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This is an archive page. The links are no longer being updated.
Testimony
Before the Senate Special Committee on Aging - NY Field
Hearing
The CDC and Emergency Preparedness for the Elderly and Disabled
Statement of
Stephen Ostroff, M.D.
Associate Director for Epidemiologic Science National Center
for Infectious Diseases
Centers for Disease Control and Prevention, HHS
For Release on Delivery
Expected at 2:00 PM
on Monday, February 11, 2002
Good afternoon, Mr. Chairman and Members of the Committee.
I am Dr. Stephen Ostroff, Associate Director for Epidemiologic
Science in the National Center for Infectious Diseases (NCID),
Centers for Disease Control and Prevention (CDC). During
the bioterrorism-associated anthrax attacks last fall, I
was the lead investigator of the CDC team sent to New York
City to assist the City's public health and emergency response
officials. I have also worked closely with New York City
officials over the years to address other emerging infectious
disease threats, particularly West Nile virus which made
its first North American appearance here in 1999. Let me
thank you for the invitation to participate in today's hearing
on emergency preparedness for the elderly and disabled and
for the ongoing interest of the Committee in this issue.
Today I will be discussing CDC's public health response
to the threat of terrorism, particularly that associated
with biological agents, and how we are working with our
state and local partners to strengthen the nation's capacity
to address these threats and improve our response in the
future.
Let me begin by providing a brief overview of CDC's activities
related to September 11th and the subsequent anthrax attacks.
Within hours of the September 11th attacks, CDC deployed
teams of responders to New York City to assist in monitoring
the impact of the event and deployed assets of the National
Pharmaceutical Stockpile to assure availability of essential
medical supplies and drugs. Within 4 hours of the first
plane attack, CDC sent a Health Alert Network message to
all 50 states, 4 cities and 1 territory advising the nation's
public health system to heighten surveillance. By the end
of that week, CDC had on-site more than 70 personnel engaged
in a range of activities, in particular, monitoring the
patterns of injury and illness in victims and relief workers;
measuring hazardous exposures at the WTC site and recommending
strategies to protect rescue and cleanup workers; and maintaining
a heightened state of alert for other events, particularly
of a biological or chemical nature. These activities were
still ongoing when anthrax was recognized in New York City
on October 12th, and CDC augmented its onsite presence to
assist in investigating the sources of infection, assessing
workplace contamination, enhancing laboratory diagnostic
capability, and providing antibiotic chemoprophylaxis to
thousands of affected individuals at the various media outlets
and postal facilities.
The episode of bioterrorism-related anthrax was the first
instance of the intentional use of this agent in U.S. history.
Overall, there were a total of 22 cases of anthrax in Florida,
Washington DC, New Jersey, New York, and Connecticut, with
five fatalities. Eleven of the cases were the cutaneous
(or skin) form of anthrax, while the remaining eleven were
the inhalational form of the disease, which has traditionally
been associated with mortality rates in excess of 80%. In
New York City, there was a total of eight anthrax cases,
seven cutaneous and one inhalational, with one fatality.
Among all 22 cases, the mean age of patients was 46.6 years,
with a range of 7 months to 94 years. However, it was observed
that persons with inhalational disease were significantly
older (mean age 60.3 years) than persons with cutaneous
disease (mean age 32.9 years). Since there is little previous
experience with the intentional use of anthrax, we do not
know if this age differential is a usual feature of anthrax.
For some diseases such as West Nile virus, older individuals
are at higher risk of developing severe disease if infected.
However, in the recent anthrax events, it may simply reflect
the fact that the workers who handled the letters in New
York City were somewhat younger than the postal workers
who processed them in other locations. Of note, two of the
five fatalities occurred in persons over the age of 70 years.
The response to the anthrax episodes was rapid, intense,
and comprehensive. During the peak phase of the investigation,
CDC had more than 200 persons in the field in the various
locations, with hundreds of additional personnel in our
home offices supporting the field effort, handling thousands
of public and media inquiries, disseminating information,
and processing many thousands of clinical and environmental
specimens. Over 1.4 million individual participants were
recipients of distance learning broadcasts originating from
CDC via satellite broadcasts and web streamed video. The
Epidemic Information Exchange (Epi-X)public health's
established, secure communications networkprovided
local CDC investigative teams, state epidemiologists and
other public health officials a forum for posting and discussing
new and evolving information, as well as for receiving information
from CDC. The urgent notification feature was used to alert
state epidemiologists by pager and phone of the report of
the first anthrax case in New York City, and over 90 other
reports were posted and local response plans were distributed.
It has been estimated that approximately 25% of CDC's workforce
was involved in some aspect of the anthrax response. Similar
efforts occurred on the part of public health agencies in
the directly involved states, and in the less involved regions
as well. All states and localities were called upon to respond
to public concerns about the events, and state public health
laboratories throughout the country were overwhelmed with
samples for anthrax testing, all requiring rapid turnaround
and handling as part of a potential criminal investigation.
In all sites combined, approximately 10,000 persons were
recommended by public health authorities to receive 60 days
of antibiotic prophylaxis as a result of their exposure
to anthrax spores. The incidence of adverse reactions among
these persons was similar to those previously reported for
the antibiotics which were offered. Among those persons
offered prophylaxis, none developed either inhalational
or cutaneous anthrax once the antibiotics were started.
The events of September 11th and the anthrax episodes demonstrate
the critical need for a strong and flexible public health
system which can effectively respond to bioterrorism as
well as to the numerous naturally-occurring public health
threats that affect U.S. citizens every day. This system
needs to be able to smoothly integrate its activities with
a variety of emergency response and law enforcement partners
and the health care community, and it needs to seamlessly
operate at the federal, state, and local levels.
Congress first allocated funds to CDC to begin to address
the need to build state and local capacity to address the
threat of bioterrorism in 1999. CDC's program for bioterrorism
preparedness and response has focused on the following areas:
Planning for emergency preparedness
Development of epidemiologic capacity and monitoring systems
Development of capacity to rapidly and accurately identify
biological agents
Development of capacity to rapidly and accurately identify
chemical agents
Development of standards for respiratory protection for
responders to biological, chemical, and radiation hazards
resulting from acts of terrorism
Development and enhancement of communications systems to
allow public health officials to share critical and timely
information through the Health Alert Network, distance learning,
and Epi-X
Development of the National Pharmaceutical Stockpile
Regulation of the shipment of selected biological agents
and toxins
Even before the events of last fall, CDC had in place cooperative
agreements with all state health departments, as well as
many large local health departments, to build capacity in
some or all of the program areas just mentioned.
Some of CDC's accomplishments during this period include
the development and deployment throughout the country of
12-hour push packs of essential medical supplies and drugs
to be used in the immediate aftermath of an event; development
of the Laboratory Response Network that includes approximately
90 state and local public health laboratory facilities around
the country which use standardized testing procedures and
reagents to identify threat agents such as anthrax, plague,
tularemia, and botulism; and deployment of syndromic surveillance
systems at high profile events to assure rapid recognition
of biological or chemical terrorism; and release of the
first standard for first responders' respiratory protection
against weapons of terrorism.
However, the events of last fall demonstrate that we must
move much more rapidly to expand our capacity in all of
these areas. We must assure that all states and localities
are adequately prepared to address biological threats to
their populations and can mount an effective response. In
late January, HHS announced that a total of $1.1 billion
in funding would be provided to states to assist them in
their bioterrorism preparedness efforts. On January 31st,
Secretary Thompson sent a letter to the governor in each
state detailing how much of the $1.1 billion his or her
state would receive to allow them to initiate and expand
planning and building of the public health systems necessary
to respond. The funds will be made available through cooperative
agreements with State health departments, to be awarded
by CDC and the Health Resources and Services Administration,
and through contracts awarded by the Office of Emergency
Preparedness with cities for the Metropolitan Medical Response
System Initiative.
The funds are to be used for development of comprehensive
bioterrorism preparedness and public health emergency response
capabilities; upgrading infectious disease surveillance
and investigation; enhancing the readiness of hospital systems
to deal with large numbers of casualties; expanding public
health laboratory and communications capacities; education
and training for public health personnel, including clinicians,
hospitals, and other critical public health responders;
and improving connectivity between hospitals and local,
city, and state health departments to enhance disease reporting.
The State of New York will receive $29.4 million in funds
and the City of New York $22.8 million in funds from CDC.
Biological agents such as anthrax, smallpox, and botulism
are considered bioterrorism threats because of their extreme
virulence and relative ease of dissemination. Should they
be used, they would likely affect all segments of the population,
including children, healthy young adults, and older people,
with substantial morbidity and mortality in all groups.
However, there are certain challenges for older Americans
related to bioterrorism. One relates to the drugs and vaccines
used to treat and prevent these diseases. Many have side
effects, such as dizziness or nausea, which make them particularly
difficult to use for prolonged periods in older persons.
In addition, older people are more likely than other groups
to be taking other medications, some of which might have
known or unrecognized drug interactions with recommended
antibiotics. The FDA approved "Indication and Usage"
of the licensed Anthrax Vaccine Adsorbed is for use in persons
between 18 and 65 years of age.
Additional research is necessary to better understand the
infectious dose of agents such as anthrax and whether the
amount of exposure necessary for development of disease
could be lower in older individuals than other age groups.
This issue arose with respect to the potential risk posed
by low numbers of spores which could be present in cross-contaminated
mail. Even recognizing that any such risk was small given
the large volume of mail in this country, CDC issued prudent
guidelines for persons who wished to further reduce their
risk of exposure to contaminated mail.
At the NIH, the National Institute of Allergy and Infectious
Diseases (NIAID) leads the effort to develop new and improved
vaccines. As part of its smallpox dilution study, the NIAID
will soon undertake a study to examine the effect of re-vaccinating
individuals who were previously vaccines 30-plus years ago
to determine the spectrum of reactions and safety. This
study will be open to anyone over age 35 who has evidence
of prior vaccination. The NIAID also plans to engage in
studies of "next generation" smallpox vaccines
that can be used in all segments of the population, including
the elderly.
In addition to older people, another group of citizens should
be given consideration in developing bioterrorism and emergency
preparedness plans. This group are our citizens with disabilities
and functional limitations. As with older people, some will
have increased susceptibility due to compromised immune
systems or poor health status. Many will also be on medications
and thus drug interactions could be an issue.
In developing emergency preparedness plans,
it is just as important to remember to address some general
issues that impact older Americans and those with disabilities
regardless of the type of emergency: natural, bioterrorism,
chemical, nuclear, etc. These issues include but are not
limited to:
Older people and people with disabilities often need more
time than others to make necessary preparations in an emergency.
Emergency and disaster warning must be given in a variety
of formats to reach people with vision and hearing impairments,
including closed captioning, audio alerts, and additional
visual cues. These warning mechanisms assist everyone in
an evacuation, not just people with disabilities.
People who are blind or visually-impaired, especially older
people, may be extremely reluctant to leave familiar surroundings
when the request for evacuation comes from a stranger.
Although a well trained, guide dog and other assistance
animals can become confused or disoriented in a disaster,
people who are blind or partially sighted may have to depend
on others to lead them, as well as their dog, to safety
during a disaster.
People with impaired mobility are often concerned about
being dropped when being lifted or carried. Preparedness
must include learning proper techniques to transfer or move
someone in a wheelchair and what exit routes from buildings
are best. If a person is separated from his or her mobility
device during the evacuation, plans for recovering the mobility
device or moving that person once outside the danger area
must be considered.
Some people with mental retardation, or people who are cognitively
impaired, may be unable to understand the emergency and
could become disoriented or confused about the proper way
to react. Emergency warnings may need to be modified to
permit the individual with cognitive impairments to better
understand and respond to the warning
Many respiratory illnesses can be aggravated by stress.
In an emergency, oxygen and respiratory equipment may not
be readily available.
People with epilepsy, paralysis, Parkinson's disease, end
stage renal disease and other conditions and impairments
often have very individualized medication or treatment regimes
that cannot be interrupted without serious consequences.
Some may be unable to communicate this information in an
emergency.
Care should be taken to ensure that temporary shelters are
accessible and have alternate communication services available
for people with visual and hearing impairments.
In conclusion, CDC is committed to working with other federal
agencies and partners, state and local health departments,
and the health care community, to ensure the health and
medical care of our citizens. Although we have made substantial
progress in enhancing the nation's capability to prepare
for and respond to a bioterrorist episode, the events of
last fall demonstrate that we must accelerate the pace of
our efforts to assure an adequate response capacity. The
best public health strategy to protect the health of civilians
against biological terrorism is the development, organization,
and enhancement of public health prevention systems and
tools. Priorities include a strengthened public health laboratory
capacity, increased surveillance and outbreak investigation
capacity, and better health communications, education, and
training at local, state, and federal levels. Not only will
this approach ensure that we are prepared for deliberate
bioterrorist threats, it will also ensure that we will be
able to recognize and control naturally occurring new and
re-emerging infectious disease threats. A strong and flexible
public health system is the best defense against any disease
outbreak or public health emergency.
Once again, let me thank you for the opportunity to be
here today and to assist the citizens of New York City last
fall and in the future. We look forward to working with
you to address the health and security threats of the 21st
century.
At this time, I will be happy to answer any questions you
may have.
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revised: February 11, 2002
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