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Testimony
Before the Senate Special Committee on Aging - NY Field Hearing

The CDC and Emergency Preparedness for the Elderly and Disabled

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 network—provided 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:

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 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.