a physician and a graduate of
Stanford University. He completed a fellowship in infectious
diseases at the University of Virginia and is one of the
world's foremost experts on infectious diseases. Dr. Hughes, we
thank you for coming and welcome you here. You may begin your
testimony.
Dr. Hughes. Good afternoon. Thank you for that kind
introduction, Senator.
I am Dr. James Hughes, Director for the National Center for
Infectious Diseases at the Centers for Disease Control and
Prevention. Thank you for the opportunity to be here with Dr.
Richard Jackson, who is Director of CDC's National Center for
Environmental Health, to discuss the response to disease
outbreaks caused by biological and chemical terrorism. I will
focus on terrorist events involving biological agents, and Dr.
Jackson will address chemical events.
The bombings of the World Trade Center in New York and the
Federal Building in Oklahoma City taught us how vulnerable we
are to terrorist attacks. A biological or chemical attack used
to be considered unlikely but now seems entirely possible,
given the availability of information on how to prepare such
weapons and activities by groups such as Aum Shinrykyo which
released nerve gas in Tokyo's subway and experimented with
biological weapons.
An attack involving a biological agent may not be
immediately detectable because of the delay between exposure
and onset of illness which for infectious diseases can range
from several hours to several weeks. For example, if the
organism that causes anthrax were released in an airport, some
victims might be in other cities or even other countries before
they experience symptoms. An attack involving an organism such
as those causing plague or smallpox that is spread from person
to person could lead to a second and third wave of illness and
involve health care workers and emergency responders.
In his recent address at the U.S. Naval Academy, President
Clinton announced his intention to upgrade our public health
systems for disease detection and early warning. Many Federal
agencies are collaborating to formulate policies and strategic
plans to ensure prompt and effective responses to terrorist
attacks, and CDC is working with Dr. Knouss in the Office of
Emergency Preparedness and other Government entities, including
FDA, DOD, FEMA, and the FBI.
Protection against terrorism requires a strong public
health system at the local, State, and national level. CDC's
plan, Addressing Emerging Infections Disease Threats: A
Prevention Strategy for the United States, launched an effort
to rebuild the public health system's capacity to detect and
respond to infectious diseases. Through fiscal year 1998, $59
million have been appropriated to implement the plan
incrementally.
CDC will issue an updated version of this plan later this
year which, like the 1994 plan, will emphasize that we must be
prepared for the unexpected, whether it be an influenza
pandemic, naturally occurring outbreaks of food-borne disease
or drug-resistant infections or the deliberate release of
anthrax by a terrorist.
The cause of an outbreak is not always clear at first. For
example, in 1993 a physician with the Indian Health Service in
the Southwest reported that two previously healthy young people
had died from acute respiratory failure, and additional cases
were subsequently identified by other physicians. Investigation
revealed that the outbreak was not caused intentionally, but
rather by a previously unrecognized hantavirus spread by
rodents.
Senator Faircloth. Spread by what, Doctor?
Dr. Hughes. Rodents, deer mice actually. Critters, we say.
[Laughter.]
However, the techniques required to diagnose this outbreak
were similar to those that would be needed to respond to a
bioterrorist attack.
Four components of the response to disease outbreaks are
important to preparedness to address acts of terrorism in a
coordinated fashion, starting with detection of unusual events.
After a bioterrorist attack, initial disease detection is
likely to take place at the local level, so it is essential to
work with the medical community including emergency medical
departments, poison control centers, and emergency responders.
A recent Institute of Medicine report recommended expanding
CDC's emerging infections initiative to improve State and local
infrastructure.
The second component is investigation and response which
are also likely to take place at the local level initially, as
we have heard.
Third, rapid diagnosis will be critical so prevention and
treatment measures can be implemented quickly. Because the
agents most likely to be used as bioweapons are not currently
major public health problems in the United States, we have
limited biocontainment laboratory space and surge capacity to
work with them. In addition, future events could involve
organisms that have been genetically engineered to increase
their virulence, manifest antibiotic resistance, or evade
natural or vaccine-induced immunity.
Finally, communications are crucial as delays will increase
the probability that more people will be exposed.
PREPARED STATEMENT
In conclusion, a strong and flexible public health
infrastructure is the best defense against any disease
outbreak, whether naturally occurring or intentionally caused.
CDC's ongoing efforts to strengthen disease surveillance and
response at the local, State, and Federal levels can complement
efforts to detect and contain diseases caused by bioweapons.
Thank you very much for your attention. I will be happy to
answer any questions.
Senator Faircloth. Thank you, Dr. Hughes.
[The statement follows:]
Prepared Statement of Dr. James M. Hughes
I am Dr. James M. Hughes, Director, National Center for
Infectious Diseases, Centers for Disease Control and Prevention
(CDC). With me today is Dr. Richard Jackson, Director of CDC's
National Center for Environmental Health. We are here to
discuss a very important topic: the public health response to
disease outbreaks caused by biological and chemical terrorism.
Our testimony summarizes the present system of public health
surveillance and control at the state, local, and Federal
levels. I will focus primarily on terrorist events that involve
biological agents, and Dr. Jackson will address events that
involve chemical agents.
U.S. VULNERABILITY TO TERRORISM
The bombings of the World Trade Center in New York and the
Federal building in Oklahoma City taught us how vulnerable we
are to terrorist attacks within our own borders, even in times
of peace. We know that in addition to bombs, today's terrorists
can choose among many highly dangerous agents, including
biological and chemical agents.
An attack with a biological or chemical weapon used to be
considered very unlikely, but now seems entirely possible. Many
experts believe that it is no longer a matter of ``if'' but of
``when'' such an attack will occur. They point to the
accessibility of information on how to prepare biologic and
chemical weapons (on the Internet and elsewhere) and to
activities by groups such as Aum Shinrykyo, which, in addition
to releasing nerve gas in Tokyo's subway, experimented with
botulism and anthrax. Moreover, the Federal Bureau of
Investigation (FBI) recently investigated a situation in Las
Vegas where an individual was in possession of the organism
causing anthrax. Although the individual had an attenuated
strain of anthrax used in an animal vaccine rather than a
virulent strain, the incident provided another reminder of how
easily a terrorist might cause serious illness and panic in a
U.S. city.
The release of a biological agent or chemical toxin may not
have an immediate impact because of the delay between exposure
and onset of illness, or incubation period. For example, when
people are exposed to a pathogen like anthrax or smallpox, they
will not know that they have been exposed, and they may not
feel sick for some time. The incubation period may range from
several hours to a few weeks, depending on the microbe and the
dosage. If a group of people in an airport were exposed to the
organism that causes anthrax in an aerosolized form, some of
them might be far away--perhaps even overseas--by the time they
experienced the first symptoms.
Moreover, if an attack involved an organism like those
causing plague or smallpox that is spread from person to
person, there could be a second or third wave of illness, and
health care workers treating patients would be at risk of
infection. Each wave of illness could be larger than the one
before, as more and more people were exposed. In the best-case
scenario, an observant health worker would recognize that
something out of the ordinary has occurred and alert public
health authorities. In the worst-case scenario, the first wave
of cases may not appear to be connected--or may be mistaken for
other diseases--and the outbreak would continue for some time
before the diagnosis is made and action is taken to contain it.
We may have only a short window of opportunity--between the
time the first cases are identified and a second wave of people
become ill--to determine that an attack has occurred, to
identify the organism, and to prevent further spread.
Most people agree that investing in defense is imperative,
even at a time when the average American is not threatened by
war, but defense is not solely through military means. As the
anthrax example illustrates, the initial response to a
bioterrorist act is likely to be made by the public health
community rather than by the military. Protection against
terrorism requires a strong public health system at the local,
state, and national levels.
PLANNING AND PREPAREDNESS
Many Federal agencies are working together to formulate
policies and strategic plans to ensure prompt and effective
responses to terrorist attacks that employ biological or
chemical agents. In his commencement address at the U.S. Naval
Academy on May 22, 1998, President Clinton announced his
intention to upgrade our public health systems for disease
detection and early warning, both to improve our preparedness
against terrorism and to help us cope with naturally occurring
infectious disease outbreaks. CDC and other agencies are
assessing what is necessary to implement such an upgrade.
CDC also is participating in a working group on domestic
and international surveillance for bioterrorism, conducted
under the auspices of the Emerging Infections Task Force of the
Committee on International Science, Engineering, and Technology
(CISET), National Science and Technology Council. The Task
Force is based in the White House Office of Science and
Technology Policy (OSTP). In addition, CDC works on
bioterrorism issues with the Office of Emergency Preparedness
(OEP), OSTP, and the National Security Council.
Interagency planning will be especially important to ensure
the availability of medical supplies needed to respond to
terrorist acts. In addition, CDC, the National Institutes of
Health (NIH), DOD, and other agencies need to collaborate on a
research agenda to address scientific issues related to
bioterrorism.
CDC'S ROLE
To respond effectively to the threats of bioterrorism and
epidemics, CDC and State and local health departments must act
together as they do in other areas of public health. CDC and
State and local health departments are the Nation's three-part
shield of defense against public health threats of all kinds.
Public health response to terrorism requires recognition of the
unique, yet interdependent, roles that local, State, and
Federal agencies play.
As the Nation's prevention agency, CDC's mission is to
monitor the health of the U.S. population and investigate and
contain disease outbreaks, including those that are due to
deliberate acts of terrorism. In 1994, CDC issued a strategic
plan, Addressing Emerging Infectious Disease Threats: a
Prevention Strategy for the United States, which launched a
major effort to rebuild the component of the U.S. public health
system that protects U.S. citizens against infectious diseases.
The plan focuses on four goals, each of which has direct
relevance to preparedness for bioterrorism: disease
surveillance and outbreak response; applied research to develop
diagnostic tests, drugs, vaccines, and surveillance tools;
disease prevention and control; and infrastructure and
training. Through fiscal year 1998, $59 million has been
appropriated to implement the plan incrementally, with the help
of many partners, beginning with the most critical areas and
programs, and the President's fiscal year 1999 budget includes
an additional $20 million to continue this effort.
CDC intends to issue an updated version of the plan later
this year. Like the 1994 plan, the new plan emphasizes that we
must always be prepared for the unexpected--whether it be a
naturally occurring influenza pandemic, multiply antibiotic
resistant infections, or the deliberate release of anthrax by a
terrorist.
INVESTIGATING DISEASES OF UNKNOWN CAUSE
CDC is often asked to assist State public health
authorities or foreign health ministries when the cause of an
outbreak is unknown. Early in an investigation, it may not be
possible to know whether an outbreak is caused by an infectious
agent or a chemical toxin. For example, a recent outbreak of
acute kidney failure in children in Haiti was thought to be
infectious, but investigation revealed that the illnesses were
caused by chemical contamination of a medication used in
children.
In recent years, it has become more common for outbreak
investigators to consider the possibility of a terrorist event
when they investigate the cause of an outbreak. This
possibility arose during the investigations of the 1993
outbreak of hantavirus pulmonary syndrome in the United States,
the 1994 outbreak of plague in India, and even the 1995
outbreak of Ebola hemorrhagic fever in the Democratic Republic
of the Congo (then Zaire).
Whether an outbreak has a natural or man-made cause is not
always clear in the first stages of an epidemiologic
investigation. This point is well illustrated by what happened
during the first days of the hantavirus outbreak in 1993. In
May of that year, a physician at the Indian Health Service
(IHS) in a southwestern State reported that two previously
healthy young people had died from acute respiratory failure.
Over the next few days, additional cases were identified by the
State medical examiner's office and by other IHS physicians.
The epidemiologists ruled out leakage of an air-borne toxic
chemical from a nearby munitions depot. Microbiologists
conducted laboratory tests for pneumonic plague, inhalational
anthrax, and pulmonary tularemia, and were able to rule out
these diseases. These three infections, though rare, occur
sporadically in the southwestern United States, where they are
endemic in the local animal populations. All three could have
been biological weapons. Throughout the investigation, there
were rumors that a biological agent had been released as an act
of genocide against the Navajo people who lived in the affected
area.
As public health investigators proved, the outbreak was not
caused by a chemical or biological weapon, but by a newly
identified, highly lethal virus spread by rodents. Fortunately,
CDC's application of sophisticated molecular biologic
techniques led to the rapid identification of a previously
unrecognized hantavirus as the cause of this illness five
months before the virus was finally cultured using conventional
techniques. The investigative skills, diagnostic techniques,
and physical resources required to detect and diagnose this
outbreak were similar to those that would be needed to identify
and respond to a bioterrorist attack.
Our experience with the hantavirus outbreak shows that a
strong public health system for disease surveillance, outbreak
investigation, and laboratory diagnosis is essential to protect
the nation. With each outbreak investigation, public health
personnel become better trained and more experienced in
addressing cases of unexplained illness.
PUBLIC HEALTH RESPONSE TO TERRORISM
Four components of the public health response to disease
outbreaks are important to U.S. preparedness to address acts of
terrorism in a coordinated fashion: detection of usual events,
investigation and containment of potential threats, laboratory
capacity, and coordination and communication.
Detection of unusual events.--The public health effort to
combat infectious diseases in the United States is based on the
early detection of unexpected cases or clusters of illnesses,
so that small outbreaks can be stopped before they become big
ones. In its recent interim report, ``Improving Civilian
Medical Response to Chemical or Biological Terrorist
Incidents,'' the Institute of Medicine (IOM) cites public
health departments' existing mission to promptly identify and
control infectious disease outbreaks. The IOM report recommends
expansion of CDC's emerging infections initiative as a means of
improving State and local surveillance infrastructure.
In the case of a bioterrorist attack, the initial detection
of a disease is likely to take place at the local level. It is
essential to work with members of the medical community who may
be the first to recognize unusual diseases, and with State and
local health departments, who are most likely to mount the
initial response--especially if the intentional nature of the
outbreak is not immediately apparent. Strong communication
links between clinicians, emergency responders, and public
health personnel are important.
As mentioned, an astute physician--on the basis of only two
unusual cases--alerted health authorities to what turned out to
be an outbreak of hantavirus pulmonary syndrome. In contrast,
during the 1995 Ebola outbreak in Zaire, there was no
surveillance system in place, and the outbreak was not detected
until at least two waves of infection had passed and many
people, including a large number of health care workers, had
died. Thus, early detection and response is critical.
As part of the implementation of CDC's plan for emerging
infections, CDC has established the Epidemiologic and
Laboratory Capacity (ELC) program to help State and large local
health departments develop the skills and resources to address
whatever unforeseen infectious disease challenges may arise in
the twenty-first century. One of the specific aims of the ELC
program is the development of innovative systems for early
detection and investigation of outbreaks. By July, thirty State
and large local health departments will receive support from
the ELC program. CDC has also entered into agreements with
seven State health departments, in collaboration with local
academic, government, and private sector organizations, to
establish Emerging Infections Program (EIP) sites that conduct
active, population-based surveillance for selected diseases, as
well as for unexplained deaths and severe illnesses in
previously healthy people.
CDC has also helped establish sentinel surveillance systems
that involve local networks of clinicians and other health care
providers. One such network includes emergency departments at
eleven hospitals in large U.S. cities. Another includes
fourteen travel medicine clinics in the United States, plus
seven overseas. A third network includes over 500 infectious
disease specialists throughout the country. CDC is using these
and other provider-based networks to alert and inform the
medical community so that health workers can help recognize and
assess unusual infectious disease threats.
Investigation and response.--As is the case for any
naturally-occurring infectious disease outbreak, the initial
response to an outbreak caused by an act of bioterrorism is
likely to take place at the local level. In the most likely
scenario, CDC--as well as DOD and security agencies--will be
alerted only after a State or local health department has
recognized a cluster of cases that is highly unusual or of
unknown cause. CDC is working with State and large local health
departments through the ELC program and other efforts to
provide tools, training, and financial resources for local
outbreak investigations.
CDC's Epidemic Intelligence Service (EIS) trains personnel
to respond to outbreaks and other disaster situations to aid
state and local officials in the identification of potential
causes and implement appropriate solutions. It is interesting
to remember that the EIS was established during the Cold War in
response to the threat of biological warfare. In addition, CDC
trains Public Health Prevention Service (PHPS) specialists who
can provide on-site programmatic support to extend the manpower
of state and local public health staff.
Once the cause of a terrorist-sponsored outbreak has been
determined, specific drugs, vaccines, and antitoxins may be
needed to treat the victims and to prevent further spread.
However, depending upon the pathogen that causes the outbreak,
appropriate medical supplies may not be readily available since
these organisms are uncommon causes of disease in the United
States. This is an important issue that is being addressed
collaboratively by a number of Federal agencies, including CDC,
OEP, FDA, and other parts of the Department of Health and Human
Services; DOD; FEMA and the Department of Veterans Affairs.
In his May 22 speech, the President also announced that the
United States would create stockpiles of medicines and vaccines
to protect our civilian population against biological agents
our adversaries are most likely to develop. A number of Federal
agencies are working collaboratively to address this important
issue as well.
Laboratory support.--In the event of a bioterrorist attack,
rapid diagnosis will be critical to the immediate
implementation of prevention and treatment measures. However,
because none of the biological agents considered most likely to
be used as bio-weapons are currently major public health
problems in the United States, we have limited capacity to
diagnose them, either at the State and local or Federal level.
We must also prepare for the possible use of other agents
as bioterrorist threats. This was illustrated by a 1984
foodborne outbreak of salmonellosis in Oregon caused by
followers of Bhagwan Shree Rajneesh and a 1996 foodborne
outbreak of shigellosis in Texas caused by a single
perpetrator. Future events could involve organisms that have
been genetically engineered to increase their virulence,
manifest antibiotic resistance, or evade natural or vaccine-
induced immunity.
In recent years, CDC has helped State health departments
acquire the capacity to detect naturally occurring outbreaks of
foodborne diseases. In 1997, the success of that effort was
underscored when the Colorado State Health Department, using
DNA fingerprinting techniques developed/standardized at CDC,
detected a small cluster of cases of E. coli infection caused
by consumption of a single brand of frozen hamburger patties.
Twenty-five million pounds of ground beef were recalled, and a
potential nationwide outbreak was averted. Providing state
health departments with the capacity to detect outbreaks of
diseases caused by terrorists may avert disasters with even
greater potential to devastate our country.
Coordination and communications.--One of the major
objectives in CDC's emerging infections plan is to improve
CDC's ability to communicate with State and local health
departments, U.S. quarantine stations, health care
professionals, other public health partners, and the public. In
the event of an intentional release of a biological agent,
rapid and secure communications will be especially crucial to
ensure a prompt and coordinated response. Each hour's delay
will increase the probability that another group of people will
be exposed, and the outbreak will spread both in number and in
geographical range.
CDC may also need to communicate with WHO and with the
ministries of health of other nations, especially if persons
exposed in the United States have traveled to another country.
Because of the ease and frequency of modern travel, an outbreak
caused by a bioterrorist could quickly become an international
problem.
CONCLUSION
In conclusion, a strong and flexible public health
infrastructure is the best defense against any disease
outbreak--naturally or intentionally caused. CDC's on-going
initiatives to strengthen disease surveillance and response at
the local, State, and Federal levels can complement efforts to
detect and contain diseases caused by the biological agents
that might be used as weapons.
Thank you very much for your attention. I will be happy to
answer any questions you may have.
STATEMENT OF RICHARD JACKSON, M.D., M.P.H., DIRECTOR,
NATIONAL CENTER FOR ENVIRONMENTAL HEALTH,
CENTERS FOR DISEASE CONTROL AND PREVENTION,
U.S. DEPARTMENT OF HEALTH AND HUMAN
SERVICES
Senator Faircloth. And now we will hear from Dr. Richard
Jackson. Dr. Jackson is the Director of the Centers for Disease
Control's National Center for Environmental Health in Atlanta.
Dr. Jackson received his medical training as a pediatrician
at the University of California at San Francisco and further
studied at the University of California at Berkeley. He
currently serves on the Senior Health and Advisory Committee
within the Department of Defense.
I welcome you, Dr. Jackson, and we will hear your
testimony.
Dr. Jackson. Thank you, Senator.
The Center for Environmental Health is a sister center to
Dr. Hughes' Center for Infectious Disease. We do the non-
infectious issues, such as disasters, including heat waves,
tornadoes. We look at radiation hazards to the population. We
were involved in the investigation following Three Mile Island,
following Chernobyl, following weapons tests, around sites
where nuclear weapons were being produced, looking at health
effects in civilian communities. We monitor birth defects in
the population and we monitor disabilities in the population.
But the primary activity that I would like to talk about
today is monitoring chemical exposures in the population. We
have at the National Center for Environmental Health the
premier laboratory in the world for looking at chemicals in
people. We do not look at chemicals in air, in water, in food,
or in animals. We look at chemicals in people, and that is what
we are good at.
We have worked for 20 years now with the Department of
Defense assisting them in analysis of chemicals, for example,
in veterans and in GI's. We were involved in the evaluation of
the health effects in Bhopal, India 14 years ago where 3,000
people were killed, and one of my staff was in Tokyo following
the Sarin gas episode looking at the health effects where 12
people died there.
My personal experience in this area was most dramatic with
the spill in the Sacramento River where 35 miles of river--the
fish and other animals were killed along the river and an
entire community was sickened downwind from the Dunsmere spill
episode. In such episodes, you do not know, initially when they
start, whether you are dealing with a chemical or an infectious
agent, and you do not know whether this is a random, accidental
event or if it is a deliberate misdeed. There is one thing you
always do know. You also know that you are going to have a lot
of very worried people. You are going to have a lot of calls
from the media. You are going to have a lot of calls from
elected officials that want to know what is going on.
We were involved in the episode of the methyl parathion
spraying in seven States around the Nation, including
Mississippi and Illinois. This was an illegal insecticide that
was being sprayed in homes. At least 14,000 people were exposed
to these chemicals because of this illegal use. A large number
of people were made ill. It is reported that perhaps two people
died from this episode. The question was whether a home was
safe to go into, and just measuring a little bit of chemical
off in one corner of the house was not going to tell you
whether a child was safe in that house or not. What we needed
was a special method to actually look at chemicals in people.
In some cases we would decide the people had to get out of that
house right away, be put in a motel for weeks at a time. That
house needed to be sometimes ripped out completely and
completely rebuilt. Other homes, no treatment was needed
whatsoever. It was the monitoring of the people, measuring the
chemical in the people in that home, that helped us decide what
the follow-up should be for each of those homes for each of
those 14,000 people.
The ability to analyze this chemical in the people, the
methyl parathion, in the people saved 50 million dollars' worth
of rehab and remediation work.
In the area of chemical terrorism, most people think that
someone will drop like a stone when they are exposed to one of
these chemicals. Cyanide, for example, people die almost
immediately. But, in fact, for many of the chemicals that we
would be worried about, there would be many people with much
lower doses of exposure. There were 5,000 people that were
concerned and injured in the Sarin episode in Tokyo who did not
die. And there is every reason to believe--and a person
testified, a doctor testified, before you about a month ago
that said in Iraq people were exposed to complex mixtures of
chemicals, not simply one chemical.
So, the important issue for the laboratory is knowing who
was exposed and how much were they exposed to. This is the
information that the public and the doctors want: Who was
exposed and how much did they get. The site managers need this
information and the people that have to look at this weeks
later are going to need this information about the exposures.
The good news is the CDC lab can tell you about these
individual chemicals. The bad news is we need a couple of tubes
of blood oftentimes for each of these chemicals. It takes days
and sometimes weeks, and each one of these is a special and
expensive test.
There is a need for our ability to have a rapid toxic
screen to look at a large number of chemicals relatively
rapidly, to be able to turn that round, to give that
information back to site managers, to give it back to the
doctors who are caring for these people, and to develop the
capacity within State and local health departments to do this
analysis themselves.
PREPARED STATEMENT
We at the Center for Environmental Health are looking
forward to working with our partners at this table and the rest
of the people who will be testifying before you today on the
importance of the laboratory in figuring out who was exposed
and how much they were exposed to.
Thank you.
Senator Faircloth. Thank you, Dr. Jackson.
[The statement follows:]
Prepared Statement of Dr. Richard Jackson
I am Dr. Richard J. Jackson, Director of the National Center for
Environmental Health of the Centers for Disease Control and Prevention
(CDC). I appreciate the opportunity to summarize CDC's role in
responding to chemical terrorism. As a former State public health
official, I have experienced first hand the panic, fear and chaos
associated with disease outbreaks and disastrous events.
As Dr. Hughes summarized, CDC's mission is to monitor the health of
the U.S. population and investigate and contain disease outbreaks,
including those that are due to deliberate acts of terrorism. As with
biological terrorist threats, CDC's response to chemical terrorism
includes four components: surveillance and outbreak response;
laboratory capacity to measure toxicants in the blood, serum or urine
of people; disease prevention and control; and infrastructure and
training. Whereas the Environmental Protection Agency has the lead for
the effects of chemical toxicants on the environment, CDC's role
pertains to the effects of chemicals on human health.
CDC responds to chemical emergencies, whenever and wherever they
occur, whether the emergency is caused by an act of terrorism or an
accidental release. Television has given us all the opportunity to see
a glimpse of the serious impact both of these types of emergencies can
have on the population of a city or country. Two such examples in
recent years are the chemical plant explosion in Bhopal, India and the
terrorist attack in the subway in Tokyo, Japan. In December 1984, an
explosion at a chemical plant in Bhopal, India caused an extremely
toxic substance to be released into the air in an area surrounding the
plant--a densely populated part of the city. In this incident, an
estimated 30 to 40 tons of the substance were released into the
atmosphere during a 2- to 3-hour period, resulting in over 3,000 dead
and 60,000 seriously injured of the more than 200,000 people exposed.
In the second example, in March 1995, a terrorist group in Japan
released Sarin gas (a nerve agent) into the air of Tokyo's subway
system. Within 24 hours of the attack over 5,000 people had sought
medical attention. By the end of the crisis almost a thousand people
were identified as experiencing some health effects and 12 people died.
In the end, it was only the inefficiency of the mechanism used to
disperse the chemical agent that prevented casualties from being far
worse.
The reason I have chosen to cite these two examples today is to
point out the variability of the types of chemical emergencies that
have occurred elsewhere and that could occur in the United States.
There are three points I would like to make about the emergency
response responsibilities and capabilities at the various levels of
government: (1) the nation's public health system, health officials at
the local, State, and federal levels, is a critical resource aimed at
protecting the health of U.S. residents whenever a health emergency
occurs; (2) CDC has the expertise and capacity to respond to many types
of chemical emergencies; and (3) the Federal agencies tasked with
responding to chemical emergencies are discussing ways to improve our
response capabilities to better triage exposed populations and
communicate with our partners, the media, and most importantly, the
public.
PUBLIC HEALTH ROLE IN RESPONDING TO CHEMICAL EMERGENCIES
Terrorism is a community problem. Health decisions for the
community in response to a terrorist event require the involvement of
public health professionals from the local, state, and Federal levels.
State and local public health officials will be among the first to
respond to any chemical weapon attack, long before any Federal units
are on the scene. It is these local public health professionals with
whom CDC has had a long term relationship. It is CDC that State and
local officials call upon for help and advice in any kind of public
health emergency. And, it is the State and local public health
professionals who work along side the local police, firefighters, and
emergency medical personnel and who have the greatest impact on the
health and safety of people in affected areas.
We, in public health, also have the responsibility to protect the
community of emergency responders--so that they do not become victims
as well. We have the responsibility to protect the community of exposed
people--to carry out surveillance, to determine who has been exposed to
toxic chemicals and at what level they have been exposed, to ensure
that they receive appropriate care and treatment, and to create
registries during the early stages of the event to allow for
appropriate long term follow up. Lastly, we have the responsibility to
protect the larger community impacted by a terrorist act--to calm the
panicked and worried well with good scientifically based but
understandable information and to help communities recover from the
trauma of a terrorist act or chemical emergency. Experienced public
health doctors, laboratorians, and epidemiologists are essential in
helping communities to respond quickly and to sort out questions of
exposure, treatment, and recovery.
CDC'S EMERGENCY RESPONSE CAPABILITIES
CDC has considerable experience working on all types of chemical
emergencies. When a disaster or emergency occurs, CDC responds to
requests for assistance from state or local agencies by helping to:
--Make a preliminary assessment of the situation either by telephone
or by sending an emergency response coordinator or team to the
site;
--Coordinate our activities with those of the local, state, and other
federal personnel, including assistance to help protect the
health and safety of emergency response teams;
--Provide assistance to help protect the health and safety of
emergency response teams;
--Develop a strategy for dealing with the public health aspects of an
emergency;
--Provide technical assistance in areas such as epidemiology,
toxicology, and laboratory science;
--Perform any necessary laboratory tests, most of which are currently
beyond the capacity of local, state, or university laboratory;
--Determine when protection, treatment, and prevention objectives are
achieved; and
--Set up a program to deal with the recovery process.
Throughout the response process, CDC makes resources
available to use in aiding both the short term response and the
long term recovery of the community involved. We have state of
the art communications equipment that allows us to provide a
link between on-site and off-site responders. CDC has a staff
of health communicators and educators, who are invaluable to
our communications with the media and the affected and worried
public. CDC has the experienced professionals, including
doctors and epidemiologists, needed to triage victims, ensure
medical treatment for those who are ill, and provide follow up
for those who are at risk of disease. And, CDC's laboratory
capacity is unique in the world in that it has the technology
and highly trained professionals necessary to make measurements
of chemical exposures in people.
One common thread in the laboratory component of the public
health response to these tragedies is to determine what
chemical agents were used, who has been exposed to the agents
and to how much. This information is critical for appropriate
medical treatment for those who have been exposed, and to allay
the fears of those who have not been exposed.
CDC'S LABORATORY CAPACITY
CDC's environmental laboratory is unique in that it is the
only laboratory that can accurately measure more than 200
toxicants (chemicals) in people, not simply in the environment.
Such measurement is known as biomonitoring. Let me provide an
example of the value of this information and how CDC's
scientific capacity helped to address a recent chemical
emergency involving the pesticide methyl parathion.
Methyl parathion is illegal for indoor pesticide use
because it acts as a nerve agent. Though not as strong as the
nerve agent used by terrorists to kill people on a Japanese
subway in 1995, it affects people the same way.
Starting in the fall of 1996, seven states--Mississippi,
Louisiana, Texas, Arkansas, Tennessee, Alabama, and Illinois--
became aware that methyl parathion was being used indoors to
control indoor pests. Two children died. Thousands of homes
were affected. In order to take appropriate action, public
health officials had to determine who had been exposed and to
what extent. They also had to respond to a flood of calls from
people who feared that methyl parathion had been sprayed in
their homes.
State and local health officials asked CDC, the Agency for
Toxic Substances and Disease Registry, and the Environmental
Protection Agency to help with this emergency. To quantify
human exposure to this deadly pesticide, CDC's Environmental
Health Laboratory developed a mass spectrometry assay to
measure a metabolite of methyl parathion in urine. Through this
unique test, it was possible to determine the amount of
exposure a person had to this nerve agent. State and other
federal officials used CDC's test to determine who had been
exposed, how much, who was at greatest health risk, and whether
homes needed to be evacuated and remediated. To date, more than
14,000 persons in these seven states have been tested--4,000 of
whom were assured they had no significant exposure. In the
absence of CDC's unique laboratory capacity and diagnostic
test, there would have been be no way to obtain this personal
exposure and health risk information. In addition to the public
health benefit, CDC's test provided precise exposure
information which averted more than $50 million in unnecessary
home remediation costs. The methyl parathion emergency just
described illustrates the importance of precise measurements of
chemicals in people, not simply in the environment. Similar
laboratory and epidemiologic capability and response would be
needed to respond to an act of terrorism.
Having such measurements means that in any chemical
emergency persons truly exposed can be identified, and persons
not exposed could be reassured they were not at risk. Emergency
response and medical personnel can then focus their limited
resources in the most efficient and effective ways possible.
ADDITIONAL STRATEGIES BEING CONSIDERED
In addition to the current capabilities that I have just
described, CDC is working with other Federal agencies to define
improved systems and technologies for responding to these types
of emergencies. Some of the strategies being considered
include:
--The development of the laboratory capacity to more rapidly provide
critical measurements chemical agents in people.
--The provision of additional training for local health professionals
in order to assure that there are an adequate number of highly-
trained professionals at state and local levels who know how to
address and manage these chemical emergencies, including
physicians who know the proper medical treatment for victims.
--The provision of training, laboratory capacity, quality assurance
and quality control, along with the development of technology
that can be transferred to Regional or State laboratories to
aid in the response to chemical emergencies.
--The enhancement of current information and communication systems at
the local, state, and Federal levels.
In closing, I would like to reiterate that public health at
all levels--local, State, and Federal--is the integrating
factor in our response system to all types of health
emergencies. One of the most critical components of the public
health response to a chemical weapon terrorist attack is the
capability of state and local public health agencies. Personnel
working at state and local public health institutions will be
among the first to respond to any act of terrorism. Whether
natural or intentional, health emergencies require an immediate
response, capacity to triage victims, medical treatment for
those who are ill, follow-up for those who are at risk of
disease, and assistance to help communities recover from the
crisis.
Thank you for the opportunity to testify today. I will be
happy to respond to any questions you may have.
POTENTIAL PROBLEMS
Senator Faircloth. I do not have a lot of questions, but I
have a few.
I want to thank the panel for an informative and somewhat
frightening presentation as to what we could be facing and how
little we are aware of the potential problem that exists.
Chief Fincher, the two men that were arrested in Las Vegas
recently, when they boasted to an informant that they had
anthrax--it took 3 days to determine what the substance really
was, which seems to me like a long time. Now, I have never
examined anything to find out whether it was anthrax or not,
but if it really was, 3 days would have given it time to do
most anything it was going to do. How long did it take you in
the Charlotte incident to determine what the material was?
Mr. Fincher. After doing the x rays and the questioning of
the subject who had the instrument with him, it was determined
there were no other agents attached to it other than
explosives. So, it was quickly determined.
But listening to his discussion about having anthrax with
him--that is the word he used--we got with the South Carolina
law enforcement in South Carolina to check his home, and he had
petri dishes in there, connections to the Internet system, and
actually growing some type of fungus or molds inside of an
aquarium. We never did determine what he had at home, but we
know that it was not anthrax. We knew the instrument he had
with him was just an explosive device.
Senator Faircloth. How long did it take to do all this?
Mr. Fincher. I would have to yield to the experts in that
area, sir.
Senator Faircloth. How long did it take you in Charlotte
before you found out?
Mr. Fincher. 16 hours.
Senator Faircloth. 16 hours.
Mr. Fincher. Yes, sir.
Senator Faircloth. I have been told that Charlotte was 1
of the 12 cities that will be trained through the 120-cities
project that the Justice Department is sponsoring. This project
apparently provides training for local responders to help
prepare for a terrorist attack.
Once you have been trained, where does the money come from
for the equipment and manpower to do the job?
Mr. Fincher. That is a question that we all have, sir. We
know that the training is a good first step. It is more of an
awareness level training, and the Department of Defense will
leave approximately 300,000 dollars' worth of equipment in our
community just kind of on permanent loan. But we are going to
need specific training on the instrumentation, the protective
devices to protect our actual first responders who are exposed.
Senator Faircloth. So, there is no plan for funding right
now to train you, but to provide the money for personnel or
equipment beyond what the Department of Defense would leave
with you, there is no planning for funding beyond that?
Mr. Fincher. No, sir; not that I am aware of.
Senator Faircloth. Dr. Knouss, do you consider epidemics
an emergency we need to prepare for?
Dr. Knouss. I take it by that question that you are talking
about naturally occurring epidemics.
Senator Faircloth. That is right, yes.
Dr. Knouss. OK, because we are also very concerned about
trying to plan for an influenza pandemic as well at the same
time and many of our colleagues at the Centers for Disease
Control are also trying to deal with some of the issues that
are common to how to deal with naturally occurring epidemics as
well.
But, sir, we are at the present time, and as the President
announced 1\1/2\ weeks ago at Annapolis, we are going to be
making a concerted effort at the present time to begin to be
able to strengthen our capability, particularly in the public
health infrastructure dealing with some of the research and
development activities and trying to enhance some of our
response capabilities to deal with the potential for an
epidemic that might result from a terrorist attack.
One of the things that I just might point out is that there
are some potential biological weapons that do not present the
threat of an epidemic in terms of secondary and tertiary
spread. What they do present is a very massive initial exposure
to an illness. So, for example, with a disease like anthrax,
the risk is to those people that are initially exposed, but
anthrax is not a disease that will be passed on from person to
person.
On the other hand, a disease like bubonic plague, which we
were very concerned about when we had the scare from the
incident in Ohio and some other threats that have arisen, that
disease is highly infectious and can be passed on from person
to person.
I think that Dr. Hughes might at some point address this
issue of the dual challenges of one where you have an attack
that might expose a large number of people in an initial
incident as opposed to one in which you really run the risk of
secondary and tertiary spread of the disease from person to
person as a result of the initial infection of the population.
But, yes, sir, we are concerned about preparing for the
possibility of epidemics. They are different in nature. Each
one has its own unique characteristics and presents its own
unique challenges. We are now, I would say it is safe to say,
really in our initial planning stages of how to be able to best
prepare the country to be able to deal with that kind of
attack.
Senator Faircloth. You mentioned--I have just enough
knowledge to be aware of my ignorance. On the bubonic plague,
it was a bacterial disease, was it? Does that still exist? Is
there potential to break out somewhere again in the country?
Dr. Knouss. With your permission, Senator, one of the
preeminent infectious disease experts is sitting to my left and
I would really like to be able to defer to him to answer those
kinds of questions.
Senator Faircloth. Dr. Knouss, if you are not in politics,
you should get into politics. [Laughter.]
You understand how to handle a problem. This whole Senate
was designed by Tom Sawyer, you know the story of painting the
fence? Pass it on. [Laughter.]
Dr. Hughes, I was just reading on the bubonic plague. I
think it wiped out one-third of the people in Europe and many
cities. I notice Toulon, Marseilles lost as much as 60 percent
and it took 100 years to rebuild the population to what it was
when it first struck.
Now, my question is, does bubonic plaque still exist today?
Dr. Hughes. That disease most certainly still exists and
the organism exists. In fact, it is present in the United
States, and every year in this country we have between 5 and 15
cases.
Senator Faircloth. Of bubonic plague?
Dr. Hughes. Of bubonic plague, and they occur in Western
States. I might say that over the past 10 years, the geographic
extent over which they have occurred has actually increased.
So, it is an example of a disease that is emerging in new areas
in this country.
Now, globally it is a much bigger problem, and you may
recall the epidemics of plague in India in 1994 that caused
major----
Senator Faircloth. I do not recall. Was bubonic plague in
India in 1994?
Dr. Hughes. Yes; there was an outbreak of bubonic plague.
Well, just briefly to comment on that because it is important
in several ways. There was an outbreak of bubonic plague in a
rural area about 150 miles east of Bombay, and then an outbreak
of bubonic plague, the type of plague that can be transmitted
from person to person, in a city named Surat. It resulted in
total economic collapse in the city of Surat, fleeing of the
population, including many health care workers, and had major
implications for the United States. It provided another
reminder that we live on a global village and there was
legitimate concern about the potential for patients with
bubonic plague coming from India into the United States because
of the volume of travel from India to the United States. So, it
highlights how problems in other parts of the world are
directly germane to us in this global village in which we live.
It also emphasizes very clearly how absolutely critical
surveillance is, epidemiologic response capacity, and
laboratory diagnosis capacity. When that outbreak occurred,
there was one functional WHO collaborating center in the world
that could be called upon to deal with this problem, and that
happened to be at our facility in Fort Collins, CO.
Senator Faircloth. Do we have a global monitoring program?
And the changes in Russia--how would that have affected it? And
how many people does the Centers for Disease Control have to
monitor for plague outbreaks? How many people are looking at
potential plague epidemics around the world?
I read something rather interesting. I am sure it is
redundant for you. It came out of the chicken flu in Hong Kong
that in World War I--I believe they called it spanish flu
then--took literally months to move from Kansas where it
probably began to Verdun in the front lines of Europe. It was
literally months, but today the way the world moves so rapidly,
most any disease could be around the world within literally
hours.
How many people do we have to monitor such a possibility?
Dr. Hughes. Well, I guess all CDC employees, sir. These
diseases can break out anywhere in the world.
Now, we have our hands full----
Senator Faircloth. Now, what now? Six?
Dr. Hughes. The global population.
Senator Faircloth. No, no, no. How many people does the
Centers for Disease Control have to monitor these possible
plague epidemics?
Dr. Hughes. Well, the total number who work at CDC is about
6,500 people. There are about 1,100 in the National Center for
Infectious Diseases.
Now, fortunately, of course, we are not in this alone. We
work globally to support the efforts of the World Health
Organization to strengthen global surveillance around the
world, and the influenza situation is a good example of why
that is so critical.
That episode in Hong Kong involving the avian influenza
strain that had never before infected humans was a very loud
wake-up call about the long overdue state that we are in, in
terms of the next influenza pandemic.
Senator Faircloth. Dr. Jackson, some States would like to
close their State laboratories and have private laboratories
take over. In your judgment would this compromise our
protection or improve it? Is keeping a State agency open
necessarily good or bad? What would be your opinion as to
States closing labs and contracting with private laboratories?
Dr. Jackson. Senator, you cannot do epidemic investigations
without a strong laboratory. Bad data is worse than no data at
all. You are better off not knowing than being given bad
information. You have got to have strong labs working with you.
The State labs perform an extremely important function. A
lot of the tests they do are not terribly cost effective. If
you are only looking at 10 rabies tests a month or you are only
looking at a certain chemical like dioxin or solvents in the
blood or something like that, they tend not to be cost
effective for a commercial laboratory. They tend to be too high
tech for a hospital laboratory, and yet this is a public
service that State and local laboratories need to provide to
the public health protectors in that community.
I think it is very dangerous to back away from the support
for public health laboratories either at a State or a local
level. We are going to have to be smart about it because not
every lab ought to offer every test, but we have got to figure
out the best way to deploy limited resources to make sure that
we have got the services close to the people that really need
it.
Thank you.
Senator Faircloth. I was interested in the rapid toxic
screen project that you have underway. I understand the
military is involved in the project as well. Can you tell me
why this would be a valuable tool in the event of an epidemic
or attack?
Dr. Jackson. When one of these events occurs, literally
thousands of people arrive at the hospital door, and you have
got to very quickly figure out who are the people that are
going to need immediate care. You will take care of those
people right away and you can figure out by looking at them
pretty much what kind of treatment they are going to need.
There is going to be a whole group of people that you are going
to have to figure out what do they really have on board. Are
they going to be exposed to a carcinogen? Do they have
reproductive or birth defect hazards that they are going to be
concerned about, a string of other exposures?
These are not routine tests that any laboratory can run,
and you need an ability to take a human specimen, a blood
specimen, a urine specimen, and look at that chemical in that
person to say how much they have. It is going to be important
to the person making a decision at the scene. It is also going
to be important to people who are trying to reconstruct this
event a bit later on to tell people and communicate here is
what you need to worry about.
That episode I was talking about in Sacramento on the
Sacramento River, one of the things we had to decide very
quickly was to tell women whether to go get a certain kind of
blood test for neural tube defects, a birth defect, because
this chemical was associated with reproductive hazards. So,
knowing who had how much chemical was very, very helpful to the
people on scene.
Senator Faircloth. How many containment labs do we need?
Dr. Jackson. Containment labs are the biological labs, and
I am going to defer to Dr. Hughes on that.
Dr. Hughes. We need more than we have, sir.
Senator Faircloth. How many do we have?
Dr. Hughes. Well, it depends on how one defines a
biological lab. Let me give you a specific example to answer
that question. When people talk about containment labs or
maximum containment labs that came into play in the ``Hot
Zone'' book that you mentioned, those are labs that conduct
work at biosafety level 4 where people have to wear space
suits, among other protective equipment. There are two of those
in the United States, one at CDC and one at U.S. Army Medical
Research Institute of Infectious Disease [USAMRIID] at Fort
Detrick in Frederick, MD.
Senator Faircloth. The one at Fort Sam Houston?
Dr. Hughes. No, no. Fort Detrick in Frederick, MD.
Senator Faircloth. OK, I am sorry.
Dr. Hughes. We refer to it as USAMRIID facility there. But
there are two in the United States.
There is one in South Africa. There is one in Russia, at
least one. There is one being built in Canada. There is one
being built in France. But the global capacity to work with
those types of agents is very limited.
Beyond those agents, though, there are many other organisms
that need to be worked at at relatively high levels of
biocontainment, and we and others are constrained for that
space as well.
Senator Faircloth. Dr. Knouss, I am going to ask this
question and we will wind it up. When can we expect vaccines
and antibiotics to be in the hands of the people in the field
like Chief Fincher?
Dr. Knouss. We are trying now to decide what are the most
important things to have in a stockpile, particularly for
dealing with biological terrorist attack, how large that
stockpile should be, how it should be positioned. When we began
working with the cities to create metropolitan medical strike
teams, we developed----
Senator Faircloth. What are you doing now?
Dr. Knouss. It is the systems that are the local response
capability that we have been training in the 27 largest cities,
and hopefully in the not too distant future, we will be getting
to Charlotte as well.
We created a list of pharmaceutical supplies that most of
the cities have purchased using some of the funds that we have
provided to them.
What that does not cover is the potential for biological
attack. Now we are at the point where we are trying to
determine how large a stockpile ought to be, how it ought to be
able to be distributed, how much needs to be prepositioned at
the local level as opposed to at a national level because for
any one of these events, the difficulty in planning for them
and the difficulty in the cost associated with it is that these
are relatively low probability but very high impact events. In
other words, there is a low probability that any single
community might be affected by one of these events, but if it
is, it will have a very serious impact if we are not able to
prevent it.
So, the question then for us becomes how best to be able to
invest in what kinds of antibiotics and vaccines, how to
preposition them, how to be able to distribute them rapidly
after a determination has been made that there is a significant
exposed population.
For two issues we still have a lot of work to do in terms
of being able to develop good vaccines.
The current vaccine supplies for smallpox are becoming less
potent because they are held over from our smallpox eradication
days and the decision has to be made as to how we are going to
adequately vaccinate a population if it still should be exposed
to the use of smallpox or release of smallpox, if that should
ever occur again in the population.
And the second is on the anthrax vaccine, all the total
production is being used by the military. Therefore, we are
really at a position now where we have to start thinking about
whether or not a second generation of anthrax vaccine that
would require fewer doses than the current vaccine should be
developed, how much supply we are going to need and where it
ought to be prepositioned.
So, all of those are very serious questions that we still
have in our minds. A lot of discussions are taking place at the
present time. I think probably in the not too distant future,
the administration will be in a position to be able to come
forth with some proposals in that regard.
Senator Faircloth. Dr. Knouss, the Government has
absolutely the best planners and thinkers. If something
happened today, we have nothing, do we? Is that what you are
saying?
Dr. Knouss. No; I am saying it a little bit differently
than that, Senator.
Senator Faircloth. Do we have anything this afternoon?
Dr. Knouss. There are some things that we are ready for,
but there is a lot of----
Senator Faircloth. Anthrax.
Dr. Knouss. Well, there is some anthrax vaccine that is
available and we have a lot of anthrax antibiotics. But we do
not have an adequate system in order at the present time, if we
had a very large exposed population, to be able to deal with
that problem, and that is what is of concern to us. It is going
to be some time----
Senator Faircloth. Why not? How long have we been planning
on this? How long have we known that potential terrorist
attacks were out there? We do not have a system. We must have
known it for a long time. If we do not know now, when will we
find out?
Dr. Knouss. There are two aspects of that, Senator. One is
that I think everyone's sensitivity has been heightened.
Senator Faircloth. Has what?
Dr. Knouss. Has been heightened. Our sensitivity to the
potential problem has been heightened.
Senator Faircloth. How long has it been heightened? It has
been how long since the Oklahoma bombing, how long since we
have been reading about the terrorist potential for
antiterrorist viruses and whatever from the Persian Gulf
conflict?
I sit here as a citizen and it sounded like we are no
farther along than we were, say, 5 years ago. We are still
studying. We are still planning. We are giving it thought. We
are thinking about it, but if something happened today on a
situation that has been developing in this country for years,
5, 6 years, it would sound to me from what you are saying that
we would be pitifully prepared. Is that not true or are we
ready to go this afternoon?
Dr. Knouss. We are at neither of those extremes.
Senator Faircloth. We are what?
Dr. Knouss. We are at neither of those extremes. We are
making progress but we have a long way to go. That really sums
up the position that we are in at the present time. We have
taken a lot of steps over the last several years. Let me just
say from the time that we were at Oklahoma City and experienced
what happened at Oklahoma City, we made an enormous progress in
prepositioning assets for the Olympics that took place in
Atlanta, Georgia and were able to respond in Centennial Olympic
Park when that bombing took place.
We have now been training teams in some cities around the
country. We have some additional capability of being able to
respond to a chemical attack.
Senator Faircloth. To what?
Dr. Knouss. To a chemical attack.
Senator Faircloth. Well, I don't understand we're speaking
of the American people. The millions and hundreds of millions
and billions of dollars that have been poured into these kind
of programs, and I would like to hear that it was further
developed than it is, but if it is not.
Dr. Hughes, I am having trouble understanding. Did you tell
me we had thousands of people monitoring on the plague
epidemics around the world? Will you tell me exactly how many
we have working on worldwide plagues?
Dr. Hughes. Oh, on plague, OK. Let me be very specific
about that. We most certainly do not have thousands.
Senator Faircloth. How many people?
Dr. Hughes. In 1994 when----
Senator Faircloth. I mean in 1998--now.
Dr. Hughes. May I have 30 seconds to tell it? Because I
think you will see that plague is an area where we have made a
little progress because of the wake-up call in India. I
mentioned there was one WHO collaborating center, laboratory in
the world in 1994. It was staffed by one person. One person.
Senator Faircloth. We had one laboratory with one person.
Dr. Hughes. Right.
Senator Faircloth. Did they feel like it was overstaffed?
[Laughter.]
Dr. Hughes. We are not sure who that person talked to.
[Laughter.]
Clearly not overstaffed; clearly understaffed. But yet we
were the last line of defense for the world really in helping
the Indian Government----
Senator Faircloth. Even that one person----
Dr. Hughes. We obviously mobilized a few other people who
knew something about plague and we sent four people to India to
work. Now, today----
Senator Faircloth. We are not really taking it seriously
if we have one lab with one person.
Dr. Hughes. The only reason we had one was because of those
few cases that occur in the United States each year that I
mentioned to you.
Today we have probably five or six. I would have to check
for the record to be precise, but we have approximately six
people working on plague. But that plague laboratory has been
rejuvenated as part of this incremental implementation of the
CDC plan. So, we are in better shape with plague than we would
be with anthrax, say, where we have nobody basically working on
anthrax.
Senator Faircloth. Gentlemen, thank you so much. To each
of you, I thank you. It is something that the American people
are more concerned about than you might expect. It is something
we hear about. I realize you are under constraints to be able
to expand and hire. Thank you.
Gentlemen, thank you and we will continue to discuss the
country's preparedness or lack thereof for epidemics and
bioterrorism.
PREPARED STATEMENT OF DR. DAVID L. HEYMANN, ON BEHALF OF THE WORLD
HEALTH ORGANIZATION
We have received a prepared statement from Dr. David L.
Heymann, on behalf of the World Health Organization, his
statement will be inserted into the record at this point.
[The statement follows:]
Prepared Statement of Dr. David L. Heymann
THE NEED FOR GLOBAL SURVEILLANCE AND MONITORING FOR INFECTIOUS DISEASES
The challenge
Infectious diseases remain a global problem in the late twentieth
century. Global surveillance is an urgent necessity to protect the
health of people throughout the world. There is reason to believe that
the emergence of previously unknown diseases and the re-emergence of
old ones is increasing. One-third of the 52 million deaths in the world
in 1995 were due to infectious diseases, and this ratio remained the
same in 1996 and 1997. Infectious diseases spread when adequate
financial and human resources are not devoted to infectious disease
control and when microbes in animals find suitable conditions to jump
the species barrier and infect humans. Factors responsible for the
increase in infectious diseases include social changes such as mass
population movements, rural-to-urban migrations and accelerated
urbanization, population growth, rapid transport, global trade, new
food technologies, and new life styles as well as environmental changes
such as altered land use patterns and irrigation that increase the risk
of human exposure to animal reservoirs and vector-borne infections. A
new outbreak may first appear in a circumscribed area, but with
expanding global travel and trade, the disease can span entire
continents within days or weeks as influenza periodically demonstrates.
The diseases that have crossed, or threaten to cross, international
borders menace international public health security. Today these
infectious disease outbreaks and epidemics are not only costly to the
economies of the countries in which they occur, but are also a concern
for all countries because no country is safe from infectious disease.
For example, during 1997:
--Major cholera epidemics spread throughout eastern Africa, affecting
hundreds of thousands of people in more than ten countries over
several months; trade sanctions were unnecessarily placed on
fish exports from these countries resulting in severe economic
impact on their fragile economies;
--Yellow fever fatalities were reported in seven countries in Africa
and South America;
--Meningitis caused major epidemics in Africa, with over 70,000
deaths reported in the 1996-1997 season;
--More than 15,000 cases of typhoid fever with resistance to first
line antibiotics occurred in Tadjikistan;
--Epidemic typhus resurged in Burundi with over 30,000 cases and
untold deaths;
--An avian influenza virus emerged in humans in Hong Kong, killing
six out of eighteen people, and was carefully monitored for its
potential to be the next pandemic influenza threat;
--Rift Valley Fever afflicted thousands of people, killing hundreds
and many of their livestock in Kenya and Somalia;
--The prevalence of hepatitis C continues to increase in countries
where blood is not screened prior to use and where
sterilization of medical equipment is faulty;
--Lassa fever, with high mortality, re-emerged in Sierra Leone;
--An outbreak of dengue fever occurred in Cuba for the first time
since the 1981 epidemic;
--The investigation of an unexpectedly large human monkeypox outbreak
in Africa raised new issues about this important disease and
the safety of smallpox vaccination in the era of AIDS;
--The number of cases of new variant Creutzfeldt-Jakob Disease
reached twenty-four in the United Kingdom and France combined
with the continuing threat of bovine spongiform Encephalopathy
(BSE or mad cow disease), and the United Kingdom's economic
loss from BSE was estimated to have reached 5.7 billion U.S.
dollars;
--Eschericia coli 0157 continued to surface in industrialized
countries including Japan and the United States; and
--Vancomycin-resistant Staphylococcus aureus was identified in Japan
for the first time, and later in the United States.
The solution
The concern of industrialized countries such as the United States,
where prevention and control efforts have dramatically decreased
infectious disease mortality, is international public health security:
ensuring that infectious diseases which are occurring elsewhere do not
spread internationally across their borders.
The concern of developing countries is to detect and stop
infectious diseases early, thus avoiding high mortality and negative
impacts on tourism and trade. Yet, developing countries are constrained
by the lack of appropriate technologies and the difficulty of financing
the necessary interventions on a sustainable basis.
The solution, which addresses the interests of both the
industrialized and developing countries, is to combine their efforts to
strengthen detection and control of infectious disease. The major
requirements for the prevention and control of infectious diseases
globally and nationally are:
--Strong global and national epidemiological surveillance and public
health laboratories to detect infectious diseases, to provide
data for analyzing and prioritizing health services, and to
monitor and evaluate the impact of control efforts plus global
monitoring and alert systems to bring together laboratories and
disease surveillance systems from all countries to share
information internationally through electronic and printed
media.
--Sustainable and well-managed infectious disease control programs
which effectively diagnose infectious diseases and administer
vaccines, curative drugs, and other interventions where and
when they are needed.
--Continuing research and development of simple-to-use and robust
vaccines, antimicrobial drugs, and laboratory tests for
effective surveillance, prevention, and control of infectious
diseases.
WHO's global strategy and collaboration with CDC
To combat the spread of infectious disease a global framework is
needed to build up the necessary networks for surveillance and control
of infectious diseases. The World Health Organization works to build
such a global framework and effective networks through its Division of
Emerging and other Communicable Disease Surveillance and Control (EMC).
WHO has responded to the threats of infectious disease by
developing a four-part strategy for international surveillance. First,
WHO has instituted a global monitoring and alert system for
communicable diseases that brings together laboratories and disease
surveillance systems from all countries to share information
internationally through electronic and printed media. Revision of the
International Health Regulations (IHR) is underway and will be proposed
for adoption by the World health Assembly in 1999. The new
International Health Regulations will require Member States to report a
spectrum of communicable disease syndromes of international public
health importance in addition to the three specific diseases covered at
present. These proposed new regulations are now being field-tested.
Second, WHO rapidly and widely disseminates global information
collected from national Ministries of Health, WHO Collaborating
Centers, and governments via electronic means and the WHO World Wide
Web site. EMC also has an electronic alert system designed to help
facilitate expert verification of unconfirmed outbreak information on a
confidential basis. Third, WHO helps in establishing national and
regional preparedness for communicable disease prevention and control.
EMC provides manuals, standards, and guidance to national centers. The
weak link in current global monitoring capacity is the collection of
clinical/epidemiological data. At present, few countries have an
adequate national infectious disease monitoring system, and most are
extremely weak. Some of the most important geographical regions in
terms of disease emergence, are the weakest, and this situation needs
to change. Finally, WHO encourages international preparedness for
communicable disease prevention and control, which supports and
augments national and regional preparedness while national systems
improve their capabilities.
The key to global surveillance and control of infectious diseases
has been a collaborative effort between WHO and its partners, including
national-level agencies like the Centers for Disease Control and
Prevention (CDC), which play a critical role in continuing domestic
surveillance and control which minimizes the risk of international
transmission of infectious diseases.
WHO's goal is to strengthen national preparedness in all countries,
which will require a substantial long-term commitment of human and
material resources by many partners to strengthen the infrastructure
and processes for disease control and surveillance in poorer countries.
WHO's role has been to reinforce global laboratory-based surveillance
by providing training and support to existing WHO Collaborating Centers
and laboratories. WHO gives seed funding for development and
distribution of diagnostic reagents and designates new centers and
laboratories to fill geographic gaps. CDC already provides valuable
assistance in quality assurance to WHO supported laboratories
monitoring bacterial, viral, parasitic and zoonotic diseases throughout
the world. CDC also provides expert training in epidemiology and other
areas of public health, working with WHO and other international
partners.
WHO has improved global epidemiological surveillance and
facilitated rapid reporting of and response to infectious disease of
international public health importance. Surveillance has specifically
focused on developing a system to detect and investigate unusual
infectious disease outbreaks, whether naturally occurring or
intentionally caused. WHO has been working with the monitoring group of
the Biological Weapons Convention (BWC) to make sure that all diseases
of concern to BWC are included in these surveillance guidelines. WHO
Member States and WHO's network of regional offices, country
representatives, and technical partners such as CDC are now being
linked electronically for verification and response. The response
mechanism permits rapid and coordinated international investigation and
containment of infectious disease outbreaks of international
importance. WHO-coordinated international response broadens
international cooperation so that no country is required to shoulder
the entire burden of responding to an infectious disease outbreak of
international importance. Without such a coordinated international
response, many disease outbreaks could have resulted in extensive
international spread.
EMC is strengthening global surveillance through adding new
collaborating partners to the network of WHO Collaborating Centers in
infectious disease and/or the anti-microbial resistance (ARM)
monitoring network. WHO is working to incorporate military laboratories
which often have good capabilities even in poorer countries, together
with WHO Collaborating Centers into the global monitoring system for
diseases and antimicrobial resistance.
Increased support to CDC for international collaboration with WHO
would permit more rapid strengthening of surveillance and control
capabilities worldwide, especially in poor countries. By permitting
rapid detection and containment of infectious diseases when and
wherever they occur, the risk of their entering the United States of
America is minimized. Together, WHO and CDC will be working to advance
all of the elements of current efforts to strengthen the global
monitoring system to ensure international public health security.
STATEMENT OF MICHAEL OSTERHOLM, Ph.D., CHAIR, COMMITTEE
ON PUBLIC HEALTH, PUBLIC AND SCIENTIFIC
AFFAIRS BOARD, AMERICAN SOCIETY FOR
MICROBIOLOGY
Senator Faircloth. I would like to welcome the second panel
of experts and I would like to take a moment, if you would, to
limit your opening statement to 5 minutes, but do not feel you
should rush. We asked you to come and if you are not through,
why, we will cut the light off and you can finish.
The three panelists are Dr. Michael Osterholm. Is that
right, Doctor?
Dr. Osterholm. That is right.
Senator Faircloth. He will be representing the American
Society for Microbiology. He is chair of the Committee on
Public Health and serves on the public and scientific affairs
board, the task force on biological weapons, and the task force
on antibiotic resistance. He is a professor at the School of
Public Health at the University of Minnesota and serves on the
editorial board of a number of prestigious medical journals,
including the New England Journal of Medicine and Science
magazine. Thank you for being here.
The second witness on this panel will be Dr. Edward
Thompson. Dr. Thompson is a physician and has a masters of
public health degree from Johns Hopkins University. He has
served as Mississippi health officer since 1993 and will
represent the views of the State public health professionals
today. Thank you, Dr. Thompson.
Our third witness will be Dr. Ralph D. Morris, president of
the National Association of County and City Health Officials.
This group represents nearly 3,000 local public health
departments. He is a medical doctor and director of the
Galveston County Health Department in Texas. I assume Galveston
is in Galveston County.
Dr. Morris. That is correct, sir.
Senator Faircloth. Does it go beyond the island?
Dr. Morris. Well, we consider anybody north of the causeway
a Yankee, sir. [Laughter.]
Senator Faircloth. Dr. Osterholm, we will begin with your
testimony please.
Dr. Osterholm. Thank you. Senator Faircloth, we would like
to thank you on behalf of the American Society for Microbiology
to be able to be here with you today to testify on issues
related to public health needs and the threat of bioterrorism.
The ASM has submitted a written statement for the hearing
record, which I will briefly summarize.
The high consequence implications for bioterrorism puts it
into a special category that requires immediate and
comprehensive response. However, the ASM believes that
enhancing the public health infrastructure response to
bioterrorism will also increase our ability to respond to
naturally occurring and reemerging infectious diseases that now
seriously threaten the health and security of the United
States.
Biologic weapons for the use against civilian populations
differ in important respects from other weapons of mass
destruction and require a very different approach for the
deterrence, detection, and response. Understanding these
differences is critical.
A key difference is that most biological weapons cause
diseases that exist in nature. This is even true for the
fictional examples of genetically engineered biological weapons
since the symptoms they cause may not differ significantly from
the infectious diseases that are found in nature. The
investigative steps for detecting and identifying a biologic
agent released into a civilian population will be the same as
that for a naturally occurring agent. Therefore, the first and
most fundamental defense strategy for dealing with bioterrorism
is to develop effective means for combating infectious diseases
and improving our public health infrastructure and biomedical
research capacity.
However, experts have concluded that the ability of the
U.S. public health system and allied health professionals to
deal with emerging diseases is in serious jeopardy today. Even
with the recent infusion of Federal support for the emerging
infections program, the overall infrastructure for infectious
disease surveillance at the Federal, State, and local levels
has seriously suffered. Gaps in surveillance have a direct
impact on our overall ability to respond to threats or acts of
bioterrorism.
Such deficiencies are a very critical, weak link in our
Nation's defense against biological weapons. Unlike nuclear
convention bombs or even chemical weapons, a biological weapon
is unlikely to cause instant harm. Because symptoms take days
to develop, an act of bioterrorism may go undetected for days
or even weeks after it occurs. For some of the diseases, many
secondary cases could occur among contacts of ill persons and
would also be randomly distributed. Delay in detecting these
cases by hours could mean the difference between an order of
magnitude in the increased number of serious illnesses and
deaths.
Successful detection of a secret bioterrorist attack
depends on many members of the health care and public health
system promptly recognizing an unusual infectious disease
pattern. This will require a concerted effort of clinicians,
specialized personnel to confirm the diagnosis of the suspected
disease agent, public health experts to determine multiple
causes have occurred simultaneously but unexpectedly, and
finally additional experts to conclude that the cases of
disease in question were not acquired naturally but through a
deliberate act of bioterrorism.
All of the recent efforts surrounding the use of the
National Guard, Department of Defense, and local hazmat teams
will do nothing--I repeat, will do nothing--to assist us in the
recognition and even in many cases our response to biological
terrorism.
State health departments and CDC resources and expertise
are vital for detecting bioterrorist actions in the same way
that its expertise has helped in identifying the biological
agents responsible for unusual, naturally occurring disease
outbreaks. However, currently neither the CDC nor the State
health departments have the capacity to respond to threatened
bioterrorism actions involving potential weapons such as
anthrax, plague, tularemia, or smallpox.
One major concern is that the CDC does not have adequate
and safe space for working with these relatively rare but
dangerous etiologic agents. State health departments also do
not have the expertise or facilities for working with exotic
agents. Additional funding, not reallocated funding, but new
funding for laboratory facilities, equipment, and research is
urgently needed.
Ensuring the adequacy of vaccines and the antimicrobial
drugs will be critical for minimizing casualties with an attack
with biologic weapons. Federal agencies should investigate the
needs and accessibility for vaccines and antibiotics that may
be necessary in the event of a bioterrorism attack and they
should work with pharmaceutical industries to ensure that
emergency supplies can be produced and made available on short
notice.
The ASM, therefore, makes the following specific
recommendations to increase U.S. preparedness.
First, an investment of approximately $200 million could
provide an essential first step toward enhancing efforts to
address bioweapons threats.
Second, the CDC plan to combat new and reemerging
infectious diseases should be funded at a proposed level of
$125 million in fiscal year 1999.
An additional $50 million is needed to complete phase II of
the new laboratory facility at CDC that will be used for
working with particularly dangerous microbiological pathogens,
including those that might be used for bioterrorism purposes.
The ASM believes it is imperative that CDC be given
specific resources at a minimum of $1 million to implement the
congressionally mandated program to monitor the transfer of
select infectious agents.
Congress mandated CDC to implement and enforce regulations
for monitoring the transfer and exchange of biologic agents
within the United States under the authority of the Anti-
terrorism and Effective Death Penalty Act of 1996. However,
section 511 of that act, regulatory control of biologic agents,
was intended to protect public safety while allowing free and
open scientific research. Regulations implemented by the
Department of Health and Human Services are not currently
fulfilling that mandate. The registration program for
laboratories transferring and receiving specified infectious
agents must be funded by Congress to prevent interference with
very valuable and critical scientific research.
PREPARED STATEMENT
In closing, the ASM believes that improving the U.S.
bioterrorism response capabilities will provide broader
benefits to public health overall. Efforts to improve disease
surveillance, biomedical research, and development of improved
diagnostics, therapeutic agents, and vaccines serve the dual
purpose of protecting the public health and defending against
biologic weapons. None of the additional capacity implemented
to counter the threat of bioterrorism will be inactive or
wasted.
Thank you for the opportunity to testify. I would be
pleased to respond to your questions at the appropriate time.
Senator Faircloth. Thank you, Doctor.
[The statement follows:]
Prepared Statement of Michael Osterholm
Mr. Chairman, Senator Faircloth, members of the Subcommittee, thank
you for inviting the American Society for Microbiology (ASM) here today
to discuss issues related to the public health infrastructure,
epidemics, and bioterrorism. I am chair of the Public Health Committee
of the American Society for Microbiology's Public and Scientific
Affairs Board and my testimony today is presented on behalf of the ASM.
For the record, I am the State Epidemiologist and Chief of the Acute
Disease Epidemiology Section of the Minnesota Department of Health.
The ASM is pleased to have this opportunity to serve as a resource
to the Subcommittee and offers to make its full professional
capabilities available, particularly as you consider some of the
special public health needs that stem from threats of bioterrorism. We
would like to thank Chairman Specter, Senator Faircloth, and other
Senators on the Subcommittee for convening this hearing and also for
their past and continued strong support for the infectious disease
programs of the Centers for Disease Control and Prevention (CDC) and
the National Institutes of Health (NIH), both of which are critical
components of an overall national defense against infectious diseases
and bioterrorism. We particularly thank Senator Faircloth for
initiating this hearing.
The ASM is the largest single life science society in the world,
with over 42,000 members, representing a broad spectrum of
subdisciplines in the microbiological sciences, including medical,
environmental, and public health microbiology as well as infectious
diseases. The Society's mission is to promote a better understanding of
basic life processes and the application of this knowledge for improved
health and environmental well being. For nearly a century, ASM has
brought its scientific, educational, and technical expertise to bear on
issues surrounding the safe and appropriate study, handling, and
exchange of pathogenic microorganisms. On numerous occasions, members
of the Society have provided advice to government agencies and to
Congress concerning both technical and policy issues related to the
control of biological weapons. The ASM has established a Task Force on
Biological Weapons Defense to assist in formulating policy on
scientific issues.
INFECTIOUS DISEASES AS A PUBLIC HEALTH THREAT
The threat of bioterrorism needs to be considered in the broader
context of the public health threat posed by infectious diseases.
Although biological weapons pose a new and credible potential threat,
naturally occurring infectious diseases caused by emerging and
reemerging pathogens seriously threaten the health and security of the
United States on an existing and continuing basis. The high consequence
implications for bioterrorism put it into a special category that
requires immediate and comprehensive response. However, the ASM
believes that building the public health infrastructure to respond to
bioterrorism will also increase our ability to respond to the naturally
occurring and reemerging infectious diseases which seriously threaten
the health and security of the United States. In 1996, for example,
infectious diseases ranked as the third leading cause of death in the
United States. Moreover, since 1980, the death rate in this country
from infectious diseases has increased almost 60 percent. During this
same period, more than 30 infectious agents have been discovered--most
of them dangerous, and some of them deadly.
Infectious agents, old and new, pose challenges of immense
complexity to the researchers studying them as well as to the
physicians and other healthcare providers who are helping patients
combat them. Many factors help to account for why the traditional
patterns of infectious disease have been changing, including shifts in
human demographics, improper uses of antibiotics, changes in climate
patterns, changes in host-parasite interactions and microbial
evolution. Meanwhile, enormously expanded world travel and
unprecedented international trade provide an efficient means for
transporting agents that cause infectious diseases from one part of the
world to another, making it possible for a dangerous pathogen to move
from a remote village virtually anywhere in the world to an
industrialized U.S. urban center very quickly, typically in less than
24 hours.
Infectious diseases may be introduced into an unsuspecting U.S.
population not only from natural human, animal, or plant sources but
also deliberately as part of a ``bioterrorism'' scheme--that is, as
part of a release of pathogens intended to harm humans directly or to
damage the animals or plants on which we depend. Although casualties
may be limited if unsophisticated groups deploy biological weapons, the
threat of mass deaths from a biological weapons attack is of grave
concern.
The ASM recognizes that there is serious public concern about
pathogenic microorganisms being used as weapons by nations or
individuals. As these concerns are addressed, we recommend a thorough
review of general strategies and specific measures needed to protect
the public. With this in mind, the ASM offers the following
observations and recommendations.
UNIQUE ASPECTS OF BIOLOGICAL WEAPONS
Biological weapons differ in several important respects from other
weapons of mass destruction and thus require a different approach for
deterrence, detection, and response. Understanding these differences is
critical to formulating public policy.
A key difference is that most biological weapons cause diseases
that exist in nature and may occur spontaneously in human populations.
This is even true for fictional examples of genetically engineered
biological weapons, since the symptoms they cause may not differ
significantly from the infectious diseases that are found in nature.
The investigative steps for detection and identification of the agent
would be the same as that for a naturally occurring agent. Therefore,
the first and most fundamental defense strategy for dealing with
bioterrorism is to develop effective means for combating all infectious
diseases. Fears about state sponsored or individual terrorists
intentionally spreading agents of infectious disease should not
distract us from the underlying war against naturally occurring
diseases, including emerging infections that threaten to spread as new
epidemic waves causing illness and death.
Improving the public health infrastructure and biomedical research
capacity is the most effective approach for addressing both familiar
and new or emerging infectious diseases. However, several expert
committees, including one convened by the Institute of Medicine, have
concluded that the ability of the U.S. public health system and allied
health professionals to deal with emerging diseases is in serious
jeopardy. For example, a 1992 survey by the Council of State and
Territorial Epidemiologists indicates that the number of professional
positions dedicated to infectious disease surveillance in most states
has fallen below a vital threshold, making infectious disease
surveillance efforts inadequate throughout much of the United States.
Even with the recent infusion of federal support for the emerging
infections program, the overall infrastructure for infectious disease
surveillance at the state and local level has suffered. In part this
has been due to the substantial reductions in support for surveillance
of vaccine-preventable diseases, HIV infection and tuberculosis.
Frequently, state and local health departments will share
infrastructure support with other disease programs. In many states no
one is tracking foodborne and waterborne diseases any longer. Such gaps
in surveillance have a direct impact on our overall ability to respond
to threats or acts of bioterrorism.
Such deficiencies count for a great deal because, unlike nuclear or
conventional bombs or even chemical weapons, a biological weapon is
unlikely to cause instant harm. Thus, because symptoms take time to
develop, an act of bioterrorism may go undetected for days or even
weeks after it occurs. For example, if a biological agent were secretly
released in a busy metropolitan travel center, such as Washington's
Ronald Reagan National Airport, cases affecting travelers might not
begin to appear until 2 to 14 days later and, by then, among
individuals in scattered locations throughout the United States and
other parts of the world. If the disease were even moderately
contagious, secondary cases would occur among contacts of ill persons
and would also be randomly distributed. Delay in detecting these cases
by hours could mean the difference between an order of magnitude in the
increased number of serious illnesses and deaths. In particular, for
such agents as anthrax, plague and even smallpox, a delay of hours in
responding to these potential disease problems will result in many more
cases and deaths.
Thus, initial detection of a bioterrorist attack could be difficult
and the response to it would certainly entail a much more complex
strategy than is typically required following an incident involving
explosives or chemical weapons. Current systems for counteracting
bioterrorist attacks are erroneously being built on models for
incidents involving chemical agents, such as the release in 1995 by
members of the Aum Shinrikyo of sarin gas in Tokyo. In this and other
cases like it, the impact of the attack is immediate, localized, and
the affected area and victims are readily identified. Hence, medical
management and decontamination efforts can be directed quickly to
specific sites. Moreover, first responders and military strike teams
can be trained to anticipate such events in a useful fashion, thereby
giving some assurance that damages may be minimized, if not altogether
avoided.
In the case of a clandestine biological attack, however, sick
individuals will not likely be met first by specially trained first
response teams. Instead, these infected individuals will seek medical
attention in a variety of civilian settings, including emergency rooms,
doctors offices, or clinics at scattered locations. Successful
detection of a secret bioterrorist attack thus depends on many members
of the health care and public health system promptly recognizing an
unusual infectious disease pattern. This will require the concerted
efforts of clinicians, specialized laboratory personnel to confirm the
diagnoses of the suspected disease agent, public health experts to
determine that multiple cases have occurred simultaneously but
unexpectedly, and, finally, additional experts to conclude that the
cases of disease in question were not acquired naturally but through a
deliberate act of bioterrorism.
unique role of the centers for disease control and prevention
To respond to such threats, a multiagency partnership involving
federal, state, and local authorities is essential. The ASM believes
that the Centers for Disease Control and Prevention is an indispensable
civilian component of this partnership. In particular, its resources
and expertise are vital for detecting bioterrorist actions aimed at the
general population, much in the same way that its expertise has helped
in identifying the biological agents responsible for unusual, naturally
occurring disease outbreaks. Therefore, it is important to enhance
existing public health systems for detecting unusual disease events,
the capacity to investigate and control potential threats, and the
laboratory capabilities to identify and diagnose suspected agents.
In combating bioterrorism or in responding to natural infectious
disease outbreaks, the public is best protected when health care
professionals and diagnostic laboratories work together with state and
local health departments as well as with the CDC to ensure that unusual
outbreaks of diseases are detected and identified early and that
appropriate epidemiological and treatment responses are rapidly
initiated. For example, during the outbreaks of Legionnaires' disease
in 1976 and of hantavirus pulmonary syndrome in 1993, alert physicians
notified their respective state health departments and the CDC of
unusual cases of illness. In these separate incidents, similarities
among the many case reports were noted by state officials and CDC
experts working in partnership. They conducted follow-up investigations
to identify the cause of the diseases, the sources of infections, and
appropriate prevention strategies to implement. Despite these
outstanding examples of public health response, the existing
surveillance systems in place still required that days occur between
the initial recognition of sporadic cases and the recognition of an
outbreak by state and federal authorities.
Although the partnership between CDC and state health departments
has been established for decades, the system for communication and
cooperation is far from perfect and badly needs modernizing and other
improvements that will help to automate the system and make best use of
new electronic means for assembling and analyzing data. Rapid channels
of communication and information systems must be linked to allow for
examination of multiple data sources to detect unusual patterns or
early warnings of disease.
tracking of potentially dangerous biological agents
Among specific responsibilities, Congress mandated CDC to implement
and enforce regulations for monitoring the transfer and exchange of
biological agents within the United States, under authority of the
Antiterrorism and Effective Death Penalty (AEDP) Act of 1996. However,
although section 511 of that Act, ``Regulatory Control of Biological
Agents,'' was intended to protect public safety while allowing free and
open scientific research, regulations implemented by the Department of
Health and Human Services (HHS) are not fulfilling that mandate. In
particular, a registration program and fee schedule for institutions
and laboratories transferring and receiving specified infectious agents
are interfering with valuable scientific research without providing the
public a safety benefit.
The ASM has recommended that CDC be given specific resources of at
a minimum $1 million to implement the congressional mandate under
section 511 of the AEDP Act of 1996 without imposing undue restrictions
on scientific research. Additional funding would also enable CDC to
provide specific new educational and training programs to ensure
research institutions are in full compliance with that Act, which is
intended to restrict the availability of potential biological warfare
agents without hindering legitimate research. U.S. officials, including
experts at CDC, should also be involved in monitoring exchanges at the
international level of infective agents that could pose a threat to the
United States. The ASM recognizes that the major mission of the CDC is
not regulating, but to detect, diagnose, prevent and control infectious
diseases.
ENHANCING THE CAPACITY TO RESPOND TO THREATS
When bioterrorism activities are suspected, state and federal
response teams largely made up of public health and medical delivery
infrastructure, must respond quickly to minimize the impact and
exposure to whatever infectious agents that have been deployed.
Recently described efforts by teams from the Department of Defense and
local or national guardians will likely play a minor meaningful role in
this response. The incubation period before symptoms appear varies for
different infectious diseases and also depends on other factors,
including dose and means of exposure. In most instances, response teams
can expect at least a small window of opportunity during which exposed
individuals may be treated to prevent illness from developing.
However, to take advantage of such opportunities, public health
officials and other members of such response teams must be able to
identify and then quickly diagnose those individuals who were likely
exposed to the infectious agent, so that they can be appropriately
treated and quarantined as necessary. The ability to respond quickly
and effectively to such incidents depends absolutely on having well-
balanced, appropriately trained teams at the ready. Such teams require
highly skilled individuals from several disciplines, including those
with clinical, laboratory, microbiological and epidemiological
expertise.
Currently, neither the CDC nor state health departments have the
capacity to respond fully to threatened bioterrorist actions involving
potential biowarfare agents, including those that cause anthrax,
plague, tularemia, and brucellosis. One major concern is that the CDC
has little capacity for working with these diseases and does not have
adequate and safe laboratory space for working with these relatively
rare but dangerous etiologic agents. State health departments also do
not have the expertise or facilities for working with exotic biological
agents. Moreover, few laboratories are prepared to conduct the
analytical tests needed to identify such agents.
RECOMMENDATIONS FOR ACTION
Hence, additional funding for laboratory facilities and equipment
is urgently needed. Research is also needed to develop diagnostic tests
that are simple, rapid, inexpensive, and capable of being conducted
locally. Most laboratory tests for targeted biological agents take
special expertise and considerable time to confirm. Improved diagnostic
methods with faster turn-around times need to be developed and made
widely available. For instance, to improve nationwide surveillance
efforts, state health departments will need access to diagnostic
methods that enable them to compare the molecular ``fingerprints'' of
locally isolated infectious agents to those that appear in a national
electronic database. CDC does not have established agreements with the
Department of Defense to access rapid testing technology. In addition,
appropriately trained epidemiologists are needed at the federal and
state level to investigate disease outbreaks and to serve as part of
surveillance system teams.
Another major concern is that many of the microorganisms that might
be used as biowarfare agents are not causing major public health or
veterinary health challenges in the United States. Hence, there is
little if any capacity nationwide to deal with large outbreaks of these
diseases. Moreover, few physicians or veterinarians have had to deal
with actual cases of these diseases, making it unlikely for them to
suspect isolated cases caused by such relatively rare and unfamiliar
illnesses. To close such gaps, specific training is urgently needed for
physicians, other health care personnel, and veterinarians.
Professional societies with expertise in these areas will play an
important role in providing such training.
The ASM would like to draw attention to the Institute of Medicine's
interim report, ``Improving Civilian Response to Chemical or Biological
Terrorist Incidents.'' This report contains many useful recommendations
for Congress and the Administration to examine. Importantly, the first
recommendation in the IOM report is ``to provide federal financial
support for improvements to state and local surveillance
infrastructure,'' including expansion of the CDC Emerging Infections
Initiatives. The IOM report also recommends that professional societies
be enlisted in the effort to educate first responders, emergency
departments, and poison control centers by incorporating useful
information on biological and chemical warfare agents into texts,
manuals, and reference libraries. Professional societies, including
ASM, could assist in such efforts.
In closing, ASM recognizes that preparedness to protect U.S.
citizens against the threat of bioterrorism will require additional
federal resources. The ASM, therefore, makes the following specific
recommendations:
--The ASM estimates that an investment of approximately $200 million
could provide an essential first step toward enhancing efforts
to address bioweapons threats.
--The ASM further recommends that Congress fully fund the CDC plan to
combat new and reemerging diseases at a proposed level of $125
million in fiscal year 1999.
--An additional $50 million is needed to complete phase II of the new
laboratory facility at CDC that will be used for working with
particularly dangerous microbiological pathogens, including
those that might be used for bioterrorist purposes.
--The ASM recommends that CDC be given specific resources at a
minimum of $1 million to implement the congressionally mandated
program to monitor the transfer of select infectious agents.
As we mobilize these resources, we must ensure that we also
maintain or strengthen our essential public health efforts. Diverting
resources needed for vaccines that protect the public against deadly
natural diseases such as polio and diphtheria would be wrong. Thus,
even as we prudently build our capacity for countering the genuine
threat of bioterrorism, we must not overreact to that threat by
ignoring our vulnerability to naturally occurring infectious diseases.
The ASM believes that improving U.S. bioterrorism response
capabilities will provide broader benefits to public health. Efforts to
improve disease surveillance and research and development of improved
diagnostics, therapeutic agents and vaccines serve the dual purpose of
protecting the public health and defending against biological weapons.
For example, enhanced surveillance and response systems will allow
faster detection and intervention for other infectious diseases that
affect the U.S. population. Clinical, diagnostic, and epidemiological
expertise are not currently available for detecting and combating
certain key biological agents; moreover, improved computer hardware and
software are needed to improve infectious disease surveillance and
communication capabilities.
Very importantly, biomedical research must also be expanded to find
new ways of preventing and treating infectious diseases. Basic research
is the underpinning for the long term ability to address infectious
disease threats.
None of the additional capacity implemented to counter the threat
of bioterrorism will be inactive or wasted.
Thank you for the opportunity to testify. I would be pleased to
respond to any questions.
STATEMENT OF EDGAR THOMPSON, M.D., M.P.H., CHAIR,
GOVERNMENT RELATIONS, ASSOCIATION OF STATE
AND TERRITORIAL HEALTH OFFICIALS
Senator Faircloth. Dr. Edward Thompson.
Dr. Thompson. Thank you, Senator.
Senator Faircloth. You are--what is your title?
Dr. Thompson. I am the State health officer for the
Mississippi State Department of Health. I am what in most
States is called the commissioner of health.
Senator Faircloth. OK, yes. Thank you.
Dr. Thompson. We spoke earlier of plague, Senator. There is
a human plague of which most of us are ignorant, but those of
us named Ed are very familiar with it. The disease causes
everyone to assume that if your name is Ed, it is short for
Edward. In my case it is not. It is Edgar. But thank you for
the attempt.
I am here representing the Association of State and
Territorial Health Officials, and for the record I am Dr. Ed
Thompson.
I would like to talk to you for a minute about why we as
public health officials from the State level are here. I mean,
after all, we need a Federal response to bioterrorism. The
Federal agencies and the Department of Defense will take care
of all this and everything will be well. Well, to quote Three
Dog Night, ``that ain't the way that it works.'' This is going
to have to be addressed at the State level as well.
I would like to talk just a minute about why, in addition
to our other expertise, we and some of the other public health
doctors are here today. It is because we have seen a glimpse of
the enemy. We have seen directly the effects of an outbreak of
disease or an incident of chemical contamination in a
population. Just 3 weeks ago we had a fatal case of----
Senator Faircloth. Where was this 3 weeks ago?
Dr. Thompson. Just 3 weeks ago in Mississippi, in Jackson.
We had a fatal case of meningococcal meningitis in a school,
and when you deal with the frightened parents and the frantic
educators and the frothing media, you see in microcosm what a
biological attack could do. Trying to provide reassurance in a
packed community center in a north Mississippi town where three
cases of Rocky Mountain spotted fever have occurred, two of
them fatal, you see what terror is.
As shocking and deadly as the bombings of the World Trade
Center and the Oklahoma City Federal Building were, the lethal
and disruptive potential of biological agents is even greater
with an ability to create sustained fear and disruption
unmatched by explosives and chemical poisons. Any public health
official who has dealt with the effect of even a small outbreak
of infectious disease in a community can tell you that
infectious agents are an ideal terrorist weapon.
Readiness for the possibility of biological terrorism not
only means making sure our national security systems are
adequate, but that our public health system has the ability and
the resources to respond. An effective public health response
can mean significant reduction of damage and death.
Now, a critical role of State health departments in
responding to biological terrorist attack will be detection.
The appearance of an unusual disease or increased cases of an
ordinary disease will likely be first recognized through public
health surveillance at the State and local level. We saw this
in 1984 in Oregon when a terrorist attack using salmonella
bacteria was detected and averted when local public health
authorities through basic public health surveillance identified
the threat.
Another of our most important goals will be to provide
manpower. Much of the case finding, immunizing, medication
delivery, and other hands-on control will be done by State and
local health department nurses, environmentalists, and disease
investigators. Our experience with the chemical contamination
of thousands of Mississippi homes with methyl parathion
illustrates this. Despite the deployment of dozens of Federal
personnel from several agencies, the majority of the manpower,
or much of it nurse power, came from the State and local health
departments.
Senator, you asked earlier if the Nation is prepared to
respond to bioterrorism. Well, if the States are prepared, the
Nation is prepared, and if the States are not, the Nation is
not.
Are the States prepared? Well, States are not prepared now,
but State and local health departments are uniquely qualified
to become prepared and to fill critical roles. We have skill
and experience in rapidly mounting mass immunization campaigns,
large scale administration of medications, emergency public
communications, and disaster response. We do all these things,
not just practice them. We are the experts in basic
surveillance and disease reporting because we are the ones who
do it for most diseases. We have the foundation on which to
build a solid system to deal with outbreaks and epidemics,
whether natural or manmade, but much remains to be done.
The most immediate need is for a comprehensive national
strategy to address the threat of bioterrorism. On May 22, the
President announced his intent to create one and ASTHO commends
him for that leadership. In holding this hearing, Senator, you
too are providing leadership on this issue. But the focus so
far has been on planning by Federal agencies. Dealing with
bioterrorism will depend on civilian Federal agencies, the
military, and State and local public health and other
officials. No one of the three can do the job alone.
Congress and the administration need to convene a national
planning process involving State and local governments, as well
as the affected Federal agencies, including especially the
Centers for Disease Control. We need a national plan
coordinated at the Federal, State, and local levels among
public health agencies, emergency management, law enforcement,
and the military. This planning process must involve State and
local public health officials at every stage.
The other major need is for resources. Some of these
resources involve new technology or making existing technology
available to States, especially the public health laboratories.
But even more important is support, funding, for essential
public health activities and infrastructure. Not all the
infrastructure needed by the States is at the State level. CDC
and its infectious disease and environmental laboratories are
national resources on which all States draw in public health
emergencies. Funding to improve and assure their capacity to
meet these needs is critical to the States.
Only the coordinated national planning process we are
calling for will answer the question of what defending against
bioterrorism will cost. We estimate as much as $200 million for
public health infrastructure alone, but it will be a unique
bargain. Some emergency preparedness measures are limited to
emergency use. Public health preparedness for bioterrorism is a
broader investment.
PREPARED STATEMENT
Improved surveillance, laboratory capability, and
communication systems will be immediately applicable to
naturally occurring diseases, including emerging infectious
diseases and epidemic diseases, such as influenza. The same
technology and infrastructure that is needed to detect and
control disease of deliberate origin can be used against
naturally occurring health threats day in and day out in every
State.
I thank you and I look forward to answering the questions
at the appropriate time.
Senator Faircloth. Thank you, Dr. Thompson.
[The statement follows:]
Prepared Statement of Dr. Edward Thompson
Mr. Chairman, Senator Faircloth, Senator Cochran and other Members
of the Subcommittee, I am Dr. Ed Thompson, Health Commissioner for the
State of Mississippi. I am here today representing the Association of
State and Territorial Health Officials (ASTHO). ASTHO is an alliance of
the chief health officer in each of the 57 states and territories in
the United States. My testimony also reflects the perspectives of the
Council of State and Territorial Epidemiologists and the Association of
State and Territorial Public Health Laboratory Directors. It is not
intended to represent a formal position on the part of any of the three
organizations, as none of them have adopted specific positions on this
issue.
ASTHO greatly appreciates the leadership that you have shown, Mr.
Chairman, in holding this hearing on the role of public health in
responding to bioterrorist threats, a subject of immense importance for
our nation's security and well-being, and currently overlooked. ASTHO
also greatly appreciates the leadership you have shown, Senator
Faircloth, in sponsoring S. 1786, a bill requesting the Centers for
Disease Control and Prevention to report within 60 days information
regarding its ability to respond to the growing threats of viral
epidemics and biologic and chemical terrorism and the resources it
needs to adequately respond. This bill, and your interest in bringing
this issue to the attention of the Congress, is federal leadership at
its best. ASTHO applauds you and thanks you. I also want to extend
special appreciation to Senator Cochran who has always been
particularly responsive to state health officials' program priorities
and to the public health needs of the citizens of Mississippi and the
nation.
I don't need to remind this Subcommittee why this hearing is
needed. The terrorist bombing of the World Trade Center in 1993 and the
Alfred P. Murrah Federal Building in Oklahoma City in 1995, and the
nerve gas attack on the Tokyo subway in 1995 are seared into Americans'
consciousness. As shocking and deadly as these bomb and chemical
attacks were, the lethal and disruptive potential of biological agents
is even greater, with an ability to create sustained fear and
disruption unmatched by explosives and chemical poisons.
Recent conflict with Iraq over weapons inspections remind us that
biological and chemical weapons are probably in the possession of a
number of hostile governments. Even more frightening, weapons of mass
destruction, including deadly biological agents, are very likely within
the capability of a number of non-governmental extremist groups both
domestic and foreign.
This means we must also be aware of and prepared for the
possibility of a major biological terrorist event here, at home, in the
United States. Readiness for such an attack not only means making sure
our national security systems are adequate and vigilant, but that our
public health system at the federal, state and local level has the
ability and the resources to rapidly identify, investigate and control
the consequences of a terrorist event that could affect thousands of
Americans. An efficient, effective public health response can mean the
difference between chaos, widespread panic and increased casualties and
significant reduction of disease, disability and death related to the
event.
The importance of the public health role cannot be overemphasized.
For example, in the case of a biologic terrorist attack involving the
release of smallpox at a major sports event in an outdoor stadium in a
major U.S. city, such as Los Angeles, the disease, which has a 30
percent fatality rate among healthy adults, would rapidly become
epidemic. The longer the release event goes unrecognized, the more
widespread the infection and the number of eventual victims could
quickly become millions.
My testimony will address the specific role of state health
departments in responding to a serious biological terrorist event, the
current readiness of states to respond, and what states need to
appropriately respond. I will confine my comments to a biologic
terrorist event because a chemical or radiological attack, for many
states, falls largely to other agencies such as emergency management,
for major response. An attack involving a biologic agent, on the other
hand, uniquely requires the capabilities of the state health
department.
My testimony will also point out that appropriately preparing for a
bioterrorist attack will have positive outcomes--on a daily basis--by
improving our ability to address naturally occurring infectious disease
outbreaks, food safety concerns and environmental hazards.
THE STATE HEALTH DEPARTMENT'S ROLE IN RESPONDING TO BIOTERRORIST
THREATS
The role of state health departments in responding to a biological
terrorist attack will be first and foremost detection. The appearance
of an unusual disease, or increased cases of an ``ordinary'' disease,
will likely be first recognized through basic public health
surveillance at the state and local level. Identification of the
causative agent of any unusual disease cluster or outbreak may well
fall first to state or local public health laboratories. We have seen
this already in the 1984 salmonella poisoning in Oregon where a
terrorist attack was detected and averted when local public health
authorities, carrying out their basic public health surveillance,
identified the threat.\1\
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\1\ Torok, Thomas, J., et al. A Large Community Outbreak of
Salmonellosis Caused by Intentional Contamination of Restaurant Salad
Bars. JAMA, Vol 278:5, pp. 389-395.
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Another primary role for state health departments in the event of a
biological terrorist attack is coordinating assistance to local health
departments that may become quickly overwhelmed and reporting
epidemiologic findings to appropriate federal agencies, primarily the
Centers for Disease Control and Prevention. Each state's health
department is likely to be substantially engaged in any serious
biological terrorist attack within its borders even if only a few
individuals become seriously ill.
Another key state activity is the development of a bioterrorist
plan that actively involves the participation of the state's health
department. Regular training, including periodic table top and field
practice drills, implementing the bioterrorist plan will be required.
Regular updating of the plan will be needed as intelligence about
likely bioterrorist agents becomes available. It is essential that
state health departments have the resources to respond to a major
bioterrorist event within their state borders because proximity reduces
the time involved to detect the agent which in turn is essential to
institute control and treatment measures that will reduce related
disease and death. The reality is that minutes count when responding to
a bioterrorist attack.
One of our most important roles will be to provide most of the
actual response force. At the most basic level, whatever combination of
case-finding, interviewing, immunizing, medication delivery, or other
hands-on control techniques are needed for the particular biological
agent and situation will be largely carried out by state and/or local
health department staff. It is our nurses, our environmentalists, our
disease investigators who will actually do the work, if it gets done.
Mississippi's recent experience with the chemical contamination of
thousands of homes with methyl parathion illustrates this. Despite the
deployment of dozens of federal personnel from several agencies, the
majority of the manpower (much of it nursepower) came from the state
and local health departments.
The likely scenario that a few major cities have either already
tested, or are planning to test, in a table top exercise unfolds as
follows: A bioterrorist event occurs involving the unannounced release
of anthrax spores in an open air location during a major public event.
The first responsibility immediately falls to the local health
department to detect that an unusual number and type of case reporting
is occurring. Responsibility for diagnosis of the agent falls next to
the local or state public health laboratory. Investigation, by
interviewing victims, again is the responsibility of the local health
department, with assistance from the state health department, in order
to identify the source of the agent, when the release took place, and
who might have been exposed. Other critical phases of the exercise
where major responsibility falls to the local health department, with
assistance from the state health department, involves the distribution
of vaccine and other essential treatment resources and distribution of
diseased victims around the state and region as thousands become
symptomatic.
Essential state health department functions in preparing for and
responding to a bioterrorist incident would involve the following
specific activities:
--Epidemiologic surveillance.--Active surveillance for the occurrence
of unusual diseases or conditions. This is an essential current
function that needs significant enhancement to ensure timely
detection of a bioterrorist event. Timeliness is critical.
Victims of a biologic attack will not exhibit symptoms for
days, or even weeks. The delay between exposure and onset of
illness, in the case of an infectious agent such as smallpox,
can mean spread of the disease to hundreds, even thousands. If
it occurs in a major metropolitan area the disease could become
pandemic in a matter of hours. Detecting the agent as soon as
possible can save lives.
--Active surveillance involves active monitoring of a comprehensive
reporting system and both routine and periodic education of
mandated reporters: physicians, hospitals, medical examiners,
and clinical laboratories about the signs and symptoms
indicative of exposure to the most likely bioterrorist agents.
These include the infectious microorganisms that cause anthrax,
brucellosis, plague, Q-fever, tularemia, smallpox, viral
encephalitis, and hemorraghic fever; and the bacteria-produced
poisons botulinum toxin and staphylococcal enterotoxin B; the
plant-derived toxin ricin, and fungal metabolite T-2 mycotoxin.
These are the core military biological weapons. In addition,
surveillance of the state's vital records department for
premature deaths in otherwise healthy individuals will signal
unusual disease exposure. To conduct active surveillance, state
health departments will need adequate numbers of
epidemiologists trained in recognizing and instituting
appropriate control measures for both natural, unintentional
events such as pandemic influenza as well as bioterrorist
agents.
--Laboratory analysis.--Active surveillance is dependent upon
laboratory capability to rapidly analyze samples for exposure
to bioterrorist agents. This requires, ideally, at least one
laboratory per state that is appropriately equipped to detect
the most hazardous etiologic agents such as smallpox, and
Bacillis Anthracis, the causative agent of anthrax. This
requires at a minimum Biosafety Level 3 containment facilities.
Biosafety Level 4 containment facilities, may be needed in
certain high risk states, or regionally, but the Centers for
Disease Control could handle this function if provided
additional capacity. If established in states or regions,
Biosafety Level 4 facilities also require personnel trained in
handling, testing and reporting biohazardous agents and the
availability of laboratory assays indicating exposure to nerve
agents and cyanide and serological, immunological, and nuclear
assays for identification of all the expected biological
terrorist agents.
--Public health laboratories are ideally suited for the critical role
of identifying bioterrorist agents, but most will need
considerable upgrading to carry out their essential detection
function, and should have access to rapid detection kits for
the most likely bioterrorist agents currently only available to
the military. These ``smart kits,'' or other instrumentation
like them, that have been developed by the National Naval
Research Institute should be required equipment in every state
and local public health laboratory. State public health
laboratories also need protocols and procedures for rapid
submission of samples both from the field (hospitals,
commercial laboratories and local health departments) and to
CDC which serves as a national and world-wide reference
laboratory. Additional laboratory staff trained in detecting
bioterrorism agents will need to be located in close proximity
to high risk metropolitan areas.
--Verification of the bioterrorist agent through laboratory analysis
is essential to institute effective delivery of definitive
treatment measures. Rapid, seamless electronic communications
among federal, state, and local levels is also an important
public health laboratory capability. Again, minutes count when
responding to a bioterrorist attack.
--Epidemiolgic investigation.--Rapid, efficient epidemiological
investigation will be needed to identify likely sources of
contamination or infection, e.g., common food, water, or air
sources. This involves basic ``shoe leather'' epidemiologic
interviews with those who have been exposed as well as others
logically connected to the event. This function is essential to
establish where the exposure to the bioterrorist agent occurred
and when it occurred so that appropriate control and treatment
measures, such as rapidly distributing ameliorating vaccine,
can be instituted. This involves having adequate numbers of
infectious and environmental epidemiologists additionally
trained in bioterrorist detection that can be made available to
local health departments. It also means ``shoe leather''
interviewers should be considered for advance vaccination
protection as essential health care workers.
--The importance of this basic public health activity cannot be
overemphasized. It is essential to effective control of an
infectious agent that can rapidly affect thousands and even
threaten millions of lives world wide if it becomes pandemic.
--Information and communications systems.--Reporting will need to be
electronic and permit receipt, compilation and analysis of
information from multiple reporting sources such local health
departments, hospitals, clinics, etc. This is also critical
with regard to laboratories which must have communication links
to federal, state, and local public health agencies. The
communication system must be electronically compatible and,
ideally provide 100 percent coverage of the state's population.
Communications also need to be seamless with federal agencies,
particularly CDC as it will have an important role as well in
any bioterrorist event.
--Coordination of essential equipment and treatment.--State's will
need to be able to coordinate essential equipment and treatment
facilities needed at the local level. Some of the
considerations will include:
--Health care facilities and personnel.--In the case of an infectious
biologic terrorist agent such as smallpox, the impact will be
felt first in emergency rooms, physician's offices, and medical
clinics. To protect essential health care workers against
biologic agents, a national program of voluntary vaccination
against likely, known military agents such as anthrax and
smallpox, should be considered. Essential health care workers
include physicians, nurses, laboratory workers and other allied
health care workers such as radiology technicians and as
already discussed, essential state and local health department
officials and workers. A biological terrorist incident probably
will not be effectively controlled without instituting, in
advance, protections for these essential individuals. On the
other hand, current limited supplies of smallpox and anthrax
vaccine probably should not be used for first responders since
they are unlikely to come in contact with victims of biologic
terrorism.
--Isolation beds.--In the case of an infectious disease agent, such
as smallpox, an adequate number of isolation beds to treat
several thousand victims must be developed, designated and
coordinated. This must be an essential component of the state's
bioterrorist plan. Implementation of rapid isolation measures,
and other controls, will be imperative in halting the spread of
the disease. Because of the likely number of victims involved,
state health departments will need to coordinate distribution
of victims around the state in medical treatment facilities
and, in many cases, across state lines to nearby cities.
--Availability and distribution of vaccines and other necessary
treatment resources.--The President has made this a national
priority and state health officials applaud him for his
leadership in addressing this critical need. A national
stockpile of vaccines against the most likely biologic
terrorist agents is absolutely essential in any effort to
respond to a biologic terrorist event. Rapidly identifying and
vaccinating individuals not yet sick, but who have been exposed
to a terrorist agent, can prevent development of the disease,
or ameliorate its consequences. Organizing the distribution of
vaccine is a basic, public health role, and must be part of a
state's bioterrorist plan.
--Much must be done, and done immediately, before it is too late. The
Institute of Medicine, at the request of the Department of
Health and Human Resources, is currently developing a report on
the research and development needs for biologic and chemical
terrorist agents. The Congress and the Administration should
move to implement its recommendations immediately and begin
production of a civilian stockpile of vaccine against the most
likely biologic terrorist agents as a national priority.
--Other treatment needs can be stockpiled in designated major
hospitals, Red Cross facilities, or other sites in high risk
areas. These would include a range of antibiotics, blood
supplies, various intravenous fluids for hydration, nutrition
and other needs. These also must be addressed in the state's
bioterrorist plan.
are states prepared to respond to a bioterrorist event?
The ``short answer'' is no, but the answer is not short. States are
not prepared now, but state and local health departments are uniquely
qualified to become prepared and fill critical roles. We have skill and
experience in rapidly mounting mass immunization campaigns, large-scale
administration of medications, emergency public communications, and
disaster response. We do all these things--not just practice them--on
an all-too frequent basis. We are the ``experts'' in basic surveillance
and disease reporting, because we are the ones who do it for most
diseases. We have the foundation on which to build a solid system to
deal with biological cataclysm, whether man-made or natural.
But in many ways we are not yet prepared. The potential is there,
but much remains to be done.
Critically, resources, both human and technical, are not adequate.
Some need to be developed, and some that once were adequate have
eroded. A fundamental need is to ``shore up'' and improve our
dangerously neglected basic public health capabilities.
A second major unmet need is planning. Most states do not have a
bioterrorist plan. Some states are currently working on a bioterrorist
addendum to their medical disaster plan--New York and Texas are two
examples. Minnesota is ready to conduct a table top test of its
bioterrorist plan. There are several others moving in this direction.
But every state needs to make this a priority.
A case example of how ill-prepared state health departments feel
they are to respond to a bioterrorist event is the quote below from a
draft document on catastrophic disaster and terrorism by the Illinois
Department of Health. The document reflects a statewide effort.
``The Department is mandated to protect the public health and
safety of the citizens of Illinois. However, limited opportunities have
been made available to adequately prepare staff for a response to a
terrorist incident involving radiological, biological, or chemical
materials. Therefore, the Department's response capabilities are
currently limited. Several factors have prevented the Department from
attaining a higher level of preparedness. These factors include:
absence of a consistent funding source for training and education
programs; limited personnel in infectious diseases, environmental
health and laboratory services programs; and a lack of Federal guidance
and information on source standards and detection methods.'' \2\
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\2\ Illinois Department of Public Health. Catastrophic Disaster/
Terrorism Report. Draft report.
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A key issue in successful planning is for state health departments
to be active participants in emergency management plans for responding
to bioterrorism. This is not happening to the extent it should in many
states. State health departments must be regarded as essential partners
in bioterrorist planning.
To assist state and local governments in the development of
bioterrorist preparedness, ASTHO calls upon the Congress and the
Administration to convene a national planning process that will involve
all affected federal agencies, including especially the Department of
Health and Human Services which has too often been overlooked in its
important role in the case of a civilian bioterrorist event, and state
and local governments. A primary goal of the planning process, in
addition to delineating activities and coordination among federal
agencies, should be to provide guidelines, or a model bioterrorist
plan, to state and local governments that they can adapt to their
particular needs and resources. States could significantly inform and
assist the national planning process--now--by surveying their public
health resources, including epidemiologic and laboratory resources;
medical care resources; and other key resources such as appropriate
stockpiling centers. California is currently undergoing a survey of its
resources to develop its bioterrorism plan.
what resources do states need now to be prepared for a civilian
bioterrorist event?
The first thing states need to be prepared is a plan. As already
discussed, this should be a national priority and will involve
coordination at the federal, state and local levels among public health
agencies, but also with emergency management agencies, law enforcement
agencies, the military, and potentially many more.
The other major need is for material resources. Some of these
resources involve new technology, or making existing technology
appropriately available to states, especially their public health
laboratories. But even more important is support--funding--for old
fashioned, but essential public health activities and infrastructure.
Congress has recently been engaged in a massive debate over the
state of the nation's public works infrastructure. The widely supported
conclusion is that we must upgrade our nation's highways which are
becoming clogged with traffic, and rebuild dangerously crumbling
bridges and tunnels. Congress has made the commitment to spend the
nation's resources to upgrade and update this fundamental underpinning
of our way of life: transportation.
State health officials are extremely concerned about another
essential, threatened underpinning of the American way of life: public
health. Public health infrastructure is not visible like highways and
bridges, but it is no less important. It has been steadily eroding over
the past two decades and is in desperate need of upgrading. The extant
challenges of food safety, pandemic influenza, and unintentional
environmental hazards are daunting enough without adequate, updated
resources, but the prospect of a civilian bioterrorist event involving
thousands of causalities is overwhelming.
The importance of the role of public health in a bioterrorist event
cannot be over emphasized. The greatest need--now--at the state level
is for planning and supporting and upgrading existing infrastructure as
follows:
--States need adequate epidemiologic resources--surveillance and
investigation.--An important obstacle to developing
bioterrorist preparedness is the categorical nature of current
surveillance funding. At least 80 percent of a given state's
federally supported surveillance must be committed to HIV/AIDS,
TB, and STDs (Sexually Transmitted Diseases). Many states have
no funds available to them for generic, active surveillance of
the occurrence of unusual disease or conditions. This is a
major public health infrastructure weakness that a bioterrorist
event would exploit immediately with terrible consequences in
unnecessary disease, disability and death. States need a source
of unfettered funding for active, generic surveillance systems
which also benefit preparedness for non-terrorist events such
as influenza, unintentional food poisoning or environmental
hazards. This should be a priority for Congress and the
Administration, but must not come at the expense of funding for
current programs which are vital and needed. States also need
an adequate number of epidemiologists trained in detection,
control and treatment of bioterrorist agents.
--States need upgraded public health laboratory facilities and
trained personnel.--State public health laboratories are not
currently equipped to detect the most likely bioterrorist
agents such as anthrax and smallpox. ASTHO recommends that most
states have a Biosafety Level 3 facility. The national planning
process should address the question of whether particularly
high risk states, or regions should have a Biosafety Level 4
facility, or whether all highly hazardous agents should be
forwarded to CDC for comprehensive analysis. If the latter, CDC
will clearly need resources to develop additional capacity.
Again, the primary issue is rapidity of diagnosis, but other
concerns are the numbers of specimens that may be involved in a
bioterrorist event and maintenance of skills in handling
hazardous materials. It is clear, however, that all state
public health laboratories require updated technologies to
quickly identify unusual microbiol agents, determine their
antibiotic susceptibility, and point of origin. ``Smart kits''
should be made available for quick screening of the most likely
bioterrorist agents; newer technologies such as polymerase
chain reaction (PCR) are needed, but many state public health
laboratories lack the equipment, staff and training to provide
these services. Once again, enhancement of state and CDC
laboratory capacity should not come at the expense of existing
program funding.
States need enhanced, electronic information and communications
systems to permit rapid assessment, analysis, and reporting.
OTHER IMPORTANT BENEFITS THAT RESULT FROM BEING PREPARED FOR A CIVILIAN
BIOTERRORIST EVENT
Enhancing public health infrastructure at the federal, state and
local levels to prepare for a civilian bioterrorist event has many
important benefits for the public's health. Improved surveillance,
investigation, laboratory capability, and communications systems will
be immediately applicable to food safety, unintentional environmental
hazards, and influenza, both the pandemic (approximately every ten
years) and interpandemic time periods. State health department
officials are faced, nearly every day, with the need to evaluate the
risk or occurrence of disease outbreak or environmental health hazards.
An adequate, updated public health infrastructure will yield a real
return on every dollar invested in prevented disease and avoided health
care costs.
Some emergency preparedness measures, though necessary, are largely
limited to emergency use. The second largest fire department in
Minneapolis is at the airport just outside the city. Every day the
airport fire department stands ready to respond to major disaster.
Equipment is in excellent maintenance condition, it's upgraded
regularly and personnel conduct regular practice runs to keep their
skills honed. Minneapolis has never had an airline disaster, but its
airport couldn't operate without its fire department.
Public health preparedness for civilian bioterrorism is an even
better investment bet. Much of the enhancement in infrastructure would
be used daily and have positive consequences--every day--for the
public's health. The same technology and infrastructure that is needed
to detect and control disease of deliberate origin in emergencies can
be used against naturally occurring health threats day in and day out
in every state. The high tech troop carrier we need to fight the war
can be an efficient school bus if the war never comes.
SUMMARY OF ASTHO'S RECOMMENDATIONS
A national planning process involving federal, state, and local
governments to respond to civilian bioterrorism should be convened. The
planning process should emphasize the role of public health at all
levels of government as the first line of defense after a bioterrorist
attack has occurred and a critical component in all phases of the
crisis.
In conjunction with the national planning process, each state
should develop a bioterrorism plan and survey their current resources
as a basis for strategic action.
There should be increased national resources committed to enhancing
the nation's public health infrastructure at the federal, state and
local level to address bioterrorism. Infrastructure enhancements should
address identified laboratory needs within the CDC, surveillance and
epidemiologic investigation at the state and local level, state and
local public health laboratory capability, and enhanced information and
communication systems. State and local public health infrastructure
funding should be flexible to permit each entity to address its own
specific infrastructure needs.
ASTHO estimates that $200 million will be needed to fund state and
local public health infrastructure needs to respond to bioterrorism,
but cautions that precise funding requirements will only become evident
through a national planning process.
STATEMENT OF RALPH D. MORRIS, M.D., M.P.H., PRESIDENT,
NATIONAL ASSOCIATION OF COUNTY AND CITY
HEALTH OFFICIALS
Senator Faircloth. Senator Cochran had planned to be here
with you this afternoon, but because a number--and I understand
a large number--of Senators are going to be out of town at
Senator Goldwater's funeral tomorrow, he had to reschedule the
hearing on Governmental Affairs which he chairs. So, he sends
his apologies for not being able to be with you.
Dr. Thompson. We will forgive him.
Senator Faircloth. Our next witness, Dr. Ralph Morris, is
president of the National Association of County and City Health
Officials. This group represents nearly 3,000 local public
health departments. He is a doctor and director of the
Galveston County Health Department.
Dr. Morris, we are delighted to have you. Are you not glad
you did not have that job in 1908 or 1903 or whenever the
hurricane destroyed the city?
Dr. Morris. We are actually getting ready to commemorate
the 100th year anniversary of that 1900 hurricane in another 2
years.
Senator Faircloth. What year did it happen?
Dr. Morris. 1900, and it was the largest natural disaster
this country has ever experienced with approximately 6,000
deaths. I can assure you, sir, as the local health officer,
that is one of the things that weighs very heavy on my mind in
terms of planning for disasters and we take it very seriously
in Galveston County in terms of hurricane preparedness.
Senator Faircloth. I do a lot of reading. I just read a
book on raising the island 18 feet after the hurricane by
building a seawall.
Dr. Morris. That is correct.
Senator Faircloth. Dr. Morris, we will hear your
testimony.
Dr. Morris. OK. Thank you, sir.
Good afternoon, Mr. Chairman. My name is Ralph Morris. I am
director of the Galveston County Health District and I am
pleased to serve as president of the National Association of
City and County Health Officials [NACCHO]. NACCHO is the
organization representing almost 3,000 local health departments
across this country.
Senator Faircloth, on behalf of the Nation's public health
officials, I want to thank you for your invaluable leadership
in addressing these important issues under discussion today.
I am here today to explain how local health departments
serve on the front lines in battling public health crises of
all sorts and why we need a national network of electronic
communication among local, State, and Federal public health
agencies.
When an outbreak occurs, regardless of the cause, local
health departments and State health departments are responsible
for gathering information and determining the cause. This
process is called disease surveillance and it is a fundamental
function of public health at the local, State, and Federal
level. Surveillance is our early warning system for protecting
the public.
In order to conduct disease surveillance effectively, local
health departments must be able to exchange information with
local doctors, hospitals, other local health departments, State
health departments, and CDC. A local health department does the
groundwork such as tracking down who has been exposed,
gathering information about the exposure, obtaining laboratory
specimens, and preventing further spread of the disease. The
local health department is responsible for giving accurate and
timely information to the media, to the community, hospitals,
doctors, and local elected officials.
Let me give you some real-life examples.
In Galveston last February, a case of meningococcal
septicemia was reported to our department on Monday morning. It
happens that the weekend before was Mardi Gras and that the
patient was an escort to one of the duchesses. Mardi Gras
attracts approximately 100,000 to 200,000 people to the island.
This individual attended two balls during Mardi Gras and was
also on a float on the main parade of Mardi Gras. It was a very
lonely feeling to get that report of this contagious,
potentially fatal disease.
We had to find out and start treatment of individuals who
were scattered all over the State who had been exposed to the
disease. We used phones to work with other local health
departments and the State health department. We played phone
tag and relied on voice mail and spent an undue amount of time
arriving at a common understanding of the problem and what we
needed to do to solve it. If we had been electronically
connected with the State health department and other local
health departments, the process would have been much faster.
Fortunately, we had no secondary cases and the patient did
survive.
Last winter in Texas, we faced another outbreak of invasive
group A Streptococcus, also known as flesh-eating bacteria. If
we had had state-of-the-art communications, we would have been
able to quickly exchange information about where the cases were
found and to accurately inform the community and local
officials about this frightening organism.
Recently we have dealt with an influx of smoke and haze
from Mexico which presented an immediate health threat to the
general public, as well as susceptible individuals. Here again,
an electronic network would have allowed us to do our work more
thoroughly, timely, and in an accurate manner. In addition,
many of us were not familiar with the specific health hazards
of this smoke and haze from Mexico.
The knowledge gap is particularly alarming with respect to
biological and chemical terrorism. Few of us in public health
are familiar with the prevention, diagnosis, and treatment of
the health effects of these agents of biological warfare. We
need quick access to guidelines for implementing emergency
measures, as well as an ability to communicate instantly and
securely with other government agencies that would respond to
terrorism. Diseases of biological terrorism are similar to
other infectious diseases. They may be insidious in the onset
and difficult to recognize. We will not recognize them promptly
enough to save lives if we do not have good infrastructure for
communication and access to information.
In the military and law enforcement, good communication are
taken for granted. In public health, we are way behind. Most
local health departments still rely on the phone, the fax
machine, and paper and pencil to do their job, and many of the
phones are still rotary. About one-half of all local health
departments do not have the use of electronic mail. At least
1,000 local health departments have no access to any online or
Internet service. Among those that do, one-third are not even
linked to their State health department, and fewer than one-
quarter can reach other local health departments
electronically. Building an electronic network requires
thoughtful planning, updated hardware and software, connections
to the Internet, and training personnel how to use it.
NACCHO strongly supports the proposal under development at
CDC for establishing a national health alert network. This
network will equip the front lines of public health local
health departments and, with essential electronic information
tools, and train public health workers in the skills they need
to protect the public.
Mr. Chairman, dramatic gains have been made in health in
this country in the past century. Life expectancy has increased
by 30 years; 25 of those years have been due to basic public
health measures. Taking these gains for granted and letting the
public health infrastructure deteriorate is asking for
disaster. When public health in one location suffers, the
health of the Nation as a whole is threatened because new
health threats do not respect geographic or political
boundaries.
PREPARED STATEMENT
CDC's health alert network will save critical time which
will translate into saving lives. The health of all Americans
depends on taking national proactive measures to preserve,
coordinate, and strengthen our public health system.
Thank you very much.
Senator Faircloth. Thank you, Dr. Morris.
[The statement follows:]
Prepared Statement of Dr. Ralph D. Morris
Good morning, Mr. Chairman and members of the Subcommittee.
I am Ralph D. Morris, MD, MPH. I am Director of the Galveston
County Health Department in Texas and am pleased also to serve
as President of the National Association of County and City
Health Officials (NACCHO). NACCHO is the organization
representing the almost 3,000 local public health departments
in the country. I am here today to explain how local health
departments serve on the front lines in battling public health
crises of all sorts, and why we need a national network of
electronic communications among public health agencies to help
protect our communities from the public health consequences of
acts of terrorism. The same high-speed access to information
that is essential for this purpose is equally important in
helping local health departments deal with a myriad of other
alarming public health threats, such as new and virulent
infectious diseases and diseases that are spread through our
food supply.
Outbreaks of disease can occur for many reasons--because
one child infected with infectious bacterial meningitis spends
a day going to classes in a school before his illness is
diagnosed--because one shipment of frozen strawberries from
Mexico arrives in grocery stores infected with the Hepatitis A
virus--because a hurricane or a flood disrupts water and sewer
lines and causes a public water supply to become dangerously
contaminated--or because a criminal introduces a lethal
biological agent, such as anthrax, into the air. Whatever the
reason for an unusual outbreak of illness, the local health
department has the local responsibility for detecting that
outbreak, tracing it to its source, and stopping its spread.
The potential public health threats we all face are growing
in number and complexity. Rapid air travel means grave
infectious diseases can be spread from one country to another
simply when an infected person takes a plane flight. Our food
supply has become globalized, and we are more vulnerable to
food-borne diseases from imported food than ever before.
Insidious bacteria that have mutated so that they are no longer
easily treatable with existing antibiotics are multiplying in
number. Virulent new viruses, such as hantavirus and Ebola, are
emerging. And reports of instances where persons have access to
biological weapons are increasing. While we rely on law
enforcement to prevent and deal with criminal acts, when those
acts pose a threat to health, we rely on the public health
system. Just as our military needs to keep up a defense against
new weapons development, so our public health system must
maintain a defense against new diseases and new ways that
diseases can be spread.
When people get sick, they seek care from their doctor or a
hospital. No single physician or hospital will necessarily
notice that anything unusual is occurring--but if they all
report any one case of unusual infectious disease that they
observe, the local health department can put that information
together to discern a pattern. This process is called disease
surveillance, and it is a fundamental function of public health
at the local, state and federal levels. Surveillance is our
early warning system that something is wrong.
In order to conduct disease surveillance effectively, local
health departments must be able to send and receive information
quickly to and from local doctors and hospitals, to and from
health departments in neighboring jurisdictions, to and from
the state health department, and to and from the Centers for
Disease Control and Prevention in Atlanta. The local health
department does the work on the ground, such as tracking down
who has been exposed to a disease, sometimes obtaining
laboratory specimens for accurate diagnosis, and taking
whatever measures are necessary to prevent its further spread.
The local health department also is responsible for giving
accurate and timely information to the media and the community.
In order to do its job, the health department needs not only
local expertise, but also immediate access to higher levels of
expertise that are available at the state health department and
at CDC.
In Galveston last February, we discovered a case of
meningococcal septicemia in a participant in the Mardi Gras
parade. We had to find and notify persons who had subsequently
scattered all over the state that they'd been exposed to this
potentially fatal disease. We used phones to work with other
local health departments. We played phone tag, relied on
messages, and spent an undue amount of time arriving at a
common understanding of the problem and what we had to do to
solve it. If all the local health departments had been
connected electronically, the process would have taken place
much faster.
Just a few months ago in Texas, several of our local health
departments and the state were faced with an outbreak of
invasive group A streptococcus, also known as ``flesh-eating
bacteria.'' Here again, if we'd had state-of-the-art
communications, we'd have been able more quickly to exchange
information about where cases were found and get accurate
information about this frightening organism out to the
community. Now we are dealing with an influx of smoky, hazy air
from Mexico, which has presented some immediate health hazards
to susceptible people, as well as some longer-term hazards that
we need to monitor. We could do this, and all our public health
emergency response work, in a more thorough, timely and
accurate manner with instant, uniform access to authoritative
information.
Every day, my colleagues in other jurisdictions face
outbreaks of illness caused by salmonella, E. Coli bacteria,
the hepatitis A virus, meningococcal bacteria, and a
frightening array of new antibiotic-resistant bacteria. None of
these diseases respects city or county or state boundaries--we
all must be well-prepared to share information about suspicious
incidents of disease, deal with outbreaks and communicate about
them to our neighbors. Agents of biological terrorism are
highly similar to other agents of disease in that they may be
insidious in onset and difficult to recognize. We won't
recognize them promptly enough to save lives if we can't trade
information with each other instantaneously.
Currently, electronic communications are the best way to
send and receive data quickly, and the Internet is the best way
to share data and get access to current information about a
disease. In the military and in law enforcement, these methods
of emergency communication are taken for granted. But in public
health, we are way behind. Most health departments still rely
on the phone, the fax machine, and paper and pencil to track
down the information they need to evaluate reports of disease,
identify who may have been exposed, analyze this data to
determine whether they've got a potential epidemic on their
hands, and call in expert advice. If they need to send or
receive information quickly, they just cross their fingers that
they can reach the right people by phone or that the fax goes
through. If there is an epidemic in the making and preventive
measures such as immunization of the population that has been
exposed to a disease are possible, saving time means saving
lives.
We have data that show just how far behind public health is
in its access to the information superhighway. About one-half
of all local health departments don't have the use of
electronic mail. At least one thousand local health departments
have no access to any on-line or Internet service. Among those
that do, one-third are not even linked to their state health
department, and fewer than one-quarter can reach other health
departments electronically. In some health departments, up to
five employees must share one computer.
Even where some type of electronic communications capacity
exists, a huge problem remains. The capacity is useless unless
people are trained to work with it effectively. Among those
health departments that do have it, 70 percent of the health
directors assessed that their staff had little or no expertise
in using on-line data and services. Building an electronic
communications network requires, therefore, not only acquiring
appropriate, updated hardware and software and modem or cable
connections to the Internet, but also training essential
personnel how to use it.
The knowledge gap is particularly alarming with respect to
biological and chemical terrorism. Few of us in public health
are familiar with the prevention, diagnosis or treatment of the
health effects from agents of biological warfare. We need quick
access to authoritative guidelines for implementing emergency
measures, as well as an ability to communicate instantaneously
and securely with other government agencies that would respond
to an instance of terrorism.
NACCHO strongly supports a proposal under development at
CDC for establishing a national Health Alert Network that will
fill the huge gap in communications capacity that now handicaps
us in our ability to recognize and deal quickly with public
health emergencies. Such a network must equip the front lines
in public health, local health departments, with essential
electronic information tools and train public health workers in
the skills they need to use it well. There must be a seamless
defensive shield, that enables the local, state and federal
partners in public health to work together to meet every
preventable health threat as it occurs. The same network that
will equip us to cope with an act of terrorism, such as an
intentional release of anthrax, will also equip us to deal with
the threats that occur even more frequently, when contagious
diseases or contaminated food or water threaten our
communities.
I and my colleagues who work in local public health are
accustomed to using scarce resources efficiently and
creatively, but most of us just don't have enough to update our
information systems and our staff to the level needed to meet
the threats posed by our nation's growing vulnerability to new
global health threats. I urge the Subcommittee to provide in
fiscal year 1999 and subsequent years sufficient funding to
develop a public health alert network in a planned, phased-in
fashion. We just can't afford to get any farther behind.
Whether the cause of a public health emergency is an innocent
cook at a church supper or an international terrorist, our need
to respond quickly remains the same. Saving time means saving
lives.
LACK OF PREPAREDNESS
Senator Faircloth. I think the general public is not aware
of the overall lack of preparedness that exists in the country,
and I think the Congress is not aware either.
Dr. Osterholm, you mentioned the Institute of Medicine
report in your testimony. I wanted to restate their first
recommendation which was to provide Federal funding to improve
the State and local infrastructure. In your view why do we seem
to keep having such a difficult time getting people to discuss
or to focus on this need?
Dr. Osterholm. Senator, I think the easy answer is, first
of all, disease surveillance and infrastructure is not sexy. It
is day-to-day work. It is like keeping our bridges in place.
Very few times do you take your car and stop before you get to
a bridge and decide do I go over it or not because I am not
sure it is safe. You just assume it is safe. You take it for
granted. We take for granted in this country that there is a
system in place to detect infectious diseases to respond to
infectious diseases and to plan for the future.
What we have really is a piecemeal surveillance system. We
do not have a blueprint in this country for figuring out when
and where and how we are going to detect infectious diseases.
It would be like if every little phone company around the
country could still set their own standards of how they are
going to share information, it would be a disaster.
The way that that is most frequently manifested is how we
come to Congress to get our money. As a State epidemiologist in
a State health department and also a member of ASM, the way I
do my disease surveillance is what can I get from immunization,
what can I get from the STD program, what can I get from the
HIV program, what can I get from emerging infectious diseases,
what can I get from the Lyme disease program, and it is one big
pot, and Peter robs Paul all the time to make sure that we have
a basic infrastructure.
While I commend the CDC for the efforts demonstrated over
here to the left of me with the emerging infectious diseases,
at the same time we have seen major cuts in our funding support
for immunization, HIV surveillance, for the area of STD and
tuberculosis, so that we never have really established what
does it take to do infectious disease surveillance in this
country and what is it we need as a basic infrastructure.
So, the bottom line is I think the reason we do not have a
good system is we have never really had a system, No. 1, and
No. 2 is that as long as we continue to fund it by robbing
Peter to pay Paul, you are always going to have a response like
this and that is the whole basis upon which this Nation's
protection is now sitting for the issue of bioterrorism.
Senator Faircloth. You mentioned the Institute of Medicine
recommendation that physician groups be enlisted to protect the
public and that is certainly reasonable. But we keep hearing
that doctors are often part of the problem, not the solution,
in addressing and reporting symptoms that might indicate
serious problems, that they simply do not do it. Is that true
or not true?
Dr. Osterholm. Well, Senator, I was born and raised in an
area of Iowa that is well known for having a lot of sinkholes,
these big holes in the ground that basically just keep getting
bigger and bigger year after year. A long time ago, farmers
recognized that if they keep pouring stuff down those holes,
but they kept getting bigger anyway, after a while they stopped
pouring things down the holes, meaning that after a while you
learn that if what you do does not make any difference, then
why continue to do it.
What has happened in many areas of this country is that
physicians and other areas of the medical care delivery system
do not work with their public health departments anymore
because the public health departments have nobody to respond,
so even if they did provide all the cases or they provided the
information, it is kind of like the big sinkhole.
Public health clearly does not want that to be the case. We
believe that that is not the way to run things. So, we have to
have that system in place.
In our State of Minnesota, we have really put a real
emphasis on this area and we have tried to be creative in our
support of funding. In fact, about 95 percent of my budget
there is what we call soft money, just like any other academic
center. We are going out constantly trying to bring in money to
support our infrastructure. In that case where we have been
able to show a clinician that if you provide a service to us,
meaning giving us the information, you will get something back
and you will have a response system. That does not occur around
much of the country.
So, I think that part of the problem clearly with
physicians and the medical care system is in part education to
make sure that they understand why and what they need to do,
but part of it is, if you tell them to do something and there
is no response, after a while they just will not do it anymore.
I think that we have unfortunately far too often conditioned
our medical community that public health will not be there in a
way that will be sufficient to merit their effort.
Senator Faircloth. I want to come back to the question
again in a minute.
But, Dr. Thompson, the National Governors Association has
scheduled their first meeting on the subject of bioterrorism
here in Washington on June 18. Do you know what we might expect
to come out of that? You are going to be here I assume.
Dr. Thompson. I do not know that I will but I would
certainly hope that the State health officials will be an
integral part of that as we would be of anything addressing
this issue.
I think what we will get out of it, I hope, is a
recognition among the Governors that there are several classes
of terrorism. Two or three of them are very similar in their
effects and their response. The sort of terrorism that is done
with explosives, the sort of terrorism done with chemicals is
responded to fairly traditionally by emergency medical service
first responders through our State disaster plans and similar
plans that address a natural disaster or a manmade disaster
where you have an impact and an aftermath of that impact.
Bioterrorism, attacks with biological agents, are a very
different terrorist weapon, and I think as the Governors
Association comes to recognize that, they will help us make the
Congress and the administration recognize as well that
bioterrorist attacks, of all the terrorist weapons that
possibly could be used, are unique in several ways, the most
important one of which is not just its effect. I believe that
biological agents are potentially the most effective, the most
devastating, and the most terrorizing of all the potential
weapons, short of nuclear weapons, that terrorists could use.
But not even that, the most important distinction that I
hope the Governors will come to understand and the rest of the
Nation as well is that the response to biological attack, to
biological agents will be different than it is to any other
terrorist weapon because it will necessarily integrally and as
the first focus involve State and local public health. It is
where it will be detected because you will not see an
explosion. You will see not even people flooding a hospital.
You will see people coming into their doctor's office sick.
After a while they may flood the hospital, but initially it is
our surveillance systems that will pick up the first fluttering
and catch it early or we will fail and we will wait until they
flood the hospitals and it is too late. It is a different
response pattern than you will use for any other terrorist
attack.
And the third major distinction is although we have got to
be prepared for all sorts of terrorism, bioterrorism
preparedness has the almost unique quality of spilling over
into everyday public health improvement activities because
almost everything we need to do--almost, not quite, but almost
everything we need to do--to prepare for a bioterrorist attack
anywhere in the country will have daily applications. Those
same laboratories, those same surveillance experts, those same
epidemiologists, those same tools will be used every day with
ordinary epidemics, with ordinary small outbreaks. Like a
battle tank we have got to have to win the war that somehow has
the ability to be a very efficient schoolbus, it is the best
bargain of all the types of preparedness we have got to deal
with.
That is what I hope we will accomplish in this meeting.
Senator Faircloth. As you described a bioterrorism
attack--I must say I had imagined it entirely different from
what you just said. I would have thought it would have been
some sweeping panic that would strike us. You are saying it
would be more of a creeping, devastating type of effect on our
bodies that would take days and maybe weeks to begin to show?
Dr. Thompson. Yes; I almost hesitate to say what I am about
to say, but I will. If we are very fortunate and we are some
day attacked by very naive, very inastute terrorists, if we are
lucky enough to get dumb terrorists, they will detonate a
capsule of anthrax over a major sports stadium or they will
announce that they have just set off a bomb containing
botulinum toxin in a busy airport, that is if we are lucky.
If I were going to do it and if we get a smart terrorist,
this is what they will do. They will quietly simultaneously or
in quick succession release smallpox virus or some other
communicable virus or bacteria in dozens of different
locations, probably not----
Senator Faircloth. That virus you mentioned, how would
that affect you?
Dr. Thompson. Smallpox? Smallpox would not begin to show--
--
Senator Faircloth. Oh, smallpox.
Dr. Thompson. Yes; old-fashioned smallpox which is not that
difficult to obtain. Although it has been eradicated from human
populations, lab samples are around.
Senator Faircloth. Would the immunity that we all got as
children not----
Dr. Thompson. It is gone. So, we would begin to see after
smallpox virus had been quietly and in an undetected manner
released in dozens of locations, probably places like Jackson,
MS, and Omaha, NE, probably not Los Angeles and New York--we
would begin after several days to see symptoms, ill-defined
symptoms, presented. As we began to recognize more and more
cases of a disease we could not quite pin down, we would
eventually diagnose smallpox through public health surveillance
techniques, and by that time, second generation cases would be
appearing in New York and San Francisco and places like that as
the people who had been in Omaha, Jackson, and Tallahassee had
now traveled to these large cities. It would have spread into
our population in a very insidious fashion before we ever
recognized that it occurred.
When a bomb blows up, you know where it hit. You know who
it blew up and you know what has to be done for them.
Bioterrorism with infectious agents has the ability to kill
people, to make people sick, and to terrorize those who are not
sick wondering if they may become sick. That is why it is such
a terrifying weapon.
Senator Faircloth. That is frightening, and this is
something that is frightening to not only me, but to a lot of
the Congress also, more so than a bomb planted somewhere. As
horrible as that is and as deadly as it is, it is likely to be
confined to a building or is a contained type of terrorism,
whereas the type of thing you are talking about, as rapidly as
we move as a nation, the terrorist would not even have to do
the spreading. They plant it in the proper airport, so they
could pretty well cover the country by sundown if they got it
out by breakfast.
Dr. Thompson. And we would not know they had been there
until 2 days later or 3.
Senator Faircloth. Literally if you planted some sort of a
virus at four, five, six major airports around the country in
the morning, you would have it pretty well over the country by
the end of that day.
Dr. Thompson. With some agents, that is true.
Senator Faircloth. If it moves that way. Certainly people
would be all over the country by the end of the day.
It is frightening to think about. In talking to Dr. Knouss,
I was somewhat frightened by his--I mean in testifying
honestly--the lack of preparedness we might have was--Dr.
Osterholm, do you want to comment on that or, Dr. Morris, or
any of you? Were you--or did I misunderstand the testimony?
Certainly it appears we need to do a lot in light of our
current unpreparedness.
Dr. Morris. I think a lot of these new threats are just
coming into our awareness and the public awareness.
Senator Faircloth. How recently, Dr. Morris?
Dr. Morris. I am sorry?
Senator Faircloth. How recently?
Dr. Morris. I would say in the past 2 or 3 years,
particularly with the incidents that have been described
earlier. I know for a local health department in terms of day-
to-day activities, we have our hands full in terms of just
keeping up with the regular activities that we have, and to
talk about planning for something so catastrophic, as Dr.
Thompson was just talking about, is almost unimaginable.
But I think we are at the point now where we have gotten a
couple of wake-up calls that if we do not pay attention and
start putting some resources or rededicating some resources, at
some point in the future, we really could be in trouble in
trying to respond to either a natural occurring epidemic or
something that is manmade.
Dr. Osterholm. Senator, I think that to answer that
question as you posed it, having spent almost 25 years in
public health, having been in the middle of a number of
outbreaks of Legionnaire's disease, toxic shock syndrome, HIV,
meningitis--I can go down the list--a number of food-borne
outbreaks, there have been outbreaks that have clearly
challenged us. There have been outbreaks when I had to be at
the bedside and watch a 17-year-old boy die of meningococcemia
realizing he shared a birthday with my daughter. There were
times that it was very hard to be in my job.
But there is simply nothing that scares the hell out of me
like this issue because the implications for this are so far-
reaching. It is so easy today to imagine how a terrorist could
take a plane and fly a line from Arlington, VA, up to Silver
Spring, MD, and put 2 million people in Washington, DC, at high
risk of anthrax over the next 2, 3, or 4 weeks. It is very
simple. Secretary Cohen showed that when he was on TV not long
ago with his bag of flour that he demonstrated what it would be
like if those were anthrax spores. Today if you hit a major
building in this country with an aerosolizing device to put
smallpox in would mean that in 2 weeks we could have tens to
thousands of cases that then would spread out.
So, I think the implications are very, very high stake
here. You heard earlier from Dr. Knouss the concept of very low
probability but very, very high consequence.
I would just share with you I think as a local person out
there representing a national organization that Washington has
responded to the issues of terrorism. The problem is it
continues to be oriented toward the area of chemical terrorism.
Senator Faircloth. The area of chemical?
Dr. Osterholm. Chemical terrorism, the kind of situation
that Dr. Thompson just shared with you. Nunn-Lugar legislation
has helped us a great deal at the local level to begin dealing
with chemical terrorism. It has done nothing for biologic
terrorism. Giving the National Guard $300 million and
stationing 12 units around the country does little to nothing
to help us with the planning of biological terrorism.
Frankly, it is the issue of the State and local health
departments that have not been brought in on any of this in
terms of planning and infrastructure support which is the
critical first step. So, I think what we have to be careful
here is not to confuse action as opposed to what is going to
make a difference, and there has been action but I have not
seen a lot yet that is going to make a difference.
Senator Faircloth. Dr. Osterholm, one time I was deeply in
debt to a bank when I was about 22 years old and far more than
a 22-year-old should have been. I went in one day and he told
me I had a problem. He told me that on a regular basis. And I
asked him which one was he discussing. And he said, your
problem is you are mistaking motion for action. And that is
something we do often in government and in governmental policy.
One question I want to ask--and our time is running out. I
understand there is a serious problem developing with microbes
that are developing a resistance to the antibiotics that we
have traditionally used. Of course, I grew up thinking that
penicillin was the miracle cure for all of our problems. Why
are these resistant microbes developing?
I mean, I understand they are developing resistance because
of the overuse of antibiotics. So, that is the why. What do we
do about it? Where is it developing? Where do we start? Is it
animals, people, or is it a problem at all?
Dr. Osterholm. Well, Senator, to give you the necessary
short answer, I will abbreviate it, but we would all be happy,
I think, to come back to a second hearing that could take up an
entire day on this very issue, a very important issue, by the
way, a very important issue.
I think the short answer is that whether it is in animals
or in humans, whether it is domestic or international, we
unfortunately have abused and used antibiotics in ways that
were never intended. Frankly, Darwinian evolution is taking
over. The bugs are winning, and while we have made great
inroads in understanding that we have a problem today, we have
only had limited action in terms of doing something about it.
Actually what we have here before you today in the issue of
bioterrorism is very consistent with responding to
antimicrobial resistance. One of the ways that we are going to
do something about it is if we know about it, and today in many
of our systems around the country, we do not have the ability
to detect it until some clinician realizes that the antibiotics
they were going to use for that patient are not working and
only find out that that particular infectious agent is
resistant to those bugs. We need a population based
surveillance system that is routinely picking this up. If you
have that in place and it is just, oh, by the way, so happens,
unfortunately, a biological terrorism event occurs, you will
pick that up too.
So, I think to address your question here, is if we had a
better system in place, we could have the information to bring
back the policymakers to other scientists to be able to say
this is how bad the problem is right now. This is what is
happening. What is it that we should and can do about it?
Senator Faircloth. How could you put such a system in
place, Dr. Thompson or Dr. Morris, in Galveston or Jackson?
Dr. Thompson. I think the first key here is--and I tend to
use the term ``State and local health departments
interchangeably because in Mississippi they are one and the
same. In places like Texas----
Dr. Morris. They are not.
Dr. Thompson [continuing]. There are large city health
departments that are independent of the State. The picture is
quite different. So, you are talking about a State health
department lab in Mississippi is comparable to a city health
department lab, say, in Galveston or San Antonio.
But around the country there are State and large city
health department laboratories that could form a big part of
the basis for such a surveillance system. A lot of the
technology is very complex, but some of it is not and can be
accomplished on a regular basis by laboratories that are
already there and need only a little bit of additional funding
to become capable of watching for the development of antibiotic
resistance. Some of the surveillance would require special
laboratories and even that of the CDC, but the basic sort of
watching to see when we see it coming could be done with a
network of State and large local health department laboratories
that already exist.
Dr. Morris. It has been mentioned earlier that the public
health surveillance system in this country is really a
haphazard system. I think the first step would be to establish
some type of plan or coordinated effort between the Federal,
State, and local levels of government in terms of surveillance.
Another essential component would be the training of public
health workers at the three levels of government to be sure
that they understand the plan and understand the basic concepts
of surveillance and epidemiology, and then finally, giving
those people and departments the necessary tools in terms of
hardware and software so that they can carry out that type of
surveillance.
I can tell you for a fact that is what we need in Texas in
terms of developing some type of comprehensive, coordinated
surveillance in our State.
Senator Faircloth. I understand this is coming about from
the resistance to antibiotics because we are giving too many
antibiotics. Is that a fair assumption of one of the problems?
The resistance comes from overuse of the antibiotics?
Dr. Morris. Overuse and then incomplete treatment regimens.
Certainly in dealing with tuberculosis, one of the major
reasons has been people taking incomplete courses of
antibiotics. Of course, that is a very long regimen.
Senator Faircloth. I remember some time ago, 40 years ago,
penicillin had just become the all-time favorite drug and
literally a lot of doctors were giving it for everything and in
massive doses, I mean, bad colds, runny noses. You went to the
doctor, you were almost sure to come out with a shot of
penicillin regardless of what you went in with. I would assume
that has changed, but that at one time was the thing.
I want to thank you all for being here today. I realize the
inconvenience of coming from Minnesota, Mississippi, and Texas.
But I want you to know that you play such a vital role in the
preparedness that should exist nationwide.
The money problems we are simply going to have to address,
but of all the things that we spend money on in this country--
and we spend massive amounts of it--I do not know of anything
more important to the population of this country as a whole
than those things we have been talking about here today. If we
cannot put it in those channels, where are we going to put it?
The public health service saves the lives and protects the
public health and the overall welfare of the people.
So, we are all going to have to become advocates and we are
going to have to speak up for these needs. In the Congress we
can get penny wise and pound foolish and spend a lot of money
in things that are not as potentially devastating to us as a
Nation like the things we have been talking about today, and
not only devastating as a Nation but for communities or
individuals.
PREPARED STATEMENT OF SENATOR THAD COCHRAN
We have received a prepared statement from Senator Cochran,
it will be inserted into the record at this point.
[The statement follows:]
Prepared Statement of Senator Thad Cochran
Mr. Chairman, I believe as you do that there must be a
stronger federal commitment to preparing our nation for the
consequences of infectious disease outbreaks and lethal
chemical exposure, terrorist or otherwise. In terrorist
situations, our armed services and police forces will be
required to act quickly to command and coordinate the
investigation of the incident and culprits, ensure the
prevention of possible civil unrest, and provide for the
defense of United States citizens from ongoing attacks.
However, the biological and chemical risks posed to our country
present a much broader problem, one that must be addressed by
the public health community--the Centers for Disease Control
and Prevention (CDC) and State and Local Health Departments.
Whether the infectious disease event or chemical exposure
results by way of nature, accident, or intent, the United
States must have a public health mechanism adequately prepared
to respond quickly and effectively to save lives. One of our
witnesses, Mississippi State Department of Health Officer, Dr.
F.E. ``Ed'' Thompson, Jr., last year successfully coordinated
the efforts of both local and national public health
organizations to quickly respond to widespread residential
chemical exposure on the Mississippi Gulf Coast. Local bug
sprayers had used cotton pesticides indoors and subjected
residents to dangerous, if not deadly, levels of chemicals.
Utilizing CDC environmental laboratories, Dr. Thompson was able
to determine very quickly the levels of contaminants in
individuals, so as to decide who would need to abandon their
homes and seek alternative housing, while allowing those with
safe levels to stay in their homes, thereby saving lives as
well as government resources.
Mr. Chairman, I am hopeful that through today's hearing we
can learn of additional ways we can prepare for the biological
and chemical threats to our nation and can assist our local,
State and national health organizations in meeting any
challenges that may befall us.
ADDITIONAL COMMITTEE QUESTIONS
Senator Faircloth. There will be some additional questions
which will be submitted for your response in the record.
[The following questions were not asked at the hearing, but
were submitted to Dr. Thompson for response subsequent to the
hearing.]
Questions Submitted by Senator Thad Cochran for Response of Dr.
Thompson
Question. Dr. Thompson, many in Washington have suggested
that the biological and chemical threat to the civilian
population is best handled by the military, since it has great
expertise in chemical and biological warfare defense and
possesses facilities such as Fort Dietrich. The military will
not doubt be a vital part of any response to biological or
chemical terrorism event, but do you think the military alone
can adequately address the public health issues associated with
such a catastrophe?
Answer. Clearly the military cannot handle a civilian
bioterrorist event alone. While the military has capabilities,
expertise, and resources that will be vital in responding to
such events, effective response to bioterrorist attack cannot
be mounted by the military alone, especially if the weapon is
an infectious agent, such as smallpox. The public health
skills, in-place systems, local knowledge, and public trust
that state and local public health departments have will also
be vital to adequate response. The third indispensable
component will be Federal civilian public health agencies,
primarily the CDC. All three, military, civilian Federal, and
State/Local public health departments, will be essential; no
one or two of them can handle it alone.
Question. Dr. Thompson, you described the need to fund a
public health infrastructure. What is your estimate of the cost
of such an infrastructure, on both the local, State, and
National level?
Answer. An initial estimate of the cost of shoring up the
public health infrastructure would be $200 million for state
and local needs, and at least $108 million for CDC and its
laboratories. A more accurate determination of additional needs
would come as a part of the national planning process, with
state and local involvement, recommended by ASTHO.
CONCLUSION OF HEARING
Senator Faircloth. So, I thank you for your awareness and
alerting us to the problem, and I intend to follow it and to
pursue it. I thank you for coming, that concludes our hearing.
The subcommittee will stand in recess subject to the call of
the Chair.
[Whereupon, at 4:07 p.m., Tuesday, June 2, the hearing was
concluded, and the subcommittee was recessed, to reconvene
subject to the call of the Chair.]
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