FY 2008 Budget Request: HHS Emergency Preparedness

Testimony

Statement by
Julie L. Gerberding, M.D., M.P.H.,
Director

on
FY 2008 Budget Request: HHS Emergency Preparedness

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

Friday, March 09, 2007

Mr. Chairman and members of the Subcommittee,I am pleased to be here today to provide an update on emergency preparedness and response activities at the Centers for Disease Control and Prevention (CDC).

Since 2001, CDC and the nation as a whole have made great progress in preparing for catastrophic events—whether the event is a bioterror attack, an influenza pandemic, a hurricane, or other man-made or natural event. We’ve learned that preparation for one type of event can provide lessons to prepare for another. By focusing on “all-hazards” preparedness, federal, state, and local partners are able to use their limited resources to prepare comprehensively for as many threats as possible. CDC and its partners have accomplished much, and there is much left to do.

CDC’s Strategic Preparedness Framework

At CDC, all-hazards preparedness is the foundation of our strategic preparedness framework. CDC has made all-hazards preparedness and emergency response a priority and is building systems to catalyze and implement preparedness and response activities. CDC collaborates with the HHS Office of the Assistant Secretary for Preparedness and Response (ASPR), the National Institutes of Health (NIH), and other HHS agencies as well as other federal, state, and local government partners, the private sector, non-governmental organizations, and tribal nations to accomplish those activities.

To do this effectively, CDC has established nine agency preparedness goals to strategically focus and efficiently direct CDC resources. These goals are aligned under three overarching categories:

Pre-Event

Increase the use and development of interventions known to prevent human illness from chemical, biological, radiological agents and naturally occurring health threats;
Decrease the time needed to classify health events as terrorism or naturally occurring in partnership with other agencies;
Decrease the time needed to detect and report chemical, biological, radiological agents in tissue, food, or environmental samples that cause threats to the public’s health;
Improve the timeliness and accuracy of communications regarding threats to the public’s health;

Event

Decrease the time to identify causes, risk factors, and appropriate interventions for those affected by threats to the public’s health;
Decrease the time needed to provide countermeasures and health guidance to those affected by threats to the public’s health;

Post-event

Decrease the time needed to restore health services and environmental safety to pre-event levels;
Improve the long-term follow-up provided to those affected by threats to the public’s health; and
Decrease the time needed to implement recommendations from after-action reports following threats to the public’s health.

Taken together, these goals provide CDC with a strategic framework from which to establish and implement preparedness programs, with the goal of integrating our activities with those of our emergency response partners at all levels of government and the private sector.

To convey the range of CDC accomplishments and how our collaboration with other federal partners contributes to those efforts, I will describe:

Examples of CDC’s recent preparedness and response accomplishments;
Collaborations within HHS, focusing on ASPR, particularly with regard to implementation of the Pandemic and All-Hazards Preparedness Act (P.L. 109-417), and NIH; and
Next steps for public health preparedness and response activities.

Recent CDC Preparedness and Response Accomplishments

CDC and our partners have made public health preparedness and response a priority. The federal government, state and local health departments, and the private sector are now much more prepared to handle the public health consequences of a catastrophic event than they were even a few years ago. CDC has contributed to this progress in the following ways:

PulseNet is a national network of public health laboratories that performs DNA “fingerprinting” on foodborne bacteria. The group of epidemiologists in the states and at CDC who regularly investigate and report on foodborne outbreaks is called OutbreakNet. PulseNet and OutbreakNet, coordinated by CDC, detected the recent outbreak of Salmonella infections and linked these infections to peanut butter. PulseNet microbiologists in health departments and federal agencies including CDC, U.S. Department of Agriculture (USDA), and the Food and Drug Administration (FDA) performed molecular sub-typing (“fingerprinting”) of Salmonella bacteria and determined that more than the expected number of infections with an uncommon strain were occurring. OutbreakNet epidemiologists in health departments and at CDC conducted intensive interviews with ill and well persons and used statistical techniques to determine that peanut butter of a particular brand was responsible. Peanut butter had never before been linked to illness in the United States. These groups also identified spinach and lettuce as the vehicles for serious outbreaks of E. coli O157 infections in fall 2006. In an outbreak setting, speed matters. The linkage of spinach to E. coli cases in the fall of 2006 led to a product recall by FDA that prevented further illness and possibly saved lives. OutbreakNet and PulseNet help CDC to achieve its goal of decreasing the time to pinpoint particular threats to the public’s health. CDC collaborates with regulatory agencies and industry to make changes that decrease the chance of similar outbreaks.
CDC’s Emergency Operations Center (EOC) has been a critical asset in CDC’s response to various emergencies. The facility allows CDC to organize its scientific teams in one location for a more efficient exchange of information and connects them internally and externally using state-of-the-art technology to ensure an efficient and effective response. The EOC is CDC’s command center for the coordination of emergency response to domestic and international public health threats and is staffed 24 hours a day, 365 days a year. CDC has been put into response mode 33 times between September 2001 and February 2007 for events such as the anthrax events of 2001, SARS and Monkeypox in 2003, multiple hurricane responses, and the recent E-coli responses in 2006. In addition, exercises, drills, and simulations are regularly conducted to help ensure more effective response operations during a real event. Twelve exercises were conducted in 2006. These included a hurricane preparedness exercise, several general knowledge orientation exercises for our responders, and a collaborative exercise with HHS to test the Continuity of Operations Plan, also known as COOP. Approximately 12 exercises are planned for 2007, including a series of exercises on pandemic influenza, and participation in TOPOFF 4 in conjunction with the Department of Homeland Security (DHS), HHS, and other federal agencies. TOPOFF, a congressionally-mandated exercise program, is a series of federal exercises designed to strengthen the nation’s capacity to prevent, protect against, respond to, and recover from large-scale terrorist attacks involving Weapons of Mass Destruction (WMD).
BioSense is a national program intended to improve the nation’s capabilities for disease detection, monitoring, and real-time situational awareness through access to existing data from healthcare organizations across the country. Data obtained through BioSense help confirm or refute the existence of an event and monitor its size, location, and rate of spread. Approximately 350 hospitals now are able to transmit real-time data to BioSense. BioSense also receives data from 466 Department of Defense (DOD) and 863 Department of Veterans Affairs (VA) healthcare facilities. CDC will continue to work with and focus collaborative efforts on state and local health departments.
The Laboratory Response Network (LRN) is a network of state, local, and federal public health, military, and international laboratories that provide public health, food, veterinary, and environmental testing capacity to respond to biological and chemical terrorism and other public health emergencies. As of March 2, 2007, there are 162 member laboratories representing all 50 states, Australia, Canada, Japan, and the United Kingdom. In 2001, there were only 91. In 2004, there were 118 LRN labs. Eighty-seven percent of the United States population lives within 100 miles of an LRN laboratory. Also, as a result of the deployment of a new H5N1 assay to LRN labs (developed collaboratively by CDC, FDA, and LRN-affiliated state public health labs), all states now have laboratory capacity to detect H5N1 influenza. In FY07, the President's Budget included a request for $3 million in new funding which will enable CDC's Environmental Health Laboratory to enhance mass spectrometry methods to measure botulinum toxins, anthrax, ricin, and other toxins used as bioweapons. The CDC Mass Spectrometry Toxin Laboratory, a collaboration between the LRN and CDC’s environmental and infectious disease laboratories, has made significant advances in the analysis of protein toxins to provide more sensitive, specific, accurate, and rapid measurement of these toxins.
CDC scientists reconstructed the 1918 pandemic influenza virus, providing an invaluable research tool for determining which viral characteristics made this particular influenza strain so virulent. Correspondingly, to ensure that this reconstructed virus is handled only by qualified researchers and institutes, CDC added the reconstructed 1918 influenza virus to the list of select agents. By being on the list of select agents, the virus’s possession, use, and transfer is regulated by CDC.
CDC’s influenza laboratories and other World Health Organization (WHO) Global Collaborating Centers and National Influenza Centers isolated and characterized strains of avian influenza and with this information recommended representative strains for use in avian influenza vaccines. CDC laboratories also employed reverse genetics methods to rapidly develop safer strains of newly-identified avian influenza viruses for use in vaccine production.
The Strategic National Stockpile (SNS) has been increasing its supply of countermeasures that could be used during an influenza pandemic. As of March 2, 2007, the SNS contains the following antiviral drug quantities: approximately 21.6 million regimens of Oseltamivir capsules with an additional 9.1 million regimens on order; and approximately 2.2 million regimens of Zanamivir with an additional 4.2 million regimens on order. In addition, the SNS contains approximately 88.9 million N95 respirators with another 16 million on order; and approximately 49.7 million surgical masks with an additional 1.7 million on order.
To help states develop their own antiviral drug stockpiles, HHS designated $170 million to subsidize the purchase of up to 31 million treatment courses of Oseltamivir and Zanamivir by CDC Public Health Emergency Preparedness (PHEP) cooperative agreement grantees. HHS will subsidize 25% of the cost, and grantees will pay the other 75%.
As part of United States global cooperation, CDC in collaboration with other parts of the US government (DOD, USDA, U.S. Agency for International Development (USAID), and the U.S. Department of State) and global public health partners (Global Outbreak Alert and Response Network and WHO) has refined and systematized its approach to international containment efforts through the Global Disease Detection (GDD) program, a network of international centers of excellence. These GDD Centers are blending diverse expertise across CDC to help detect, confirm, and contain a variety of emerging diseases – SARS, avian influenza, and viral infections like West Nile – that because of today’s global lifestyle pose a threat to U.S. public health. Currently, GDD Centers are up and running in Kenya and Thailand and are under active development in Guatemala, China, and Egypt. Each has or is developing trained rapid-response teams with supplies of personal protective equipment and antiviral drugs; resources for specimen collection; and relationships with WHO Collaborating Centers, Global Influenza Strain Surveillance Networks, and the Atlanta-based GDD Operations Center.
In December 2005, Congress appropriated $350 million in emergency supplemental funding for upgrading state and local capacity to prepare for and respond to influenza pandemics. CDC awarded $325 million to the 62 PHEP cooperative agreement grantees to convene statewide pandemic influenza preparedness summits, assess gaps in preparedness, and identify approaches to fill the gaps. The remaining $25 million will be awarded competitively to select states for the purpose of developing promising practices or novel approaches to pandemic influenza planning. The additional $250 million that Congress appropriated in fiscal year 2006 for pandemic influenza activities will be awarded this year to further enhance pandemic influenza planning and response capacity.
Through the Public Health Emergency Preparedness cooperative agreement, CDC has directly provided over $4.8 billion since 1999 to 62 state, local, and territorial grantees to support public health emergency preparedness activities. In fiscal year 2006, over $1 billion was awarded—$325 million of this designated for pandemic influenza activities. With the help of PHEP cooperative agreement funding, all states have put in place the infrastructure necessary to evaluate urgent disease reports and activate emergency response 24 hours a day, 365 days a year. In addition, we have made significant advancements in many key areas of preparedness, such as laboratory infrastructure, and communications capacity.
CDC continues to progress toward the goal of developing the Quarantine System for the 21st Century by focusing on enhancing the numbers and competencies of staff, training, physical space, and utilization of technology to meet the Quarantine System’s evolving and expanding role. In FY 2007, CDC is taking a strategic leadership role in developing community mitigation and international border strategies to be applied in the event of pandemic influenza or other emerging threats.

These accomplishments represent just a small proportion of what CDC has done to advance public health emergency preparedness and response. In collaboration with our partners, CDC will continue to support the nation in becoming more prepared to address the public health consequences of all types of emergencies.

Collaboration with Federal Partners

Within HHS, CDC works closely with ASPR, NIH and FDA on preparedness activities. Other federal partners include DOD, DHS, and the Environmental Protection Agency (EPA). Some of these collaborative activities include:

CDC and ASPR are working closely together on the implementation of the Pandemic and All-Hazards Preparedness Act (P.L. 109-417). The Act was an important step in establishing an “all-hazards” approach to public health preparedness. The passing of the Act marks another milestone in improving public health and hospital preparedness for bioterrorist attacks, pandemics, and other catastrophes, and for improving the development of new medical countermeasures, such as medicines and vaccines against biosecurity threats. The Secretary has formed two committees and eight working groups to interpret and implement the provisions of the Act. The Executive Committee, consisting of Operating Division heads, will have overall responsibility for the implementation process. An Implementation Steering Committee has been developed, consisting of senior advisors for preparedness. The Steering Committee will oversee 8 working groups that focus on key areas of the Act. CDC is an active participant in the Executive and Implementation Steering committees and co-chairs 5 of the 8 workgroups.
CDC created the Influenza Coordination Unit (ICU), which supports an agency-wide Pandemic Influenza Task Force. Task Force and ICU members also work closely with ASPR, inter-agency committees, work-groups, and other HHS agencies to complete shared tasks described in the Homeland Security Council’s National Strategy for Pandemic Influenza Implementation Plan.
CDC and ASPR have a history of close collaboration with the Strategic National Stockpile (SNS). CDC and ASPR have coordinated on the SNS budget priorities, the determination of countermeasures to include in the SNS, and the deployment strategy. The recently enacted Pandemic and All-Hazards Preparedness Act codifies the collaborative relationship between ASPR and CDC with regard to the SNS by directing ASPR to manage the SNS and oversee the advanced development and procurement of countermeasures in the SNS in collaboration with the Director of CDC.
CDC and ASPR also coordinate closely on the management of the Cities Readiness Initiative (CRI), a program to aid major U.S. metropolitan areas in increasing their capacity to dispense needed drugs within 48 hours to avert mass casualties during a large scale public health emergency, such as a bioterrorism attack. The CRI program is funded by the PHEP cooperative agreement to supplement local and state preparedness efforts. CDC currently funds CRI programs in 72 major metropolitan areas in all 50 states. A recent exercise in Seattle testing the use of the United States Postal Service (USPS) in delivering countermeasures to individuals at home during a bioterror emergency provided valuable insights for planning considerations and demonstrated the value of collaboration among federal, state, and local officials and USPS.
Because of the important role that the PHEP cooperative agreement plays in supporting public health preparedness at the state and local level throughout the nation, CDC and ASPR work together on an annual basis to develop the PHEP cooperative agreement guidance. ASPR input has been important in shaping the direction of the cooperative agreement.
CDC's Influenza Division collaborates with NIH and DOD on scientific research. One example is the collaboration of DOD, NIH and CDC on a research study examining half-dose influenza vaccinations in adults for use during a vaccine shortage. Such research is needed because the United States and other countries may experience vaccine shortages in a pandemic, especially during the early months while a specific pandemic vaccine is identified and developed by manufacturers. CDC and NIH also have collaborated to develop M-chip technology to improve rapid detection of influenza; this technology provides a significant advantage over available tests because it is based on a single gene segment that mutates less frequently than other influenza genes.
In response to lessons learned from Hurricane Katrina, CDC established a Disaster Surveillance Workgroup (DSWG) with the goal of improving the timeliness and effectiveness of public health surveillance following natural disasters. In close coordination with partners including HHS’ National Disaster Medical System (NDMS), the American Red Cross (ARC), and state and local health departments, the DSWG has developed standardized surveillance materials, which have been used during previous hurricane responses to collect health data useful in targeting public health response actions.
CDC, DHS, and the EPA collaborate on the implementation of the BioWatch program. The BioWatch program is an early bioterrorism detection system that tests the air for the presence of biological agents. Currently, there are over 30 cities participating in the program. Each city has a number of outdoor air monitoring stations that collect samples daily. This important collaboration among CDC, DHS, and EPA may help our nation detect a bioterrorist attack more quickly than could be done without the BioWatch system in place.

Where Do We Go From Here—Next Steps for Public Health Preparedness and Response

With the help of the Congress, the nation has made great strides in improving our preparedness to address the public health consequences of all types of emergencies. The nation’s public health infrastructure has been strengthened, but it is not as strong as it needs to be. We must continue to build on our investments. Some of the ways that CDC plans to continue to strengthen public health preparedness include:

Supporting state and local efforts: The PHEP cooperative agreement has provided critical resources to state and local health departments to improve their capability to prepare for and respond to public health emergencies. In our FY 2008 budget, CDC is requesting $698.3 million for upgrading state and local capacity. These resources will continue to allow state and local governments to build upon and leverage their public health preparedness capacity. It is anticipated that future allocation of funds will be influenced increasingly by consideration of grantees’ performance in enhancing public health and healthcare emergency preparedness.
Improving performance measures and accountability: CDC is committed to measuring the progress that PHEP grantees have made in public health preparedness and sharing this information with the public. As with any young program, it has taken much time and effort to develop performance measures that are specific, measurable, and validated. CDC continues to work with grantees and partners to improve the performance measures so that progress can be demonstrated and communicated to Congress and the public. The Pandemic and All-Hazards Preparedness Act solidifies the role of performance measures in assuring that progress has been made with the resources provided by tying the amount of future funding to the achievement of performance measures.
Expanding the use of exercises: Besides responding to an actual event, one way to test preparedness is through exercises. States are doing more exercises this year. Many are specific to pandemic influenza, but the lessons learned from those exercises will apply to all-hazards preparedness. CDC is actively involved in conducting a series of pandemic influenza exercises that build in intensity and test various components of our response plans. Exercises require many resources, but the experience and knowledge that they provide are invaluable. We are not prepared if we have not exercised.
Sharing lessons learned: As federal, state, and local governments and their private sector partners become more and more advanced in their preparedness, it becomes even more important to share lessons learned. Preparedness resources are limited, and it is critical to learn from the best practices of others where possible.
Increasing the speed of detection and response: Public health preparedness is tested by the adequacy of our response to actual events. Recent outbreaks of E. coli associated with spinach and with lettuce at taco chain restaurants demonstrate the importance of having enough resources to respond to an event as quickly as possible. CDC’s Emergency Operations Center has been a critical resource in coordinating the many components of CDC during large, multi-state outbreaks or other emergencies. CDC will continue to work with its partners to use the National Incident Management System to respond to events as quickly and efficiently as possible.
Enhancing the Strategic National Stockpile: The SNS is an important national resource that will deliver critical medical assets to the site of a national emergency. Our experience responding to Hurricanes Katrina and Rita taught us that the SNS needs to be nimble enough to respond to the consequences of all types of emergencies. In its FY 2008 budget request, HHS is requesting $581.3 million for the Strategic National Stockpile, an increase over the FY 2007 level. The requested increased funding would allow the SNS to purchase additional countermeasures, address pediatric dosing requirements and at-risk populations, and provide additional technical support to state and local response teams.

These are just some of CDC’s priorities for improving public health preparedness across the nation. Public health preparedness requires the integration of infrastructure development, training, communications, equipment, exercise capability, as well as many other components. CDC will continue to work with its partners to ensure that all of the capacities and capabilities that are necessary for public health preparedness improve.

Conclusion

We have made great progress in improving the state of public health preparedness throughout the nation, but there is more work to do. Preparedness is a marathon, not a sprint. CDC is committed to staying in the race, collaborating with our ASPR, NIH and other federal colleagues, and supporting our partners along the way.

CDC greatly appreciates the support of this Subcommittee and the rest of the Congress in supporting its public health preparedness activities. We thank the Congress for the passage of the Pandemic and All-Hazards Preparedness Act, which validates and strengthens HHS’s and CDC’s preparedness activities. We look forward to continuing our work with you on these important issues.

Thank you for the opportunity to share this information with you. I am happy to answer any questions.

Last revised: March 26,2009