Testimony of Scott R. Lillibridge, M.D.

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Testimony
Before the Subcommittee on Oversight and Investigations, Committee on Energy and Commerce
U. S. House of Representatives

HHS Bioterrorism Preparedness

Statement of
Scott R. Lillibridge, M.D.
Special Assistant to the Secretary for National Security and Emergency Management
Department of Health and Human Services

For Release on Delivery
Expected at 10:00 am
on Wednesday, October 10, 2001

Mr. Chairman and Members of the Subcommittee, I am Scott R. Lillibridge, Special Assistant to the Secretary of HHS for National Security and Emergency Management. I appreciate the opportunity to appear before you this morning to discuss, from a Public Health perspective, the Department of Health and Human Services (HHS) role in preparedness to respond to acts of terrorism involving biological agents.

What has HHS been doing to prepare for this kind of event? Our efforts are focused on improving the nation's public health surveillance network to quickly detect and identify the biological agent that has been released; strengthening the capacities for medical response, especially at the local level; expanding the stockpile of pharmaceuticals for use if needed; expanding research on disease agents that might be released; developing new and more rapid methods for identifying biological agents and improved treatments and vaccines; improving information and communications systems; and preventing bioterrorism by regulation of the shipment of hazardous biological agents or toxins.

Preparedness and Response

State and local public health programs comprise the foundation of an effective national strategy for preparedness and emergency response. Preparedness must incorporate not only the immediate responses to threats such as biological terrorism, it also encompasses the broader components of public health infrastructure which provide the foundation for immediate and effective emergency responses. These components include:

A well trained, well staffed, fully prepared public health workforce;
Laboratory capacity to produce timely and accurate results for diagnosis and investigation;
Epidemiology and surveillance, which provide the ability to rapidly detect heath threats;
Secure, accessible information systems which are essential to communicating rapidly, analyzing and interpreting health data, and providing public access to health information;
Communication systems that provide a swift, secure, two-way flow of information to the public and advice to policy-makers in public health emergencies;
Effective policy and evaluation capability to routinely evaluate and improve the effectiveness of public health programs; and
Preparedness and response capability, including developing and implementing response plans, as well as testing and maintaining a high-level of preparedness.

The CDC has used funds provided by the past several congresses to begin the process of improving the expertise, facilities and procedures of state and local health departments to respond to biological terrorism. For example, over the last three years, the agency has awarded more than $130 million in cooperative agreements to 50 states, one territory and four major metropolitan health departments as part of its overall Bioterrorism Preparedness and Response Program. In addition, CDC currently funds 9 states and 2 metropolitan areas specifically to develop public health preparedness plans for their jurisdictions. Many of these states and cities have participated in exercises to test components of their plans. We must continue to work with our state and local public health systems to make sure they are more prepared. This will require the interaction of state departments of health with state emergency managers to fully integrate the state's capacity to effectively distribute life-saving medications to victims of a biological or terrorism event.

HHS is also working on a number of fronts to assist local hospitals and medical practitioners to deal with the effects of biological, chemical, and other terrorist acts. Since Fiscal Year 1995, for example, HHS has been developing local Metropolitan Medical Response Systems (MMRS). Through contractual relationships, the MMRS uses existing emergency response systems - emergency management, medical and mental health providers, public health departments, law enforcement, fire departments, EMS and the National Guard - to provide an integrated, unified response to a mass casualty event. As of September 30, 2001, OEP has contracted with 97 municipalities to develop MMRSs. The FY 2002 budget includes funding for an additional 25 MMRSs (for a total of 122).

MMRS contracts require the development of local capability for mass immunization/prophylaxis for the first 24 hours following an identified disease outbreak; the capability to distribute materiel deployed to the local site from the National Pharmaceutical Stockpile; local capability for mass patient care, including procedures to augment existing care facilities; local medical staff trained to recognize disease symptoms so that they can initiate treatment; and local capability to manage the remains of the deceased.

Lessons Learned from Preparedness Exercises

An indication of the Nation's preparedness for bioterrorism was provided by the congressionally mandated Top Officials (TOPOFF) 2000 Exercise, held in May 2000, and the recent Dark Winter exercise, which was held earlier this year. Both of these drills involved scenarios related to a weapons-of-mass-destruction-attack against our populations. Part of the TOPOFF exercise simulated a plague outbreak in Denver, while the Dark Winter exercise simulated a release of smallpox.

Lessons from TOPOFF

While much progress has been made to date, a number of important lessons learned from TOPOFF have begun to shape our plans about bioterrorism preparedness and response in the health and medical area. They are as follows:

Improving the public health infrastructure remains a critical focus of the bioterrorism preparedness and response efforts.
Local health care systems should expand their health care capacity rapidly in the face of mass casualties.
Local communities will need assistance with the distribution of stockpile medications and will greatly benefit from additional planning related to epidemic response.
Ensuring that the proper legal authorities exist to control the spread of disease at the local, state and Federal level and that these authorities can be exercised when needed. This will be important to our efforts to control the spread of disease.

Lessons from Dark Winter

The issues that emerged from the recent Dark Winter exercise reflected similar themes that need to be addressed.

The importance of rapid diagnosis - Rapid and accurate diagnosis of biological agents will require strong linkages between clinical and public health laboratories. In addition, diagnostic specimens will need to be delivered promptly to CDC, where laboratorians will provide diagnostic confirmatory and reference support.
The importance of working through the governors' offices as part of our planning and response efforts - During the exercise this was demonstrated by Governor Keating. During state-wide emergencies the federal government will need to work with a partner in the state who can galvanize the multiple response communities and government sectors that will be needed, such as the National Guard, the state health department, and the state law enforcement communities. These in turn will need to coordinate with their local counterparts. CDC is refining its planning efforts through grants, policy forums such as the National Governors Association and the National Emergency Management Association, and training activities. CDC also participates with partners such as DOJ and FEMA in planning and implementing national drills such as the recent TOPOFF exercise.
Better targeting of limited smallpox vaccine stocks to ensure strategic use of vaccine in persons at highest risk of infection - It was clear that pre-existing guidance regarding strategic use would have been beneficial and would have accelerated the response at Dark Winter. As I mentioned earlier, CDC is working on this issue and is developing guidance for vaccination programs and planning activities.
Federal control of the smallpox vaccine at the inception of a national crisis - Currently, the smallpox vaccine is held by the manufacturer. CDC has worked with the U.S. Marshals Service to conduct an initial security assessment related to a future emergency deployment of vaccine to states. CDC is currently addressing the results of this assessment, along with other issues related to security, movement, and initial distribution of smallpox vaccine.
The importance of early technical information on the progress of such an epidemic for consideration by decision makers - In Dark Winter, this required the implementation of various steps at the local, state, and federal levels to control the spread of disease. This is a complex endeavor and may involve measures ranging from directly observed therapy to quarantine, along with consideration as to who would enforce such measures. Because wide-scale federal quarantine measures have not been implemented in the United States in over 50 years, operational protocols to implement a quarantine of significant scope are needed. CDC hosted a forum on state emergency public health legal authorities to encourage state and local public health officers and their attorneys to examine what legal authorities would be needed in a bioterrorism event. In addition, CDC is reviewing foreign and interstate quarantine regulations to update them in light of modern infectious disease and bioterrorism concerns. CDC will continue this preparation to ensure that such measures will be implemented early in the response to an event.
Maintaining effective communications with the media and press during such an emergency - The need for accurate and timely information during a crisis is paramount to maintaining the trust of the community. Those responsible for leadership in such emergencies will need to enhance their capabilities to deal with the media and get their message to the public. It was clear from Dark Winter that large-scale epidemics will generate intense media interest and information needs. CDC has refined its media plan and expanded its communications staff. These personnel will continue to be intimately involved in our planning and response efforts to epidemics.
Expanded local clinical services for victims - DHHS's Office of Emergency Preparedness is working with the other members of the National Disaster Medical System to expand and refine the delivery of medical services for epidemic stricken populations.

HHS will continue to work with partners to address challenges in public health preparedness, such as those raised at TOPOFF and Dark Winter. For example, work done by CDC staff to model the effects of control measures such as quarantine and vaccination in a smallpox outbreak have highlighted the importance of both public health measures in controlling such an outbreak. The importance of both quarantine and vaccination as outbreak control measures is also supported by historical experience with smallpox epidemics during the eradication era. These issues, as well as overall preparedness planning at the federal level, are currently being addressed and require additional action to ensure that the nation is fully prepared to respond to all acts of biological terrorism.

Conclusion

The Department of Health and Human Services is committed to ensuring the health and medical care of our citizens. We have made substantial progress to date in enhancing the nation's capability to respond to a bioterrorist event. But there is more we can do to strengthen the response. Priorities include strengthening our local and state public health surveillance capacity, continuing to enhance the National Pharmaceutical Stockpile, and helping our local hospitals and medical professionals better prepare for responding to a biological or terrorist attack.

Mr. Chairman, that concludes my prepared remarks. I would be pleased to answer any questions you or members of the Subcommittee may have.