Transcripts For CSPAN Public Health Preparedness Response 20180127

,or cherry Pick Committee today senator casey for serving as Ranking Member at senator murrays request. They have both been real leaders on this subject. Was the first author of the pandemic and the preparedness act. How do you say that . It the all hazards preparedness act. Helps protectaw us from the full range of Public Health threats. Terrorism,asters, and the outbreak of Infectious Disease. 2013, senator burr and can senator casey led the bipartisan authorization of the pandemic and all hazards hacked act. Many contributed to this committee. Now the bill midst to be reauthorized for a second time. The second weg is have had this year. Last week we heard from the administration on recommendations in advance of the reauthorization of the act included from the assistant secretary for preparedness for once. The fda, and the cdc. It is critical we reauthorize the act before many of the provisions expire in september. I hope we can do this in a bipartisan way. I expect that has been the tradition of the law amongst all of our bills. Aware of thet as devastation of the flu. I believe the figures are die of 50,000 americans the flu every year. Aboutllins is talk to us expediting a universal flu vaccine when she can see soon. Tennessee has seen her breaking stories this winter as the flu has put the state in the country. Andady a pregnant woman, three children have died and tennessee. The act provides the framework that enables us to be prepared and able to respond to Public Health threats. Medicineshave enough to protect americans and ensure our hospitals and state and local Health Departments are prepared to respond to Public Health emergencies. Thanks to all of our witnesses for coming today, especially the doctor who has come from tennessee. Thank you senator burr. Holding arning we are hearing facing 21st century threats. From a doctor who at Johns Hopkins center for Public Health. The commissioner of Tennessee Department of Public Health, a Senior Vice President for commercial operations, and the forair of the Alliance Public security. Head of pediatric emergency medicine at the Childrens Hospital in chicago. We will have the Opening Statement and then we would hear from the witnesses and then members will have up to five minutes for questions. I am pleased to chair the second onring to inform our work this. I want to thank the chairman for giving me the opportunity to lead the discussion. Today we will hear from some individuals with firsthand knowledge of the challenges that they see face Public Health threats on their ideas moving forward. Since the last reauthorization, the Emergency Preparedness and response framework has been tested by the emergence of pandemic flu. Multiple metro disasters and the of bola breakout and zika virus. The Lessons Learned in these events and these events or learn today. Their efforts to protect and to save lives. Season resulted in three storms that reason to question our ability to withstand periods of response. The emergence of zika to inform and to protect as many mothers and babies as possible. In 2014a breakout highlight the need to bring the knowledge and potential damage that can be brought by these threats. This deep understanding of the i look forward to learning more about the opportunity send barriers each of you see to better leverage Innovative Technologies to solve these problems. Whether it is the challenge of development of a vaccine, information crucial to the Public Health department and myths of a crisis, the infrastructure a doctor needs to rapidly care for patients, or improvements in the way these policies complement one another, your experiences reminds us we cannot let up on these efforts or lose sight of the urgency this mission demands. We must not get distracted by making changes to the laws that of outside of the focus perfecting poppa improving and , strengthening our policies and programs to make them more effective now and in the future. I look forward to the insight each witness can provide. Now i return to senator casey of for any remarks he would like to make senator casey thank you, senator. It would like to thank senator burr for his years of work on these issues. Thank you for joining us today. I want to thank our witnesses for bringing their experience and work to these issues and for joining us today. This is our second hearing on this topic, and the focus of course is our nations preparedness to combat Public Health threats as we look toward authorizing the pandemic and all hazards preparedness act later this year. Ever, we must rebuild our nations resiliency to help security threats. The threats that face our nation today are increasing in both frequency and intensity. Ever, t it is critical to foster in advance innovation and drugs innovation in the drugs, devices, and diagnostics. Yet, when we are considering any merging Infectious Disease or in engineered by a weapon that has oweapon that has yet to be seen by man or the , response to a Natural Disaster like a hurricane, we do not and will not have a vaccine or countermeasure to protect us from these scenarios. So in addition to supporting biomedical innovations, we must also strengthen our hospitals and our Public Health professionals, our front line of defense against these health threats. We must ensure that we give our communities the necessary tools and support they need to be ready when, not if, the next emergency strikes. Accounts, we have come a long way. I spoke at the last hearing about the success of the Hospital Preparedness Program, hpp, and the Public Health Emergency Preparedness program, and congress in concert with a trained to realm and in pennsylvania, one of the many examples we can site. For these programs also facilitate preparedness activities that help hospitals and publicHealth Systems with more regular occurrences. For example, when subzero temperatures caused bursting pipes at st. Vincents hospital in erie, pennsylvania, you got hit worst with snow than any place this year, the hospital contacted the Regional Health Care Coalition created through hpp funding to assist in a response to that circumstance. And yet, the funding for these Preparedness Programs has , with appropriations appropriatend levels and spiking only in and zika. O ebola the impact in reductions means a decrease in the amount of time that hospital staffs have to plan and train for an emergency. The loss of thousands of Public Health jobs, the reduction in Emergency Managers and public. Ab technicians its very dangerous to wait for a threat to emerge, to try to pass emergencyfunding bills. We must be proactive, not reactive. So how can we improve our health and ourtem repair this Public Health capacities, and thereby improve our Situational Awareness in an emergency . Can work towards a precision publichealth, using better data to more efficiently guide responses to help emergencies to benefit our communities . I think we cant. Example, as reported by the publication nature when transmission of the zika virus was confirmed in the United States, the entire country was not placed at risk. Totead, precise surveillance find two at risk areas of miamidade county, neighborhoods measuring less than 2. 5 square miles. This allowed for the targeting of resources to these regions. Welding on that experience, can expand surveillance to illuminate causes of disease and spark opportunities for prevention. Last i should say at weeks hearing, we also heard from the assistant secretary about the use of the and Power Program to identify and treat at risk individuals requiring electricitydependent medical equipment. He also identified a weakness. This system only pulls in medicare data, not medicaid and not try care data. Tricare data. So how do we ensure that we are acting on the data accurately to protect these seniors . The tragic death of 12 seniors during Hurricane Irma highlights that more needs to be done to protect the most vulnerable citizens. In fact, most of our citizens have additional characteristics that make them more vulnerable during a publicHealth Emergency. This includes our children, our parents, our rural communities, individuals with limited english proficiency, individuals with disabilities and of course individuals with chronic illnesses and more. We must do better to help our communities prepare for potential healthsecurity threats. Must continue to invest in innovative biotechnologies and we must also improve our nonpharmaceutical interventions. I look forward to the witnesses we cannies and how continue to prepare our hospitals and Health Systems to ensure equal consideration of all our constituents. Senator burr, thank you very much. You, senator thank casey. Im pleased we have got our four witnesses here today and i think each of you for taking the time to be here. I would like to introduce all four. Dr. Tom ingalls being his director of the center for Health Security and Johns Hopkins Bloomberg School of Public Health. He is recognized for his work as a writer with numerous publications focusing on Public Health preparedness, endemic him and emerging Infectious Disease as well as the prevention of and response to biologic threats. Dr. Inglesby, thank you. Thank you, senator burkert would like to welcome dr. Dreisner, who is surely the tallest commissioner of health in our country. He has served the Tennessee Department of Public Health since 2011. He has significant experience responding to state and local Public Health emergencies including Infectious Diseases like zika, and Natural Disasters like the wildfires that devastated eastern tennessee 2016. Today he will provide important insights into our nations preparedness and response capabilities at the state and local level. What is working, where we can improve, where we can protect and save more lives. Is a physician with more than 25 years of service. As commissioner of health the house protect tennesseans from publichealth threats. I appreciate his leadership in tennessee and we welcome him to the committee. John, i am sure if you were a little younger there are a couple of tennessee basketball teams that would probably recruit you tomorrow, given their records this year. Next, id like to introduce brent macgregor, he is a Senior Vice President for commercial operations at secure us the secondlargest Flu Vaccine Company in the world. Ecuris is an example of the success that can be achieved through publicprivate partnerships so we are better prepared for the threats that we face. Most three the advanced manufacturing facilities in the country with the capability to rapidly respond in the event of a pandemic flu outbreak. Mr. Macgregor is also the cochair of the alliance for bio security. The Alliance Works to promote critical partnerships between the government, industry and other stakeholders to advance and encourage the development of medical countermeasures. Brent, welcome. And finally, dr. Stephen krug, head of emergency medicine at the Childrens Hospital in chicago. Dr. Krug is also professor of media professor of pediatrics at the university and serves as the chair of the American Academy of pediatric preparedness advisory council. Dr. Krug, welcome. Esby,l turn to you dr. Ingl and you can lead off with five minutes of testimony. Chance toou, for the speak about these important issues. Inglesby, andm i am professor of medicine and Public Health. Our centers mission is to protect Peoples Health from disasters. Will provide a brief overview the opinions expressed here are my own and dont necessarily reflect the views of Johns Hopkins university. The u. S. Faces a range of major Public Health threats, any of which critical occur without much warning. These include mass bombings, chemical skills, radiation, Nuclear Threats and biological threats. Biological threats, whether natural or accidental, such as an epidemic viral strain released from a lab come or deliberate like smallpox or anthrax, are of particular concern and a big focus of my concern today. Threats can range from modest in size, up to those capable of posing global catastrophic risk. What more can be done to prepare for the stress . First, we need to strengthen the Health Care Systems preparedness, that is the capacity to care for high numbers of sick or injured during an emergency. While there has been substantial progress in preparing for small disasters in the country, the nation isnt ready to provide medical care and large catastrophes or big epidemics of contagious disease. The Hospital Preparedness Program or hpp, and has been helping to fund and build these capabilities at the state and local level but Significant Resource constraints limit what hpp can do. Its budget has decreased more 200250 since its start in. That trend should be reversed, and new initiatives like regional Disaster Resource hospitals could be a strong component in improving preparedness. Second, we need to improve our Public Health systems ability to detect and respond to threats. Since 2001 there been serious efforts at state and local warningo provide early of new outbreaks, provide lab diagnostics, investigate and communicatereaks, to the public, and sure biosafety and bio security and much more. There has been good Forward Movement but there is too much to do and not enough trained professionals to do the work. Public health relies on funding publichealth Emergency Preparedness grants. That funding has been reduced by since 2000 to come even the publichealth crises havent declined. It should be strongly supported and in addition i think a publicHealth Emergency Contingency Fund should be established which would allow rapid Public Health response funding and emergencies funding in emergencies. Third, we need to move ahead in medical countermeasure development. Many priorities remain, anduding sustained Funding Research development, manufacturing of countermeasures, transitioning to new flu vaccine technologies in setting more ambitious targets for Rapid Development of products and emergencies so they are ready in the course of a given pandemic or epidemic. Fourth, the u. S. Needs to recognize threats that could inadvertently emergent biological research. After the moratorium on pan pandemicesearch research was lifted last month, researchers can now apply for funding for ways to make the lds most lethal viruses in the worstcase this could lead to the accidental and of a virusrelease that could cause a pandemic. I dont believe the benefits of this worker worth the risks that if it is going to go ahead and would advise there be high transparency in the program and serious dialogue among concerned governments internationally on how to proceed. And finally, we should fund the global Health Security agenda. In 2014 the u. S. Helped launch with a 1 billion commitment to have countries to help countries detect and respond to threats. Since then the program has toked in 39 countries increase lab and surveillance capabilities, increase public workforces and much more. But at this point u. S. Funding soon is funding ending soon. We should continue to support it. It is the most Effective Program we have to contain international operates at their sources overseas. Improving our nations preparedness and response activity is a daunting effort. I appreciate the committees time and welcome your questions. Thank you, doctor. Senatormorning alexander and senator casey and the strongest visitors. Thank you for this opportunity to appear before the committee and discussed an issue of significant importance. Publichealthgile system. I may commissioner of health in tennessee. Health director in central appalachia for a decade before that. The thoughts i will be sharing today are my own but i am confident that they are shared shared by my publichealth colleagues across the country who try every day to respond to threats of all kinds. Measles,eats may be foodborne illness, influenza that can like this year unpredictably test our nations response rate. These threats can also be large Scale National or global events like an influenza pandemic, ebola, zika, the Opioid Epidemic or acts of terrorism. Publichealth also mobilizes during Natural Disasters like floods, wildfires, and other extreme weather events that unfortunately seldom does a Public Health jurisdiction of any size go more than a few years without experiencing. As well, for mechanisms like the Emergency Management assistance compact, unaffected jurisdictions are frequently called upon to assist neighbors. A responsibility, discipline, and service we have to get right. Lives in physical and economic help depend on it. It is something we in publichealth do every day. Its a matter of local resiliency. All disasters play out locally. Its also a matter of national security. In a few moments we have together i would like to share my perspective with you, having directly involved in planning and execution levels in the military and innocently capacity over 25 years. Start with a simple question. What is Health Preparedness and Emergency Response and recovery . It is not health, equipment, is people. Firefighters and Public Health nurses cant be hired and trained after the alarm sounds. They need to be there ready to go before the threat ever before the threat ever emerges. Preparedness is about people involved and their interconnected networks. To be truly prepared we need three things. One, trained people with local knowledge and all connected by relationships built on trust. Two, expertise and leadership at all levels, local, state and federal. And three, communication and shared Situational Awareness among responding leaders, people on the ground and experts. Create these three things after an event begins takes the one commodity that is most precious in an emergency, time. We dont have time to create this network after the event starts. In a way, the publichealth and Emergency Response network is like a safety net for a performer. It has to be in place before the show starts, anchored, inspected, and in good shape to do the job. Many people think equipment or supplies are the net but if you remember nothing else for my testimony today i would like you to remember this. Things, arele not the net. People are the net. The anchors matter but it is the people that run the response. The relationships, the knowledge and the trust created over time are what strengthen the cords, hold them together and keep them adaptable and resilient. The more towards that on grave the morenravel difficulties we have during difficult times. Things Like Communications infrastructure are essential anchors for the net. Without them the people cant be affected but the people are the net. Our accomplishment and preparedness, response and recovery over 15 years, which i have illustrated in my written remarks, can be directly attributed to the pandemic and all hazards preparedness act. This act was transformative relative to Public Health and Health Care Preparedness and has ,rovided requisite direction authorities, authorization of resources and the cadence of accountability that have become part of the culture of publichealth and enable us to do our job in the best way possible. As you consider reauthorization, priorities and resources must be did must be lined up with an everexpanding threat environment. The scale and speed it needs to protect the public are critical to this ability. Congress and this committee should be applauded for its work ,n laws that give states territories, localities and tribes the resources and tools needed to stay vigilant at this critical post and get the job done. These funds are not duplicative of Emergency Management and homeland, but complementary and essential. Sometimes depending on the hazard, Public Health is the only responder. What we ultimately need as a nation is consistent and reliable, sufficient funding to keep the people, their net, their knowledge and their networks intact. Thank you for the opportunity to speak with you today about this fundamental issue and for caring about our ability to respond to any hazard or threat for generations to calm. Generations to come. Thank you, john. Good morning, senator burr, senator casey, members of the committee. My name is Brett Mcgregor and i am the Senior Vice President of securis. I appreciate the opportunity to appear before you today as you consider the second authorization of the pandemic and preparedness act. Onould like to focus pandemic influenza and the critical role. There are three issues that would like to highlight. First, the pandemic influenza is one of the most the influenza pandemic is one of the most urgent Public Health threats we face as a nation. Second, the influence of program must finally be authorized in this years legislation, and third, Congress Must provide sustained and predictable funding to strengthen partnerships with the private sector and ensure our nations preparedness. Regarding my first point, preparing against pandemic influenza, its critical to our economic and national security. We are proud of our partnership with barta. Thanks to the leadership of members of this committee and the dedicated team at barta, our productione art facility in North Carolina is one of the best examples of a successful publicprivate target ship and bio defense. Second, despite the pandemic influenza program, authorized funding for pandemic influenza has never been included in the legislation. Result, funding for critical activities cut such as activities such as vaccines stock piling has been largely absent since 2009. Supplies are now fully exhausted. Authorized bygram congress will send a signal to the private sector that the u. S. Government is committed to preparing against pandemic threats in the future. Believes an annual authorization level of at least 535 million is needed. Regarding sustained and predictable mcm funding, over the last 12 years this enterprise has greatly improved our nations security and hasarta and while barta improved its relations with industry partners, the government should provide more certainty in the process. Ing, theent Fund Strategic national stockpile, and the Pandemic Program provides marketers with certainty after investing in the program for many years. It is there is no commercial market for mcm, Companies Like rely can only unfortunately over the last several years the private sector has come has become skeptical of the governments commitment to bio defense. Publicprivate partnerships must be sustained over time through a demonstrated commitment by the government. ,here are dozens of companies both large and small, that have s mission. O barta the reauthorization of popups authority and a renewed commitment to mcm funding will ensure investment in the field. Strongly supports the priorities identified by the alliance of bio security which im privileged to serve as a cochair. I would like to thank members of this committee, and in particular senator burr, for their commitment to reauthorizing papa in a timely manner. Ensures americans are better protected against the threat of pandemic influenza, and we are excited about our partnership with barta. We encourage the committee to fully authorize bartas Pandemic Program to ensure barta is the resources it needs to prepare against when the threats we face as a nation. Im happy to answer any questions and i thank you for inviting me today. Thank you, for that testimony. Stephen, the floors years. Good morning. Chairman burr, Ranking Member casey, members of the health of theee, dr. Steve krug Childrens Hospital in chicago and professor of pediatrics at northwestern university. Americanhair of the academy of pediatrics Disaster Advisory Council and on behalf 66,000 members i would like to thank you for inviting me. Ive been privileged to serve on federal Advisory Committees. Today as a private citizen and a member and leader of the academy. I plugged the work of this committee for strengthening and improving our nations Public Health and medical preparedness. Youarticular, i must thank for the firstever provisions for children in the last reauthorization. Those changes helped make the needs for children a much higher priority in Emergency Planning and response. We heard last week from cdc and fda leadership, each agency has a distinct role to play in ensuring our Healthcare System is prepared to meet the needs of all americans including children , during and after a disaster. Federaler of these agencies and countless hardworking employees they oversee are the back own of our nations 24 7 federal emergency readiness and response capacity. , andrequency, severity costs of emergency disasters are increasing, meaning they will remain a significant threat to our communities and nation. As such, maintaining the governments Strategic Focus on threats is critical. Will require continuing engagement of all stakeholders including Public Health, medical and Mental Health services, academia, industry and the daytoday emergency and trauma services. Foundational elements are key to thearedness, including mu Emergency Medical Services for children program. Areth care systems that regularly tested will be the most reliable and effective during a response. Regular exercises and drills and continuing education for First Responders are necessary to be ready for all populations when the disaster strikes. This is important if we hope to meet the unique needs of children. At a population level, we should strive for a more Resilient Community predisaster, as this will reduce the burden on the Health Care System during and after disasters. This means ensuring access to servicese health care and reducing disparities in all populations. Financial drivers in Todays Health Care environment are not in line with the need for facilities to be prepared for Public Health emergencies. Cost reduction measures have resulted in leaner stockpiles of supplies and equipment and workforce. , thisatient operations has promoted Emergency Department overcrowding and poor capacity during pandemics like the one we are going through right now. The capacity gap is particularly precarious in pediatrics. Disaster planning does not primaryly integrate care. In the absence of mechanisms to provide assistance to impacted providers and disrupted practices, many have been forced to leave. It is not hard to see why so many communities have responded has struggled to respond and why some may never fully recover after a disaster. Community resilience relies heavily on the resilience of the healthcare care sector, its a key pillar. Children a cap for 25 of the population and their vulnerabilities were mean fairness and response activities at all levels must account for their needs. Children are not little adults. I concur with the comments of my colleagues but i would offer three additional thoughts, in terms of recommendations. First, reauthorize the hhs National Advisory committee on children and disasters. Has provided insightful reports to improve Health Care Preparedness for children. Number two, authorized the childrens preparedness unit, which is an invaluable resource to the cdc, schools, and other institutions during recent emergencies such as ebola and zika. This unit is a best practice example of an effective publicprivate Sector Partnership that has has brought tremendous improvement to preparedness. Thirdly, lets maintain the hpp and the phap programs with increased funding. As disasters and universal risks nationur anywhere in the it is essential all jurisdictions have a baseline level of preparedness. Thank the committee for the opportunity to testify and i look forward to your questions. Dr. Krug, thank you. And as evidenced by the fact that im not sure if we in the past had a pediatrician on for related hearings, it points out the need that we need to get it right. Its hard to incorporate pediatrics in the cuttingedge technologies that on one side we are pushing, and that that will always be a challenge to us and we need more subject Matter Experts to help us navigate through that. I will recognize members for up to five minutes starting with myself and move on a security basis. Securis has worked her many years to make us better prepared in the event of an out flake of pandemic flu. Carolinaity in north is a promise in a partnership between your company and the federal government that if needed, we can flip a switch from the manufacturing a vaccine for seasonal flus the manufacturing for pandemic flus. Lessons learned from what are the Lessons Learned from this partnership and how can we improve the partnership . Thank you. A think the lessons we have learned thus far is that the partnership has been a very good one since the very beginning. What has happened in recent years is, the commitment that ecuris andade by its predecessor companies, the funding has not kept up with the threat Going Forward. Even funding for pandemic flu was not heart of the region not part of the original papa legislation, there were supplemental funds provided for the flu. Big lesson we have learned since that time is that funding has declined to available levels, particularly since 2009. You talked about commitments, and why we and while we put commitment forward with a ittnership with barta, suggests that there is not a seriousness or as seriousness fluinterest taken to the threat Going Forward. I think communication, ongoing communication is another lesson we have taken. I think for the most part the communication between barta and our company and barta and other companies that are in partnership with the government, has been good but there is always opportunity for improvement across the spectrum, naid all the way to the sns. There is still room for improvement in harmonizing how it works across the spectrum. Jurisdictional lines were difficult at the beginning but i think we have sorted through a lot of that. I hope my colleagues on this committee will remember this years flu season, the severity of it we dont know yet. But as we get smarter at predicting what the thread is going to be, this is a great example of, we are not smart enough to get it better than 32 right based on the current numbers, and that we got to look at technology that allows us to address seasonal flu in a way that encompasses all the above options that might happen. You mentioned barta. Barta is known for its work to advance new and Innovative Technologies to better combat Public Health threats. It has been externally successful in advancing innovative approaches to the development of medical countermeasures such as platform technology. What do you see as the greatest andlenge to bring these new Innovative Technologies through the medical countermeasure pipeline . I think one example of what you mentioned, senator burr, is the new and innovative let technologies and the plant in Holly Springs is an example. Its not a more conventional facility and the interaction with our to has been very strong in not only allowing us to continue to advance the effect is this the effectiveness of cellbased technology, to improved the to improve the yields of cellbased technology that actually not only benefits pandemic situation but also a seasonal one. Technology that is invested in by the government offers the potential for providing a better match in the event of a mismatched season, as we are experiencing this year. Innovation and Informational Technology have vastly improved our capabilities to monitor and attacked and identify Public Health threats in as timely fashion as is possible. Although this potential exists the federal government lags behind in its ability to leverage these technologies. How can we improve federal programs to create a more cohesive and realtime surveillance capability for Public Health threats and, just as an aside to that, do you believe we use enough open Source Information outside of we have set up, domestically and internationally . Senator berkman is a very good question. People have been working on that for a long time. There are many Surveillance Systems in the country right now that are aimed at the call. They are not all brought together under one roof, which would be very difficult to do. I know it has been a goal of the federal government to consolidate and bring those systems together. One thing we could do better is to get more information out of the Health Care System to Public Health during emergencies. Advances int of Electronic Health records but for the most part, Public Health agencies dont have any resources or analytics to be able to see what is going on in Health Care Records around the country. So if we could do more to bridge the divide between Public Health and medicine, that is where the signals are going to come in from doctors and nurses seeing unusual things and feeding that information to Public Health, getting laboratory diagnostics, getting that information together. Divideink closing that and also bringing together unusual sources of information like what is going on in the animal systems and combine that with human systems, being able to trace back foods when big food outbreaks arise. Its a very difficult counsel difficult challenge for us right now. We are much better that it better at it than we were a few years ago. Much better. I feel like mechanisms are in place for the transmission of information. All we need is one breakdown. It does make one wonder in the overall scheme of things why we are not more on top of that, a review of prescriptions written on a daily basis that gives us either confirmation of we are hearing from the Public Health arena or potentially, a sign of an outbreak of something that we pick up in prescriptions that were administered the day before. And the unusual thing is that that gives us great clarity as far as the geographical location of something, all the way down to a nine digit zip code, and it seems like all of the above that we have got to do. Senator casey. Senator burr talked about the flu this year. More thand that 70,700 cases of the flu have 17,700 casesd of the flu have been confirmed just in pennsylvania. A particularly bad flu season, it doesnt come close to what we would see on a ,uch larger scale infectiousdisease emergency and of course, a pandemic flu scenario. Care sector is already near capacity with this loop season so we are woefully unprepared to respond to a masscasualty biological event. How can we begin to prepare hospitals, lets just focus on hospitals, for masscasualty biological events . I know thats a lot to bite off, but as best you can. Thank you for the question, senator, and i certainly welcome esbys comments as well. As has been said. As has been said, fully funding the programs to prior levels would be helpful. Dr. Krug made important point about the financial incentives of the current system, just in time for supplies and for surgeng, and a limited capacity. We are seeing that in tennessee right now. I had a call with our hospitals a couple of weeks ago and i have another call tomorrow, and some of the challenges you know, this is a flu season i think that is more severe than we typically see. As senator burr pointed out, we dont know what this will look like in comparison to other flu seasons. I think one thing is true, we are reporting more. Many states are reporting all debts, our state is reporting childandpregnancy debts. We have already had several tragic venable debts and andic, preventable deaths as people hear about those things theres the perception of greater severity. And when there is a perception of greater severity people visit emergency rooms. And one thing we are doing is messaging around and asking, if you are ill, you may need to call your Health Care Provider but you may not need to go to an emergency room. So all those kinds of things are a part of what we deal with in a flu season where there is heightened awareness. In terms of assuring we are the amount of funding available to the hpp grant has been adequate for some time. And i think as you pointed out in your comments, there is a need to bolster that. Greatt think it takes a deal more, but certainly returning to earlier funding levels would be extremely helpful. Dr. Inglesb. Add that, the more we can develop our flu vaccine technologies, universal vaccine being the ultimate goal, but modernization and rapid processing being the immediate goal, the less sick people we will have an hospitals. But in the meantime we need a strong Preparedness Program through hpp, there could be other facets of that program like having more Regional Centers that crucial to more responsibility in crises, take care of more contagious patients. Level one Trauma Center system in the United States that works very well but we dont have anything like that for Infectious Disease. That could be a model. Have built biocontainment units around the country in response to ebola but most of the containment units can only take care of three patients at the most so if we want to raise the level of preparedness we might think about creating regional strength. But at most hospital they are going to need to be able to take care of patients, they are going to need proficiency, personal protective equipment and relationships with other hospitals and Public Health wherees and clinics people are getting cared for in the community. Its a network of care as opposed to only relying on the major, acutecare hospitals and to distribute the burden not to the community when there are major epidemics of flu or pandemics of flu. Im running out of time but, you mentioned the level one Trauma Center model. Yours, butord, not how do you think we incentivize int in the context of what your testimony you referred to as specialized Disaster Resource hospitals . I will ask you that question and i will come back later to dr. Krug. To incentivize that you could have some sort of competition but you would have to provide resources for it because there is no, as we have set already here today, there is no give in the system. Hospitals run on very small margins and are not going to build large programs outside their usual programs unless the government says we want you to do this and here is how. Thanks, very much. Thank you, chairman burke. Theinglesby, you wrote of Global Health agenda in your comments that was established in 2013. Where is it housed . Its in multiple agencies of the government, particularly cdc. Who is the quarterback . Bethe quarterback of would usaid and cdc directors. Senator when you referred to the Ebola Outbreak and Containment Centers that were built, from a modest standpoint we were able to meet the threat at Emory University at nih and other places, with those first doctors who came back from liberia which is where broke out. That wasthat enough at the time but how much of that you think should be built in preparation for needing it for Something Like that when it happens again . Was a National Leader in that program and i think if you speak to the leaders in that program they would say it would be difficult for them to take care of more than one or two patients in the current units. We need to get better cost information about how much those units cost. Difficult to scale those pirate orders ofthose pire by 10 or 100 but i think we could build more capacity in the systems, share the lessons that have been learned in those units, see if we can spread that responsibility out a bit further. Because right now it is a pretty small number of units like and care for any patients with that. Capital and money. And training. Capital, money, and training specialized people. You recommended having some sort of Contingency Planning money for that. Do you have any recommendation on how much it out of the . The Contingency Fund . If you based Contingency Funding on what we have spent and other infectiousdisease emergencies, we typically have spent at least 500 million to 1 billion is a country to response to things like ebola, zika, sometimes much more. Fund in that range, but others have called for 2 billion Contingency Fund which is what fema uses. , provide at would be lot of acceleration in the Public Health response to emergencies. Helps because biological because biological threats and disease threats dont recognize international boundaries, its something that other countries have to get together, right . Absolutely. Cdc is great or knitting things like that and so is u said, but that is where the International Agenda ought to coalesce . And one of its successes is that it brings in different parts of government including the finance side of government, the Security Side of government, so in the u. S. It is bigger than the cdc and usaid. And that is the model they are trying to get other countries to represent, as well. Mr. Macgregor. Mr. Macgregor. Does North Carolina manufactured the flu vaccine . Still have enough, given the current epidemic that is going on . Yes. Weve been constantly enhancing the capability of that plan. So from a seasonal perspective, we more than tripled our capacity into the market this year. That plan is also responsible as i mentioned, and delivering one third of the requirement in the event of a pandemic, and responding within a six month period. What is the shelf life of that vaccine . From a shelf life perspective, the antigen is five years. Unfortunately we do have an , antigen that is in our stockpile that is older than that from a cell perspective. That is the state of affairs as far as our cellbased vaccine is concerned. Theres the potential of being a better match in the event of a mismatched strain. So as an alternative form of manufacturing and the initial reason for the publicprivate partnership, that is the promise that our company is trying to deliver on on behalf of the government. Thank you, very much. Thanks to all of you for your testimony. Thank you, senator burr and senator casey for your leadership on this issue. To our panelists, good morning and thank you for being here. Inglesby, i wanted to start with a question for you. As we all know, puerto rico was recently devastated by Hurricane Maria and the island is still trying to rebuild from the disaster. The effects of that disaster are obviously widespread. Hospitals in New Hampshire and around the country are dealing with, among other effects, medical product and equipment iv saline such as bags, because the storm devastated some of the manufacturers on the island. What does this shortage say about our overall preparedness in the case of a future event or other types of emergencies where medical supplies cannot be easily replenished . And what can we do here in congress with this issue . Senator hassan, yes, i agree with you completely that the puerto rico hurricane and other storms have revealed how vulnerable our supply supply systems are. One possibility would be to consider whether there are some critical supplies, such as saline bags, if they are singled sourced to a certain part of the world whether or not they should , be included in the National Pharmaceutical stockpile. That is not have a stockpile is configured or resourced now so it would need to be Additional Resources for an additional mission. But the stockpile has Great Success in acquiring medicines and being able to deliver them to localities. So that would be one possibility if there was additional purpose and funding for the stockpile. Senator, can i interject . The time wont count against you, but Holly Springs is another great example, and the other two facilities that when , faced with a pandemic, we actually became visionary and we thought, what can we do to meet what we dont know . And we went into a partnership with three Different Companies where we funded three quarters of the facility of the plant, but with a condition written into it that at any point, we could turn it in to what is in the nations best interest. And all three owners knew that and participated in it. So it may be a model that we look at as we identify other things, but we have shown a degree of vision in the past. Sen. Hassan i think thats very helpful and i think the example of what happened in puerto rico after maria really helps us focus on one of the next things we should be doing. I also wanted to ask all of you and i think i start the question with you, dr. Dreisner. I love what you said about preparedness and response being about people and time. Obviously both demand resources. New hampshire uses its hospital preparedness funding to support a single statewide health care , coalition that works to bring together have a and Emergency Management professionals to ensure the Health Care System preparedness is there across the spectrum of care from hospitals , to home care to longterm care and beyond. New hampshire, like other states, relies on this funding to make sure its prepared for all kinds of emergencies, mass casualty incidents to hurricanes. Unfortunately, like many other states New Hampshire has seen a decrease in hospitalpreparedness funding in years. We dont know when the next emergency will happen or what it will precisely entail so we need to make sure the coalition in New Hampshire and is not only collaborating regularly but training regularly. Its hard to do that when funding is dramatically reduced. So i will start with you, dr. Dreisner. But from all of you, do you agree that we need to increase investments in the Hospital Preparedness Program and that it should continue to fund those efforts in all states . Thank you for your question, senator. I would say absolutely yes. If you think about who responds in my written testimony, you written testimony, i talk about professionals who do this every day. We have people who are highly trained and they are called upon. If theres an actual emergency like the one you describe, but they typically have different duties on a daytoday basis. For example one of our emergency , coordinate is in tennessee actually directs our board of Emergency Medical Services. But when we have an emergency shes in the state operation center. And then we have this third tier, which is everybody else, and the people that you are talking about. They are the Public Health nurses. They are the clinicians in the hospital. They are people called upon whenever there is a need to serve. And in training and exercising and actually responding, creating the relationships and the knowhow, what do i do, where do i go, who do i talk to those are the critical things. Those are relationships built on trust that the funding really helps solidify. And unfortunately when you , reduce that funding, that is one of the first things that goes. You try to preserve the positions, you try to preserve some of the things you have invested in, but the more tangible assets are the very things you need more of. I think you spoke to this very eloquently. Sen. Hassan i will ask the other three panelists anything you would disagree with or add dreisner just said about the funding. Just the point that it is about people. The earlier question about how we get the hospitals better prepared they have to train. If you dont have trained people coming to response will not be effective. That has been shown in many other industries, including health care. And with a focus evolving from hospitals to health Care Coalitions, which i think is an appropriate move, its not just the hospitals that need to be trained, its the entire community that needs to be trained. As an emergency physician, can i just do a brief pivot . After oxygen, the elixir of life for how we treat patients is saline. Whether youve been an explosion or bus crash, if you dont have saline, you lose lives. So there could be nothing more fundamental to our Emergency Response, after oxygen, then saline. Sen. Hassan i know im over and i will just submit for dr. Krug a question about Behavioral Health needs, especially for children and disasters and the trauma that disasters impose on our kids concerns me lately. Thank you for focusing on the specialneeds populations. Im the mother of a specialneeds young man and i thank you for raising that in your testimony. Sen. Burr senator smith. Senator smith thank you very much, senator brent senator casey and the other members of this committee for your work on this and focus on Emergency Preparedness and also to our testifiers here today. In 2015 when i was governor minnesota was hit by an avian , flu outbreak that ended up costing somewhere in the neighborhood of a billion dollars. It was the largest and most expensive animaldisease response in the history of this country. And of course it hit poultry , growers incredibly hard. So i was really relating to what you were talking about, about how this safety net that we have is about people and not stuff. Because, certainly as we responded to this catastrophe, we needed stuff, but we also really needed the people and the relationships that made our response work and function incredibly quickly, which was such an important part of it. So im quite interested in this so im quite interested in this idea of a one Health Approach and how we can build that kind of approach into our thinking about Emergency Preparedness. I know that senator young from indiana has raised this question just last week. And ive only been here for two weeks, so youve probably been talking about it much longer, but raised this question about whether we need additional approaches or resources to do this. Maybe i would like to turn to dr. Inglesby. Can you talk about what tweaks we might need to the legislation to address this question of what we ought to be doing better there . Dr. Inglesby first of all, i completely agree with the values dr. Inglesby first of all i agree with the values and principles of what health and i think you are absolutely right. Disease surveillance, outbreaks. I think that those principles you will find those principles in federal agencies. People believe there is a lot of acceptance and belief in one health. You are right it is not housed in a particular program. There arent large efforts underway to bring one health together. There is a National Bio Defense strategy being completed by the white house. Its purpose is to bring together animal health, plan health, and human health for bio defense. This is the first time the strategy has been written that way. There was a lot of coming together for the agencies over the last year on this. It is improving animal Surveillance Systems. We dont have strong animal surveillance. The human health Public Health workforce is strapped and the animal Public Health workforce is even more strapped. I am not sure if it is in the scope were not, but we dont information coming from our animal system, and it does not cross to human health busily. Easily. H dr. Dreyzehner thank you for the great question. Asi could make this point, Public Health professionals, we think about primary prevention of flu. Not that seems for pharmaceutical interventions. We have to look at it ourselve. S how do you prevent the flu from occurring in a human population, or another disease, ebola . Doing things around the animal sources are critical. The example you gave of Avian Influenza, stavin gout paving out Avian Influenza in oultry. That is an influenza strain in the human population. From my perspective, from the state Health Official expect of, i amficial perspective, interested in crafting how to specifically inglesby mentioned bringing ag professionals, Public Health professionals together to do a better job of keeping animal diseases and not allowing transfer into human beings. Someone came to Congress Years ago and said, we need money to properly prepare bushmeat in africa, because we know they are going to eat it. And how to properly gather fruits defecated on by bats. I think that would have been a hard sell. The Ebola Outbreak emanated from those practices, and lack of education around that risk. It would have been a relatively small investment. Sen. Smith thank you very much. I look forward to working on this issue of one health. Later i am interested in this question of how we respond to what is another epidemic seriously affecting children, which is the , especially in indian country. That will be for a later time. I very much appreciate your thoughts on that. , especially in indian country. Senator roberts. Sen. Roberts thank you mr. Chairman. I would like to thank the committee and are distinguished chairman for working on this issue. Last week in the Agriculture Committee we held a meeting on safe american agriculture in a globalized world. Hit theesby, you really nail on the head with your comments. A fourstar president of kansas state university, home of the now under Construction National bio and agri defense facility. Testimonys, general myers notes because there were two Homeland Security president ial , that has in 2004 been some time ago, one for people, one for animals. There is not of an executive focus on crops. I will enter his full testimony in the record. Everyasonings are one of country that essentially developed a bio Weapons Program, including the u. S. , created on agriculture as well as people. I would like to insert at this time that we have a lot of by formern this senators sam nunn and the old program on pandemic threats and also by tom ridge and Joe Lieberman with regards to agriterrorism. I myself was in charge and it was called the emerging threats subcommittee. Went to a place just north and west of moscow. Thereby seeing one of the secret cities that we are not allowed in now, but we were then because they needed the money. We were focusing on security, but in touring the area, i was really stunned with regards to vast warehouses of pathogens that they were making ready with regards to attacking a countrys food supply. We ran an exercise at that particular time. It was called crimson sky. It was sort of a misnomer because you dont want to burn carcasses or anything like that. It was footinmouth disease. By the time texas figured out they would put a stop order from shipping cattle to oklahoma or oklahoma to texas so they dont ship cattle in to kansas and nebraska and north dakota and south dakota, we had an epidemic on our hands. We had to terminate thousands if not millions of cattle. All of our exports stopped. I mean, all of our exports stopped. There was a run on Grocery Stores all throughout the country. People finally discovered their food did not come from Grocery Stores. It took us years to get back to a situation where we could literally feed not only this country, but a very troubled and hungry world. That was quite an experience for me. That is when we started on nbats. The general said first as ive indicated that every country nbats. That ever developed an offensive bio Weapons Program also targeted agriculture. Two, almost every pandemic today is a disease that can spread from animals to people. Among the bioterror threats that the Homeland Security has issued a material threat determination, all except for smallpox are zoonotic. Meaning they can reach humans from animals. They could really devastate public threats as well. Until nbat is operational in the next four to five years, i regret that its taking that long there is no u. S. Laboratory for Livestock Research to be conducted on ebola. Swine being a host animal for both. Mr. Chairman, i would like to work with you and all of our colleagues on this reauthorization to be sure that we are preparing for these zoonic threats. I have 20 seconds to ask dr. Inglesby if you would like to respond. Leading the Public Health emergency countermeasure enterprise, this is supposed to be where all the coordinating agencies, the department of defense, v. A. , Homeland Security, agriculture, along with all the First Responders involved, to update our strategy and to implement our plan annually. From your perspective, are we doing the job . Dr. Inglesby i think we have a lot more work to do in the realm lot more work to do in the realm of agriculture, food, and crop safety. I completely agree with what you said about the importance of animal vaccines, the shortage of animal vaccines to protect herds against threats to the planet. I agree with what you said to the threat to agriculture. Both animals and plants have been relatively neglected the the last years. 15we have begun to do other things around biological defense. How to organize that in the government i dont have a strong sense of how that should be organized. Its complicated in that usda is responsible for the promotion of food and the business of food. It perhaps could be difficult to have that protection of food in the same exact place. Ive seen signs of life in those thoseix months around programs that ive not seen in the last 10 years. So perhaps the program is becoming much stronger. Sen. Roberts secretary perdue and the Agricultural Research office would run that. The construction of that is Homeland Security and they are responsible for any attack on the United States. Its been very difficult to focus on this. Some years back on the intelligence committee, of which my distinguished friend is the chairman, we were able to determine what keeps you up at night, at least in the top 10 was an attack on our food supply. That is not the case today. I am talking with our cia director, mike pompeo, who happens to be from kansas. We are trying to reassess that threat, and i think its a very real one. I thank you all for your service and im over time. I yield back. Thank you mr. Chairman. Burr senator roberts, you did not disappoint me. I knew there was going to be a question somewhere in that dissertation. Senator baldwin. Sen. Baldwin this discussion today is important and timely. It brought into focus the sobering fact that if experienced one Health Emergency every year in the five years that i have been serving on this committee, from ebola to zika to the hurricanes this year. I was serving previously in the house of representatives during the 2009 h1n1 pandemic and also in 2004 when we saw a dangerous shortage of influenza vaccines due in part to our insufficient Domestic Production capabilities. We are also in the middle of a particularly severe and deadly seasonal flu year. So i wanted to focus specifically on our readiness for a pandemic flu outbreak. I am concerned with a lack of sustained and predictable funding for the pandemic vaccine stockpile. Im committed to working with my colleagues to advance a specific authorization for pandemic flu activities. Mr. Macgregor, in your testimony, i was troubled that are pandemic flu stockpile does not match the current strains of influenza, and is full of expiry vaccine components due to underfunding. And it is especially concerning, especially as we have a h7n9 bird flu circulating in china that continues to evolve in ways that has the potential to trigger a global pandemic. Are we adequately prepared for an outbreak of pandemic flu that could strike in the near term . How would a pandemic in the middle of this severe seasonal flu season complicate our Vaccine Readiness . Thank you for the question, senator. I think at the start of your statement, you immediately gave part of what would be my answer. I think your question and your comment about the stockpile as it exists today is a result of the underfunding that has occurred particularly since 2009. With the funds that were provided, kind of supplemental balances or emergency funds that were provided up to 2009 from 2009, it allowed for the building up of a stockpile of various pandemic strains. It was allowing us to test and to understand how to manufacture. This was a Good Partnership with barta and was fundamental to our preparation at that time. Since then, the funding has really dropped off as you commented. That is really whats behind the point that i was making. Theres product that sits in the stockpile today that was manufactured quite some time ago. In some cases, seven or eight years ago. Our ability and the ability of the government to replenish the stockpile, whether it be with antigen or others has been diminished by the lack of sustainable funding to support its efforts. In answer to your question, because of that, i dont believe we sit in a great state of readiness today. You mentioned the h7n9 and we are working with barta, but we need sustainable funding Going Forward to enhance our readiness. Sen. Baldwin this question is for you mr. Mcgregor and dr. Inglesby. My home state of wisconsin has long been a leader in medical innovations that help grow our economy. Not only are we home to a world renowned flu scientist working to develop a universal vaccine, but we are also the hub for Biomedical Companies producing new technologies. Stratatech, a company in madison, wisconsin is producing a new regenerative Skin Technology to treat severe burns through a contract with barta to develop tissue as a medical counter measure. Instead of painful skin graphs, they are designing tissue designed to mimic human skin and promote tissue regeneration. And mr. Macgregor, can you discuss why it is important to maintain our important to maintain our federal investment and medical countermeasure research and development to foster innovation the keeps pace with the evolving and increasing chemical and biological threats . Why dont we start with you, dr. Inglesby . Dr. Inglesby sure. I think the reason it is so important to continue investment is like the problems you described for patients with burns, for pandemic influenza, for other kinds of outbreaks, there is not necessarily a commercial market for this kind of products. So Companies Face a great deal of challenges planning. A load of uncertainty. If the government can provide more clarity both in the early phases and the research and the development phase, and the acquisition phase, companies can then decide to make investments in this space as opposed to other commercially valuable opportunities they might pursue otherwise. I think it will continue to be a very Important Role for the government to play for products that we want that are otherwise not produced by the commercial markets. I would certainly echo that comment. Its a mechanism that needs to exist to have innovative Companies Like the one you mentioned, and others that are members of the alliance for bio security to be able to continue innovating in the space. There needs to be sustainable funding in the space. The last comment i would make is just to add that its interesting to hear from a number of colleagues in the space that when you look at Institutional Investors and the like, where there used to be more of an attraction for them, when the funding was more certain, that attraction has gone away. Little to no value Institutional Investors and the like, where there used to be more of an attraction for them,n mcm work on the current context because of the lack of sustainable funding. Sen. Burr sen. Cassidy. Sen. Cassidy i enjoyed your testimony, all of you. I enjoyed it so much because you agree with me. One of you spoke about the need to have professionals, health care professionals, be able to go across lines and have liability protection. I was a practicing physician when katrina hit. There was an orthopod at the new orleans airport. The fema people would not allow people to set some of these broken bones because he was out of state and they were concerned about liability. I think we need a good samaritan. If you are from out of state and youre in Good Standing with your state, you get blanket protection. I think we need that on a federal level as opposed to the patchwork. I will say that and i have introduced a battle with senator king bill with senator king that would do so. ,r. Inglesby, dr. Dreyzehner need to haveut the a Public Health emergency fund. Senator schatz and i have for do and i have introduced something such as that. Need to have a Public Healthyou dont need a, tut when an emergency hits, i cannot be encumbered and put in escrow by another effort. You do have accountability. Gao will make sure they do it. We also take care of contracting because the previous cdc director said of ebola, he had to get 10 sign offs on travel vouchers for people to get over to west africa, and that slowed the response. He had to contract with ngos to contract to get transportation for people and goods. We are trying to circumvent that , in senator schatz and i have put something together regarding that. Let me hit on stuff thats perhaps more provocative. Dr. Inglesby, you speak about the need to maintain this international network. Theoretically, world health is doing that. Im not sure we are getting a bang for our buck with world health. You probably have relations with mean to put you in a bad position. If we are funding internationally world health and the cdc is doing it separately, that does not seem in a time of scarce resources, a wise use of resources. Thoughts . Dr. Inglesby the World Health Organization has some of the best experts in the world on diseases around the world and they are the normative agency for setting policy and guidance scarce resources, a wise use of around the world. They are not a Strong Operational agency. They dont have resources for going to train the world or going to train the world or build labs around the world. They have some money for that, but their budget is constrained as well. They depend on donors. Sen. Cassidy if they have the money, would they be capable of doing it . Dr. Inglesby not right now. Sen. Cassidy we are having to supplant International Organization with the centers of Disease Control. I understand why we are doing it , but it almost seems like we are compensating for something which should have the responsibility already. Dr. Inglesby the cdc and 65 other countries are all contributing in some way, some with a lot of money and somewhat their experts, but the global Health Security agenda was a way of getting a Large Consortium of countries to go out and help. Sen. Cassidy it seems like world health should be doing that. Let me move on. You mentioned about having regional areas of expertise. Let me go back to my formative experience with hurricane katrina. When the fecal material hit thet fan, it was just overwhelmed anything. When i went to haiti as a private citizen after the earthquake there, i was struck that the israelis came in and they just plopped down the hospital and unfolded it in every capability they need was fan, it was just overwhelmed there in a field hospital. I almost think since a Public Health emergency could happen in baton rouge, shreveport, or topeka, or you name it, how does every region have that kind of expertise as opposed to a Public Health hospital that may set up at your local v. A. , which is a government facility . Boom, weve commandeered, were taking it over. It seems like a better way to respond because you truly have expertise that is deployable in a moment. Any thoughts about that . Dr. Inglesby we should be able to rely on the local institutions. V. A. Is a great source of strength in some cities. The National Disaster medical system, the dmat teams, some of the teams that responded to katrina they responded to harvey. Sen. Cassidy let me go back to ebola, which was specialized. You have to take off your booties in a correct fashion or else you were exposed. As happened to the nurse in dallas. Dr. Inglesby the u. S. Was not prepared to send doctors and nurses to ebola. We sent Public Health specialists, but they did not take care of patients. Sen. Cassidy would it be better to have that sort of expertise that truly could go to a community and boom, we are going to be the Expeditionary Force . I am sitting next to a marine. The health care Expeditionary Force that is going to be able to manage this, and we dont have to have a lot of an Service People are hitting the door right now. We will give you inservice, but in the meantime we will provide direct care, so whether its baton rouge or topeka or new york, we know we have expertise deployed. Dr. Inglesby yeah, i do think that would be valuable. We do have Something Like that on a smaller scale called dmat teams. Sen. Cassidy but dmat is more generic. Dr. Inglesby fair enough. We do not have Infectious Disease oriented like the one youre talking about. Internationally, it would be good for us to be able to build those teams. Sen. Cassidy i yield back. Sen. Burr i would like the record to show that North Carolina tried to deliver to louisiana after katrina and to louisiana after katrina an affordable hospital. It was the governor who would not sign the Liability Agreement that put that hospital in mississippi. So we have this incredible Surge Capacity im learning about. Its just that we have hurdles in the way that stop it dead in in its tracks if it ever stop that if it ever starts the motion of collectively addressing the problem. So these are things we can work out. Sen. Cassidy we in louisiana continue to be indebted to other dmats around the nation. They so generously replied. Generously deployed. I cannot tell you the gratitude that we feel. Sen. Burr senator kaine. Sen. Kaine want to ask each of you to address a workforce question. So, the observation is this. When we reached a deal yesterday so the government would open, there were really two components to the deal. One, a guarantee of a debate and vote on permanent protection for dreamers which is very important, but the second half of that was we have to get out of continuing resolution mania and get back to real budget again to find that these priorities and others. One of the questions we are grappling with is the question of budgetary caps because of votes of earlier congresses that would impose such caps. When the caps were imposed, they were imposed equally on defense and nondefense. All of your testimony and the testimony of the Panel Last Week is about national security. This is national security. I just came from a closed hearing about Americas Nuclear posture in the Armed Services committee, but you are national security, too. One of the proposals floating around is that we would increase caps on the defense accounts but not on the nondefense accounts. You guys are nondefense so your e national security, but you are not defense. The lynchburg, virginia, economy is based pretty heavily on companies that build Nuclear Reactors that go into carriers and subs. Those are under the control of the department of energy not dod. That is a nondefense expenditure. The point that im making is that as we grapple with these caps, it would be foolish to not raise defense caps. If we are not raising caps appropriately to fund Emergency Response or we are not raising caps appropriately to fund the doe programs to build Nuclear Reactors, we are not taking care of our national security. Thats my observation. Second, workforce. The quote in your testimony written and verbal is about people. One of the things i love about this committee is that it is health, education, labor. In the education jurisdiction, we are having a set of hearings about approaching the rewrite of the Higher Education act. Programs like loan forgiveness. This is on the education side. You all approach your jobs from different backgrounds and expertise, but share any concerns you have about the current Public Health workforce in this country as you look forward, because we might be able to do something about that. We might be able to do some things about that as we grapple current Public Health workforce with the Higher Education act rewrite. If you want to start, dr. Krug . Dr. Krug thank you for the great question. As has already been said, this is a lot about people. We do need more stuff, but we do need more people. The budget environment today constrains the number of people that you can employ, which is why theres this justintime thing going on in health care, which is why we dont have a lot of capacity. In the end, there are not enough nurses to staff all the hospitals or all the clinics. Some of those limitations are greater in certain communities than others. I will defer to my Public Health colleague, but i believe there is a Public Health issue as well. What we need to do through education and some incentives is direct more of our future young people toward these important careers because these are careers where in addition to taking home a paycheck, you are making a difference. You are serving the community. You are serving the public. You may not be a special government employee, but youre still making a difference. I think if we can redirect the flow, we will be better prepared to deal with a calamity. Sen. Kaine others who would like to address it . Mr. Macgregor i will go down the line quickly. My main response to this would be some of the strain that comes on Public Health is referenced by my colleagues up here is the need to respond to an emergency. I feel a big part of the reauthorization discussion the notion of sustainable funding really has as its core the avoidance of having to respond to an emergency that puts an undue strain on the Public Health system. Its a bit drifted from your question about workforce, but i wanted to make that particular point because it gets to the sustainability question. Sen. Kaine thank you. Dr. Dreyzehner thank you, senator. A very important question, as mr. Mcgregor said in his comments about medical countermeasures and the certainty around having a market for those. Dr. Krug mentioned folks who are engaged in this area are highly committed, compassionate people, but they need certainty in the profession being there tomorrow. That has not been the case for the last 15 years. Theres been a lot of questions devotedwill the area i my life to, and called upon after 9 11 and anthrax when we developed our more modern and responsive higher capacity Public Health and preparedness infrastructure, but those are but those professionals have evolved around that. Many of them are now becoming senior. Many are retiring and making decisions as to whether they want to enter the field. Will there be a profession for me if i decide to enter the field or to stay in it . All those things are really important. Sustaining and maintaining funding is very important. Not pulling at the last minute to redirect it to some other priority is really important. You referenced that briefly. I absolutely think your points are really important. I think the threat to the Public Health workforce is that they will decide to go do Something Else and possibly they will retrain into health care, where there is a little more stability. They have other options, but they like these jobs. These are good jobs, they are important jobs in areas where they exist, both rural and urban environments. The Nations National security would be well served to recognize the passion of these professionals and the relationships they built in the lives and property they have saved in the last 15 years since this regime was reauthorized. Sen. Kaine might i ask dr. Inglesby to respond briefly . Dr. Inglesby the Public Health Emergency Preparedness program that supports so much of the Public Health workforce has come down pretty substantially since the start. Thousands of jobs have been eliminated in Public Health since we began this effort back after 9 11. I think theres great excitement in the field. Young people want to work on these issues in medicine, nursing, and Public Health. They leave schools with 30 substantial loans. With pretty substantial loans. There are some loan forgiveness programs that need to be attended to to draw people in to the field. People will come to these jobs if there is a field there. Right now, a lot of this money comes from the federal government and supports jobs directly. Continuing these programs would help ensure that we have a workforce. Sen. Kaine thank you for that. Sen. Burr senator young. Sen. Young thank you for a series of hearings on a very important topic, Public Health threats. I would like to turn to the topic of insurance for pandemics. I will be asking a question of each of you related to this topic, but by way of background, and our last hearing, we heard from admiral red from the centers of Disease Control and prevention. He said the strategy to prevent zoonotic diseases that spread from animals to people such as ebola and Avian Influenza is a reactive strategy. It made me think are there any strategies that might take this from a reactive stance to a proactive one . I found that last year the world Bank Launched the first pandemic bond to quickly finance Public Health emergencies. You may be familiar with this. Financing emergencies like pandemic influenza strains, something called coronaviruses, silo viruses like ebola, and others. According to the world bank, their pandemic emergency Financing Facility would provide over 500 million of coverage of pandemics in the next five years. My question to you is do you think congress should experiment in the creation of similar financing structures like the pandemic emergency Financing Facility or some other type of insurance mechanism to protect against pandemics . Regardless of your thoughts on that, if there are other proactive strategies, do you think we should turn to first, if you could volunteer that, i would appreciate it. We will start with dr. Inglesby please. Dr. Inglesby i very much respect what the world bank has done with pandemic bonds. Ive not studied enough whether that would be some value to do in the United States. I can get back to you with thoughts on that. One alternative that is less complicated that we talked about already would be to establish a Contingency Fund that would only be used in the event of emergencies declared by other congress with the secretary of health. By either congress or the secretary of health. We would have a fund ready to go kind of like an insurance policy. It would not be called insurance, but a Fund Available for rapid response. Sen. Young ive done work like this, new financing mechanisms related to a number of fields, from health care to social policy. This would not be all that complicated. It would be a way to capitalize a fund like those invokedrelated earlier. Thank you very much, doctor. Dr. Krug im not sure i know what insurance means anymore. Funding back to the prior levels is insurance to make sure the people that need to be there when the balloon goes up are there and able to do what they do. I think the Contingency Fund could be a very important piece of ensuring that the unknown unknowns are insured against. I have they will certainly a core and they will certainly occur. Our best insurance is making sure we have adequate people and relationships and networks and experts available at a moments notice to respond. Sen. Young thank you. Mr. Macgregor . Mr. Macgregor i would add as well that if mechanisms such as these, when you first mentioned it i thought in the event of protecting a pandemic wants it has hit, i might be inclined toward financing mechanisms that might allow us to be more prepared in advance and not having to deal with the tragic aftermath. And maybe just maybe what the world bank is proposing is something that could be more of a global kind of effort that cannot only benefit the u. S. But benefit other countries as well. By benefiting other countries, it actually contributes to the preparedness we can have here. Sen. Young thank you. Dr. Krug its good to be last. I agree with all the comments made by my colleagues. I would offer two hopefully helpful perspectives. First of all, as one of the members stated, if we can mitigate the problem and avoid the disease, that would solve a lot of problems. That gets back to a proactive vaccinations, and both globally and act a local level looking at those vectors and prevent early on those diseases before they spread. In the end, its pretty clear to me and i know you guys get this that theres not enough money to go around to make this all work. We have all told you we need to improve funding for the core elements of the process because if you want to do it for less, thats what youre going to get. You are going to get less. That is what we are seeing today. It is long overdue for a discussion with the public about the threats that we face, the reality of our resources, and how we can collectively make a difference. I think most americans share some common values, and i think our collective survival and making america stronger is something that most people would want to do. In the end, theres not enough resources when the cavalry arrives, whether its the state, local, or federal government to meet the needs of everybody in a town or city or whatnot. If citizens were better prepared , if we began a discussion about the values and the culture with personal readiness and with a strong helping the weak, helping your neighbor, maybe we would not have to rescue everybody. Maybe we would be rescuing fewer because there will be citizens who cant do that for a variety of important reasons. If we get back to the culturewer that i think i grew up with in grade school where that seemed to be a value, i think that would help us both with this and probably with some other issues as well. Sen. Young i thank you all. I threw a Novel Concept that you. If you have any additional thoughts you would like to followup with in my office later, i would be appreciative. Mr. Chairman, i would note that that point on community is something that has been invoked consistently whether were talking about the Opioid Epidemic or social pathologies , the need for more community to address a range of public issues we are dealing with. Not an easy to tackle, but an one important reminder. Thank you. Sen. Burr senator warren. Sen. Warren when a Public Health emergency hits, its all headlines about what is happening by a minute by minute or hourbyhour basis. You do not get news alerts on your phone about the years of hard work that went into making the response to the disaster actually work when everything was on the line. All the drills and the dry runs you do not get news and training. I understand these are the investments that we have to make in our nations preparedness and response capabilities if we are going to be ready when an emergency strikes. Im going to talk about one specific investment today and that is investing in the therapies or medical Counter Measures that save lives when disaster strikes. Vaccines for anthrax or ebola or influenza products, protecting us from radiation exposure, next generation antibiotics, congress in 2004 established a program called bio shield. I want to just dig in a little bit about this program. The idea was to accelerate development of medical countermeasures by investing in biomedical research. Dr. Inglesby, you are an expert on bio security. When a Company Develops a new drug or device, usually they go out and get a lot of funding from private investors. Why do medical countermeasures need Public Investment from a program like project bio shield . Dr. Inglesby the reason why Companies Need that kind of support from the government is because the products that we are trying to make for pandemics ebola vacciner that you mention, they dont have a commercial market. Sen. Warren we hope. Dr. Inglesby we hope. Access be difficult to those. Its going to be and stockpiles and we need sustained investment in those companies to get them to do this work. Sen. Warren project bio shield goten it was created, its 5. 6 billion in guaranteed funding over 10 years. It was called in advance appropriation. Congress decided in advance that it would spend that amount of money. They do not come back every year during that tenyear period to decide whether or not they would actually put the money in as promised. That changed in 2013, when the initial 10 year commitment ran out. Project bio shield had to get its funds set aside on a yearly basis like everyone else on the appropriations process. Mr. Macgregor, you work in the bio security field at a company that makes flu vaccines. The authorization levels for project bio shield, thats what Congress Says we could spend on it, have stayed exactly the same since 2013. Is that right . Mr. Macgregor since 2013, the authorization sen. Warren authorization stays the same, but appropriations levels did Congress Actually get that money out the door to you . Mr. Macgregor no. For bio shield, the authorization was 2. 8 billion and 1. 5 billion was actually appropriated. So that was a shortfall. Sen. Warren a pretty significant shortfall. And what does that mean for Companies Like yours that are trying to make decisions about researching and developing these kind of countermeasures . Mr. Macgregor you call into question what the commitment is. For a lot of companies, its very difficult in the space to do longterm planning and to forecast in a way you would typically forecast in a commercial space. It makes it very difficult to plan. I think what has happened with this uncertainty and i know ive mentioned it before, but during the initial 10 year period, there was a lot of this uncertainty and i know investment, Institutional Investment in companies in the mcm space, because there was a value that was seen there. I have heard from a number of colleagues that pool of investment has really dried up. There is little to any value that the market puts in the mcm space. Sen. Warren this really worries me. You are telling me its a market that only works if the federal government makes the investment , and that the yearly appropriations process is not working in this field. I think that is what im hearing from the two of you. It just seems to me that keeping our nation safe from these kinds of threats one of the most important investments we can make, you cannot make up ground overnight on this, but you cannot do it once the threat is on your doorstep. We have to be in this on the long haul. As the Committee Works to reauthorize, i hope we can discuss the importance of providing robust, Stable Funding to researchers who are working to help us avert the next Public Health emergency. Thank you, mr. Chairman. Sen. Burr thank you, senator warren. Let me just say to colleagues. I think senator casey and i have been in the trenches for a long time. We have written more letters to appropriators. The definitive change was when president ial budgets did not ask for the full bio shield money. A pivotal point. It was that lack of request. Unfortunately up here, as senator casey and i have found, even our letters to the appropriators would not get them to fill a hole bigger than what the president ial budget request was, and we have seen the steady decline. I think i can say on behalf of the chairman, who is an appropriator, that this committee has always said that we ought to appropriate at the authorization levels. You probably hit on the key thing that was the toughest thing to recognize, and that is where is the role of the federal governments responsibility at creating the incentive for people to create something that there is not a commercial market for . And i will say though hiding in the back of the room is one of the authors who now works as she has been feverishly writing notes, so everything you said is going to find its way back. I will tell you how difficult this was. When this was originally designed, trying to findnotes, somebody to be the spokesperson for disaster, we had to create a new position called emergency secretary of Emergency Preparedness, because nobody wanted to raise their hand and be in charge. This is something this committee has got to be absolutely vigilant on from a standpoint of what the needs are, because i would say mr. Macgregor is a great example. If this dries up, who wants to be in the vaccine space . The same reason we have a shortage of antibiotics today. Who wants to be in the antibiotics space . Its millions and millions of dollars of development. Its not only addressing this. Its technologically trying to come into the 21st century and in our regulatory and reimbursement, as you look at genebased platforms that may cure genetic defections and children on one side and diseases we have not been able to cure today that we can cure tomorrow. How do you reimburse for that . You cannot do it based on how much you put into it. You have got to look at it from a standpoint of how much we are saving over the life of living with that disease. This is foreign to government. But its something we have to tackle in a bipartisan way to get it done. Senator casey and i have just a couple more questions. If senator warren has a son, i will has some, i will stick around as long as we need to. Ifa dr. Krug, identifying emergent Public Health threats is important to treat and mitigate its effects. One of the best tools we have to gain this information is the diagnostic test. In the midst of combating ebola and zika, determining the individuals in need of treatment helped to inform providers and those on the front lines of the outbreak. How do rapid point of care dr. Krug, identifying emergent diagnostics work to better inform providers preparing for these Public Health emergencies . Dr. Krug they help immeasurably. Imagine for a moment that you are in a scenario with multiple sick victims. As one of my colleagues pointed out, your Ebola Treatment Center can maybe take care of at most three patients. Which of those three patients will you admit to the ebola treatment unit . With the Older Technology we have with diagnostic testing , which took over 24 hours back when we dealt with ebola at a treatment center, we had no other choice but to treat those patients until we were sure they did not have the disease. It came during a time of the year when we were not working at peak hospital operating capacity. If that was today, i dont know what to do with this problem because i would not know who to treat. By treating someone who may not actually have the disease any if the treatment, it could prevent someone who needs the same treatment area and icu bed and that icu care team meeting their needs. In the hospital setting and in the field, these diagnostics are terribly important. In the field, these resources are even more limited, so the fundamental decisions made in that setting are also vital. Sen. Burr tom, i want to turn to you, since dr. Krug mentioned ebola. Is this statement correct . We learned enough with the ebola crisis to understand our limitations, but we have done nothing to increase our capacity if it were to happen tomorrow. I think at a high level that is probably true. There have been some lessons built into the system, but we have not really changed Resources Available for the mission. We learned enough to know that we have little or no Surge Capacity for an Infectious Disease of that magnitude. That is true. Sen. Burr dr. Krug, let me come back to you from a pediatric standpoint there have been a number of news reports i do not know the accuracy of them that suggest that young adults taking tamiflu have had hallucinations. Hallucinations. How challenging does that make the avenue to try to expand these new treatments to the pediatrics population . Dr. Krug thanks to that you have hit the nail squarely on the head and it is not just tamiflu the bigger issue is with vaccination. With the exception of a glass of water, there are going to be side effects associated with potentially anything you prescribe or give to a patient. Whether you use something or not is hopefully driven by evidence , and the riskbenefit ratio of positive effects versus side effects. Thanks in part to social media, everything that occurs that did not occur the way it should have , and reports of adults who were having hallucinations with tamiflu make their way to places so that the average family that i care for that has a smart phone, they already know about this, and when i try to advise them at their child should have something and it is driven by cdc guidance, they say to me, but doctor, this medication will cause my child to have four heads. And that is like, well, i am not even sure that is true, and if it is true, the likelihood of that occurrence from the disease is much more likely than the four heads you are worried about. The point is that does make it more difficult. The partnership that we have been able to have and it is not just the American Academy of pediatrics, other specialties in terms of partnering the cdc and familiesut guidance to on a reliable website, so perhaps there is counter information that makes it clear that if your child has an underlying medical problem and they are in their first day of illness with the flu, tamiflu is probably a good idea. The challenging thing is to fulfill your wishes, which is to increase pediatric indications. You have to have kids that are willing to join clinical trials. We have done unusual things by emergency release order, but i think you would agree with me that is physically different than what a dose or drug might have been approved for, you do not know the reaction you are going to get. My hope is that we map out a way. There is a real interest in the there is a real interest in the committee to make sure that pediatrics indications is a normal process in the future. Dr. Krug it should bepart of the process. There are ethical concerns whenever you enroll a child in a trial. Are substantially greater than adults. So again, were calling on this as a very interesting discussion. Since we do not know of it is going to work, should we try and test the anthrax vaccine in anthrax evente an occurs . In the end, we deferred to the president ial commission on bioethics that came to the conclusion that it is probably not ethical to do that. That is the dilemma. How do you do that . Again, in an industry where it is tough to convince people to develop things for which there market is evenhe smaller for kids, and it is a steeper hill to climb. Sen. Burr i want to turn to you really quick. I think it is safe to say that countermeasures are difficult things to develop. Those human efficacy studies are not feasible in some countermeasures. So, the fda finally in 2015 set the way forward with the animal rule. My question is this, what are the challenges in successfully bringing forward a medical countermeasure by relying on bringing forward a medical countermeasure by relying on the animal rule as the pathway . It is a different approach from what we are accustomed to , so you are reliant on the data you generate from that rule, being something you have to extrapolate to something being of use in humans. So i think it is beneficial in the sense that allows us to bring medical countermeasures forward. In that regard, it is good. It is a rule that we have is an industry to adapt to Going Forward, but i think as an industry we are doing it, so it has been a good step forward. Sen. Casey mr. Chairman, thank you very much. I want to continue on the topic of children. I know were almost out of time. In the last three authorizations, we were able to put into place a new Advisory Committee on children and disasters. Appreciate your work and testimony today. The only question i have for you is, what are the areas of our preparedness planning where you see the greatest need for more attention to the needs of children . I know you have answered different parts of this, but maybe at least for my wrapup it attention to the needs of could be there. Dr. Krug arguably in all facets and again, we have made tremendous progress. From a health care perspective, and that is a narrow perspective because the whole process is bigger than health care. The Health Care Industry is primarily put together to take care of somebody like me. Somebody not a child. Somebody with underlying medical problems, towards the end of their life. I hope not. The point is that with the exception of the facilities and their smaller number that specializes in kids, the rest of the system does not. There is nothing wrong with that. That is how it works on a daytoday basis. We can build these Specialty Centers of greatness for disaster response, but every community, every institution, every clinic that is where the care may need to be provided to take care of the community. That also includes kids. Current operations, if you have a sick child, you put him in the ambulance and you send them to the tall Childrens Hospital. That is not going to work the tall Childrens Hospital has been disabled by the event or the nature of the disaster does not permit transportation, or everything is fine, but they are already full to the gills. So, the challenge we have is the good thing is everybody likes kids. We have got to get everybody better prepared to take care of kids. One of the most important ways to get there is through training. Drilling, training would make us better in caring for all populations, and certainly for children. Sen. Casey thank you very much. Sen. Burr thank you to our witnesses. I want to highlight once again, in 24 years, i have done a lot of hearings. Ive found it almost impossible to have an agency witness at the table who testified and the private panel come up second and get an Agency Person to stay in the room and listen to the private sector. This might be the first time i have looked and we have not had a government witness, but we have had agency folks who have attended to hear what the members in the private sector say about the reauthorization of the program. That is unusual. I hope it is a trend that is going to become the norm and not the exception, and i said that as a message to go back. I think your testimony is not only valuable to us, it is valuable to the agencies that are affected by the issues that are affected by the issues that you are here to talk about. So i want you to know today, they got heard not just by us , but by the agency itself. I thank all four of you for your willingness to be here for the insight you have provided to the committee. This hearing is adjourned. [gavel pound] for president of the United States. [applause] announcer tuesday night, donald trump gives his first state of the union address. Join us starting at 8 00 p. M. For a preview, followed by this beach at 9 00 p. M. Following the speech, the democratic response by congressman joe kennedy. Trumps state of the Union Tuesday night at 8 00 on cspan. On cspan radio or watch live on the cspan app. Announcer on monday, a preview of the president s state of the union address, including kellyanne conway, nancy pelosi, and senators. Live coverage hosted by the Washington Post starts at 2 30 p. M. Eastern on cspan three. This week, the white house did not release a president ial public address. Representative adam smith delivered the democratic weekly address. Mr. Smith hello, i am adam smith. I represent the ninth district of the state of washington. I am pleased to give the democratic message this week