Good morning members of the Subcommittee and Chairman Shays, I am Dr. David R. Johnson, Deputy Director for Public Health and Chief Medical Executive for the Michigan Department of Community Health. I am here today representing the Association of State and Territorial Health Officials (ASTHO). ASTHO is an alliance of the chief health officers in each of the 57 US states and territories. My testimony also reflects perspectives of the Council of State and Territorial Epidemiologists (CSTE) and the Association of Public Health Laboratories (APHL) as each of us plays a role in ensuring the readiness of local and state public health systems to respond to a weapons of mass destruction (WMD) event. ASTHO greatly appreciates the leadership that you have shown, Congressman Shays, in holding this hearing on terrorism preparedness and medical first response.

The threat of terrorist acts is no longer speculative, but reality. The terrorist bombing of the World Trade Center in 1993, and the Alfred P. Murrah Federal Building in Oklahoma City in 1995 and the 1995 nerve gas attack on the Tokyo subway are seared into Americans' consciousness. 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 (WMD), 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 biological or chemical terrorist event here, in the United States. Readiness for such an attack not only means making sure our national security systems are adequate and vigilant, but that each state has a emergency disaster plan that addresses preparedness, response and recovery for the purpose of minimizing catastrophic numbers of casualties.

One of the challenges facing the public health community in the policy debate over bioterrorism readiness has been clarifying the critical role of public health and the gaps faced by health departments to fill that role. The Association of State and Territorial Health Officials (ASTHO), in conjunction with other public health partners, has been involved in defining the essential state health department functions, with performance measures necessary for preparing and reacting as first responders to a bioterrorist incident. Some of those functions would involve: 1) epidemiologic detection and laboratory analysis, 2) compilation and analysis of information, 3) communication, and 4) coordination of outbreak control, which includes essential equipment and treatment facilities. However, for public health departments to be fully prepared to deal with a bioterrorist attack and carry out essential public health services, they must assure that the workforce at the state, regional and local levels are supplied with both the perspective and tools necessary to carry out the job. Practical training that assures appropriate response, reassures the public, and manages the media effectively will go a long way in reducing fatalities and panic with any emerging infectious disease as well as with a clandestine release of a biological agent.

My testimony will address the recent efforts of state and local health departments to respond to a weapons of mass destruction incident, the readiness and capacity of some local and state health care systems to respond and their ability to interact in the event of a weapons of mass destruction medical emergency. Moreover, the critical role of public health in these types of incidents will be discussed. I will close with some policy recommendations regarding the needs of state public health systems.

Successful preparation for a weapons of mass destruction emergency will depend on the development of a well-orchestrated plan to be used in responding to an event. The implementation of that plan will vary, depending on the nature of the attack. If the incident involves biological agents, public health officials including epidemiologists and infectious disease experts, as well as emergency room personnel and critical care unit personnel will be key players and first responders. If the incident involves chemical or explosive agents, public health officials would be complementary, but not central, to the management of the emergency. However, regardless of the nature of the attack, the role of public health in the planning aspects will include identification of existing assets and assessment of needs, resource allocation for preparedness, stockpiling of supplies, medical training for treatment and communication with the public.

None of this happens smoothly without some type of preparedness plan. Most states, major metropolitan areas, and other large jurisdictions have emergency preparedness plans to cope with major disasters such as tornadoes, hurricanes, earthquakes, plane crashes and the like. However, emergency planning for bioterrorism requires special emphasis on certain functions not normally included in disaster plans. Examples include special surveillance operations, delivery of vaccines and antimicrobial agents and other mitigation efforts. The widespread nature of adverse health effects due to the disruption of critical human infrastructure will require the expansion of the typical disaster management team.

In a covert event from a suspect biologic or chemical agent, public health officials first efforts would be focused on detection, in other words laboratory and epidemiologic analysis of the cases through the public health surveillance system. The appearance of an unusual disease or increased incidence of an ordinary disease in a normally healthy population would probably first be recognized through basic public health surveillance at the state and local level. We saw this in the 1984 salmonella poisoning in Oregon where a terrorist act was detected and thwarted when local public health authorities, carrying out their basic public health surveillance, identified the threat. Identifying a single outbreak or series of unusual disease occurrences or deaths may be the first clue that a cluster of disease may be related to the intentional release of a biological agent.

Ongoing and comprehensive surveillance is primarily applicable for biologic agents. In contrast for chemical terrorism scenarios, the rapid onset of toxic effects among persons in a single locale within minutes or hours would likely make the bioterrorist event rather obvious.

State health agencies would play a role in the detection phase. In Michigan, the Communicable Disease Epidemiology Division within our Bureau of Epidemiology facilitates a relationship between state and local public health communicable disease epidemiology programs somewhat analogous to the relationship between the CDC and states. Local health departments provide routine on-site monitoring and case investigation; state epidemiologists operate specialized surveillance systems and provide consultative and on-site assistance for the more unusual and life-threatening urgent situations.

In addition, training by state public health laboratory staff of hospital and private clinical laboratory personnel -- to recognize an unusual pathogen or bacterium -- is a critical public health role in emergency preparedness. Many pathogens look similar to naturally occurring substances and could be discarded by a hospital laboratory thereby slowing the recognition of a bioterrorist attack and, most importantly, an effective response. The capacity to rapidly determine if a substance contains a deadly microbe, or harmless powder, is essential if we want to prevent unnecessary decontamination and expensive courses of antibiotics in the case of a bioterroristic hoax, such as we have recently and repeatedly witnessed throughout the nation.

The importance of timely detection cannot be overemphasized. In the case of many biologic agents, the time lag between exposure to the pathogen and the onset of symptoms may vary from hours to weeks. An effective response will depend on the ability of the clinician to identify and accurately diagnose an uncommon disease or toxin response but also on a surveillance system for collecting and organizing information from clinicians and from functional public laboratories. This will clearly require additional resources since half of the state public health laboratories, as a recent GAO report noted, do not have enough staff to conduct regular surveillance of currently known emerging infectious diseases such as hepatitis C virus and penicillin-resistant Streptococcus pneunoniae.

Once the public health surveillance system has identified a biologic or chemical agent, the public health response begins. Epidemiological investigation determines when and where the exposure took place and whether cases are still occurring. This ongoing surveillance and epidemiologic analysis usually involves both rapid data analysis from reporting entities and interviews with sick individuals and those who are likely to have been exposed.

It is important to note that state and local health departments depend upon the expertise and support of infection control practitioners within hospitals and clinics. Coordination with these practitioners is essential if state and local health departments are to quickly learn of possible outbreaks.

An analysis of the distribution and number of reported cases provides important clues about the source of infection, which in turn can be used to guide law enforcement and to help physicians in the community make a rapid and accurate diagnosis of new cases and to begin optimal treatment. Therefore, rapid and accurate epidemiological investigation will be a key factor in minimizing suffering and loss of life in these types of incidents.

Preparing to meet the needs of civilian victims of a bioterrorist attack requires the coordination of the health care community as a whole, as well as many other organizations, experts and agencies at all levels of government. Therefore, part of the challenge involves working though the complex maze of multiple bureaucracies to figure out who does what and who reports to whom. Many states have some type of interagency advisory group that meets regularly to discuss threats from and responses to terrorist attacks. In the Commonwealth of Virginia for instance, this group is called the Virginia Department of Health Terrorism Task Force. The Task Force includes the Virginia Department of Health, state police, emergency services, fire services, transportation and the National Guard. The Department of Health’s Office of Emergency Services is responsible for notification and warning as well as coordinating all operational response activities, including logistical support. The Virginia Department of Health provides emergency response capabilities through its 35 health districts, four regional morgues and central staff offices.

Communication planning should be a major part of emergency response planning. Media relations cannot be improvised as the gravity of the disaster unfolds. State health officials also play a role in responding to press inquiries. Health officials are often the first medical personnel to be contacted by the press when an epidemic or other type of public health threat occurs. Therefore, rapid reliable information and communication systems between local heath authorities, police, firefighters, emergency management services (EMS), emergency personnel and federal agencies is essential. Lines of communication between state health departments, the CDC and the FBI among others, must be maintained and tested frequently.

As the investigation progresses, the magnitude of the problem, essential treatment and prevention measures required and environmental impact are continually assessed. If an infectious agent is involved, public health officials may have to house ill individuals in isolation units in hospitals, or in make-shift facilities, attended by medical personnel who are protected by specialized clothing, or who have received advance immunization. Public health officials may also be forced to place a large number of individuals in quarantine and temporarily close large public gathering places and transport centers. Massive distribution of stockpiled vaccine and medical treatments such as antibiotics will also be necessary. For this reason, it is very important that the nation move as quickly as possible to stockpile these materials. Without these treatment tools, there is little that public health can do to reduce the seriousness of the outbreak or ongoing disease transmission.

Under most circumstances, the initial detection and response to a terrorist event will take place at the local level. Faced with an unusual illness of unknown cause, practitioners will need to rely on clinical diagnoses while awaiting the results of confirmatory laboratory tests. While assessing events involving biologic agents, the local health department will rapidly need to review available public health surveillance data to determine the nature and extent of the outbreak. In events involving chemicals, the local health department will work closely with the Local Emergency Planning Committee, which is responsible for coordinating its response efforts with those of state and federal authorities. Local health departments would also actively gather data from health care providers and first responders regarding exposed persons and casualties in the community, deliver and coordinate delivery of medical services, and notify local and state and federal health officials.

Active surveillance is dependent upon the ability of the laboratory to rapidly and accurately analyze samples for evidence. Many clinical symptoms -- naturally occurring as the result of an attack -- will look similar in the earliest stages of disease. Only laboratory analysis can diagnose the pathogen and reveal the terrorist intent. This will require staff with the necessary technical expertise and equipment and supplies, including at a minimum, Biosafety level three containment facilities to work with extremely hazardous etiologic agents. Maintaining state-of-the-art capability for detection and identification as technological advancements occur will be required of at least one laboratory in each state. Public health laboratories, ideally suited for this critical role, will need constant upgrading of staff skills, equipment and reagents.

Patients are likely to be seen by a variety of providers in a number of different locations: emergency rooms, doctor’s offices, clinics and hospitals. Practitioners need to have a heightened awareness of the threat of bioterrorism or chemical terrorist event and liberally report any increased occurrences of what appears to be any unusual illness.

Potential routes of exposure include aerosol, food, water, blood and insect vectors. Epidemiologic investigation is essential to establish when, where and how exposure to an agent may have occurred so that appropriate control and treatment measures can be instituted promptly. These measures may include quarantine, decontamination, immunizations and medication. One can easily picture a scenario involving hundreds of victims, which would rapidly overwhelm the health care system’s ability to provide adequate isolation facilities, as well as vaccines and pharmaceuticals.

For these reasons, the public health response requires, above all, careful planning at the state level typically coordinated by emergency management teams. Every state has a disaster plan for naturally occurring problems such as tornadoes and earthquakes, but fewer state emergency management teams have meaningfully included state health departments in planning for a bioterrorist attack. Understanding the critical role of public health in such an event can go a long way to reducing the incidence of death and disease if public health resources are leveraged in the best possible ways.

Currently, CDC is providing a handful of state health departments with funding for emergency preparedness planning to serve as models for the other states. These grants, hopefully, will also make it easier to work with other relevant agencies.

Another critical role in planning is the development and implementation of training and education programs. For instance, the Illinois Department of Public Health, in conjunction with other health care organizations, sponsored several Bio/Chemical Terrorism training seminars throughout the state. The seminar, approximately four hours in length is geared towards emergency medical physicians along with emergency and trauma nurses. As of this date, the state has trained over 500 nurses and physicians and a November seminar is planned to provide further training.

Many states have also participated in regular training, including periodic table top and field practice drills, during which they practice implementation of the bioterrorist plan. One lesson learned has been that regular updating of the plan will be needed as intelligence about likely bioterrorist agents becomes available.

There are considerable challenges facing states as they try to fulfill these critical roles in the event of an attack or outbreak. State health departments will coordinate assistance to local health departments as affected localities become overwhelmed. Thus, reporting will need to be electronic and permit receipt from multiple reporting sources such as local health departments, hospitals and clinics. This is also critical with regard to laboratories, which must have communication links to federal, state and local public health agencies. All communications with federal agencies, particularly CDC will need to be seamless, as CDC will have an important role in any bioterrorist event. Furthermore, states will need to play a coordinating role with health care facilities, personnel and isolation beds. Because of the likely number of victims involved, state health departments will need to coordinate the distribution of victims around the state in medical treatment facilities and, in many cases, across state lines to nearby localities.

States also need resources and trained staff to create enhanced electronic information and communication systems that permit rapid assessment, analysis and reporting. State health departments need connections to computer networks with local health departments to allow for the rapid sharing of data on disease occurrence.

States need to strengthen the capacity of epidemiologists through staffing and training to detect outbreaks of a common disease or an unusual occurrence of an unusual disease. Improved communications with the medical community is critical so that physicians will know to report an unusual case or cluster of cases to local or state health officials at once, and conversely so that public health officials can alert doctors about suspected problems.

States also need adequate epidemiologic resources for generic on-going surveillance of unusual diseases or conditions. To conduct such surveillance, state health departments need adequate numbers of epidemiologists trained to recognize both natural and intentional events and institute appropriate measures to control them. States need a source of unencumbered funding for these surveillance systems. Systems that also benefit preparedness for non-terrorist events will also provide benefits for surveillance systems that detect influenza, unintentional food poisoning, or environmental hazards. States also need an adequate number of epidemiologists trained in detection, control and treatment of biological agents.

Public health laboratories are ideally suited for the critical role of identifying biological agents, but need considerable upgrading to carry out their essential detection function, and should have access to rapid detection kits for the most likely biological agents, which are only available to the military. State laboratory facilities need to be upgraded with appropriate equipment and trained personnel. Currently, many state public health laboratories are not equipped to detect the most likely biological agents such as anthrax and smallpox. Minimally, every state should have a Biosafety Level 3 containment facility to handle most hazardous disease-causing agents.

Additionally, all of the 50 state laboratory personnel themselves need training in both the identification of bioterrorist agents, using the newest detection techniques, and in handling the agent’s safety. Many state laboratories will need physical upgrading of their facilities to be truly safe and to accommodate new diagnostic technologies.

Through funding made available recently under CDC's Bioterrorism Program, plans are underway to implement a Laboratory Response Network for Bioterrorism Detection. Those 35, or so, states that have received funding have begun working toward having the capacity to train hospital laboratories and providing a resource for them to send their challenging bacteria to higher level laboratories in the network. But these states, and the other 15 states that have received no funding to date, will require additional resources to develop full capacity. The tests necessary to fully identify a set of biological agents may be technically infeasible for most modestly sized hospital laboratories. Therefore, the hospital laboratory staff will be taught to rule out bioterrorist agents and forward those that they cannot rule out to a public health laboratory that is trained in complete identification of the agent.

Natural and technological crises have the potential to place an intense demand on emergency medical services and/or hospital department resources, and a weapons of mass destruction event could occur without any warning. However, planning for these events now enhances probability of an effective response when the time comes, while also providing tangible benefits to the public in the interim.

Many states have been faced with anthrax hoaxes. As a result many public health departments have actively worked with the FBI to analyze the substances, resulting in a working relationship between public health and law enforcement. As a result, the victims of those hoaxes learned much more rapidly, the outcome of the investigation.

Pre-emergency response planning forges better communications between public health and emergency response sectors, which in many states operate independently. The involvement of partners and other stakeholders in pre-disaster planning facilitates buy-in and clarifies the role of each partner by identifying gaps in the ability to respond and ensuring that existing legal authorities are adequate to implement the plan when the time comes. Improvements in infrastructure made now to address the major elements of emergency preparedness planning can have immediate and lasting benefit.

State health departments have the skill and experience to rapidly mount mass immunization campaigns, administer medications on a large-scale, respond to disasters, and generate emergency public communications. Public health departments are experts in basic surveillance and disease reporting. Many states are in the process of developing emergency response plans and many have had to test their abilities because of anthrax hoaxes. Public health has a foundation on which to build a solid system to deal with biological cataclysm, whether man-made or natural.

Our nation must be aware of and prepared for the possibility of a major bioterrorist event. Readiness for such an attack means 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 effect thousands of Americans. An efficient, effective public health response can mean the difference between chaos, widespread panic, and increased casualties and a significant reduction of disease, disability and death related to such a potentially cataclysmic event.

One of public health’s most important roles will be to provide most of the actual response force. At the most basic level, a 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, environmentalists and 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 point. 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.

In closing, public health’s priority areas are:

• Planning. Preparedness planning and readiness assessment at the local and state health department level to assist in the development and implementation of plans to address public health issues following a biologic or chemical terrorist attack
• Surveillance and epidemiologic capacity. Assistance to state and major city health departments to enhance, design or develop systems for rapid detection of unusual outbreaks of illness that may be the result of terrorism involving biologic or chemical agents
• Laboratory capacity. To strengthen the capacity of state and major city public health laboratories to acquire and maintain state-of-the art diagnostic capabilities for biologic and chemical agents, and
• Health alert network. Establishing and maintaining a communications network at the state and local health department level to support the exchange of key information over the Internet, training of health workers, assuring organizational capacity to respond to bioterrorism and other urgent needs caused by health threats and rapid dissemination of public health advisories to the news media and the public at large.