Transcripts For CSPAN2 Public Health Preparedness Response 20180124

I like to call the hearing to order. And id like to recognize the chairman of the committee for a statement. Thank you senator burns. Senator casey members of the committee. How to think senator burr for chairing the hearing today and senator casey for serving as Ranking Member at senator murrays request. Theyre both been leaders. Senator per was the original author of the first passage of the pandemic. He helps protect us from the full range of Public Health threats. Natural disasters and outbreaks of net the disease. Then in 2013, senators bring caseys led the bipartisan authorization of the pandemic and all hazards act. Many can be contributed to that time including senators and see in bennett, war, hatch, roberts, and others. Now it needs to be reauthorized for second time. Todays hearing is the second weve have the sheer. Last week we heard from the administration on recommendations of advance including from the assistant secretary of preparedness and response the senators for the prevention. The flu season its critical that we reauthorize the act. I hope will do this in a bipartisan way and i expect that it has been the tradition of the lawn this committee on all of our major bills. People are not as aware of the devastation the flu season. The figures are between 12 and 50000 americans die of flu every year. Doctor collins has talked to us about expediting the universal flu vaccine which she sees you. Tennessee has seen heartbreaking things already. Already a pregnant woman and three children in tennessee have died of the flu. The act provides a Public Health framework that enables us to be prepared and able to respond to Public Health threats by ensuring we have enough medicines to protect americans and ensure we are prepared to respond to emergencies. Thanks for witnesses especially doctor dreiser who has come from tennessee. Thank you. This morning were holding a hearing of facing threats i will hear from doctor tom inglesby, director of the center for Health Security, doctor john, commissioner of the Tennessee Department of Public Health, brett mcgregor, and cochair of the alliance for bio security, head of pediatric emergency medicine at lurie Childrens Hospital in chicago. Well have an Opening Statement in the will hear from the witnesses. Im sheet please to chair the searing to a former work. I want to thank the chairman for giving the opportunity to senator casey and i to lead the discussion. Today will hear from individuals with knowledge of the challenges we face combating Public Health threats from their idea on how to move forward. Since the last reauthorization has been tested by pandemic flu, multiple master disasters, and ebola breakout and seeker virus. The Lessons Learned come from individuals like those sitting before us today. In their efforts to protect and saves lives. Blessed Hurricane Season had three major storms devastating communities raising questions about managing i was standing multiple periods of response. Besides the need for improved Data Collection and surveillance to inform and protect as many mothers and babies as possible. Further it highlighted the need that shows the knowledge that can be brought by this threat the deep undertaking for procurement and other measures. I look forward to learning about the leverages and Innovative Technologies to solve these problems. Whether the challenge of a vaccine, information crucial to a Public Health department, infrastructure of doctor needs to care for patients or improvements to the way the policies complement one another, your experiences remind us you cannot let up on these efforts early side of the urgency. We must not get distracted, improving and strengthening our policies and programs to make them more effective, known in the future. I look forward to it eat should witness can provide. Thank you. I think you for your years of work on these issues. As a think senator alexander and breaking member murray for this opportunity. Also i think our witnesses for bringing their experience and work to these issues and for joining us today. This is her second hearing on the topic. The focus is our nations preparedness to combat the Health Threats as we look towards reauthorizing the pandemic later this year. Now, we must rebuild our nations resiliency to help security threats. The threats that face our nation today are an increasing in frequency and intensity. Its critical to faster drugs, devices and diagnostics. Yet when were considering things that have yet to be seen by my response to it Natural Disaster like a hurricane, we do not and will not have a vaccine or countermeasure to purge tech tests. So in addition to supporting biomedical innovations we must strengthen hospitals and Public Health professionals, a front line of defense against these Health Threats. We must assure to give communities the tool and support they need to be ready, when, not if the next emergency strikes. Weve come a long way. I spoke at the last hearing about the Preparedness Program in the context of a trained realm in pennsylvania. One of many examples we could site. The grants for these programs facilitate preparedness activities that help hospitals and Health Systems with more regular occurrences. When subzero temperatures cause bursting types, they contacted a local Emergency Management and Healthcare Coalition created through hpp funding who assisted in the response from that circumstance. And yet funding has decreased with appropriations falling behind authorized levels spiking only in the response to ebola and zika. The impact means a decrease in the amount of time hospitals and medical staff can plan and train for an emergency. The loss of thousands of Public Health jobs, the reduction of Emergency Managers and lab technicians. Its dangerous to wait for threat to emerge to pass bills. We must be proactive, not reactive. How can we improve the Health Care System preparedness and thereby improve our Situational Awareness in an emergency . Can we work toward a precision Public Health using better data to guide responses to benefit our communities . I think we can. As reported by the publication, nature, when the seeker virus was confirmed in the united states, the entire country was not declared at risk. Instead surveillance defines two areas of miamidade county. The measure less than two and half square miles. This allowed for targeting of resources. Building on that we can expand to eliminate disease and spark opportunities for prevention. Last weeks hearing we heard from assistant secretary about the use of the empower program to identify and treat at risk individuals requiring electricity dependent medical assisted equipment. The system only pulls in medicare the tragic death of 12 seniors were needs to be done to protect our vulnerable citizens. The dr. Is also a professor of pediatric Northwestern University school of medicine and serves as the chair of the American Academy of pediatric Disaster Preparedness Advisory Council. Welcome. With that i will turn to you doctor and lets begin. You can laid off. Thank you. Senator, members of the committee, thank you for the chance to speak today about these important issues. I am the director of the center for Health Security at Johns Hopkins Bloomberg School of Public Health where i am a professor of medicine and Public Health. Dissenters mission is to protect Peoples Health from epidemics and disasters and build resilient communities. I provide a brief overview of key areas my center, colleagues and i consider vital to the nation preparedness and response capabilities. The opinions expressed are my own and do not necessarily reflect the views of Johns Hopkins university. Health threats could occur without much warning. These include Natural Disasters, ecological accidents, Mass Shootings and bombings, chemical spills and potential use of chemical weapons. Radiation and Nuclear Threats and biological threats. Biological threats whether Natural Light aged seven and nine in china were accidental such as an epidemic release from the land were deliberate like smallpox or anthrax. A particular concern and a big focus of my comments today. Biological threats can range from modest in size, up to those capable of opposing global catastrophic risks. What more can be done to prepare for these threats . First, we need to strengthen Healthcare System preparedness. That is the capacity to care for high numbers of sick or injured in an emergency. There has been substantial progress in prepare for disasters but the nation is not ready to prepare radical care in north contest of your big epidemics of contagious disease. The hospital Preparedness Program has been helping fund and build the capability is at the state and local level. Significant resource constraints limit what they can do. It has more than 50 percent since it started in 2002. The command should be reversed. New initiatives like establishing regional Disaster Resource hospitals can be a strong new additional components in improving medical preparedness. Second, we need to strengthen the ability of the Public Health system to detect and respond to threats. Since 2001, there been serious efforts at the cdc, state and local efforts or local level to provide early warning, lab diagnostics, investigate and contain outbreaks, communicates the public and ensure safety and security. There has been good Forward Movement but theres too much to do and not enough trained professionals to do the work. The Public Health relies on funding from cdc, Public Health Emergency Preparedness grants. The funding has been reduced by nearly 30 percent since 2002. Even the Public Health crises have not declined. This should be strongly supported and in addition i believe that a Public Health Emergency Contingency Fund should be established which would allow rapid Public Health response funding and emergencies. Third, we need to move ahead in medical countermeasure development. It has been Good Progress but many parties remain anthony sustained funding and Research Development manufacturing and acquisition of countermeasures. Technologies and setting more ambitious technologies for products and emergencies so they are ready in the course of a given pandemic or epidemic. Fourth, the us needs to recognize stress that could inadvertently emerge from biological research. After the moratorium on Pathogen Research was lifted last month, researchers can now get apply for funding to study for example, ways of making the worlds most lethal viruses like h5n1 bird flu like seasonal flu. This can lead to accidental or deliberate release of the strain of virus that can cause an epidemic or pandemic. I do not believe the benefits of the worker worth the risks. If it will go ahead i advised that there be high transparency in the program and serious dialogue among concerned governments internationally and how to proceed. Finally, we should fund the global Health Security agenda for g hsa. In 2014 they launched ghsa with a billiondollar commitment to help prevent, detect and respond to Infectious Disease threats. Since then, the cdc and usad have been working to increase lab and surveillance to abilities, strengthen public workforces and much more. At this point, us funding for ghsa is ending soon. We pull away from the ghsa, other countries will likely do the same. We should continue to support it. It is the most effective that we have to do this overseas. Improving nations preparedness and response capacity is a daunting complex endeavor. But i am confident it is achievable. I appreciate the committees time and i welcome your questions. Thank you doctor. Good morning. Chairman and senators. Distinguished committee members. Thank you for this opportunity to appear before the committee and discuss an issue of significant importance to the common defense of the country. A strong agile and resilient Public Health and medical preparedness and response system. It is an honor to be here senator. I am the commission of health in tennessee is a local Health Director for a decade before that and many years before that as well. I will be sharing with you today my own thoughts but im confident they are shared by my Public Health colleagues across the country. We strive every day to prepare and respond to threats of all kinds. These debts may be Infectious Disease outbreaks like the measles, foreignborn illness and annual epidemic of seasonal influenza. Not like this you can unpredictably test our responsiveness and capacity. These can also be largescale, national or global events like a influenza pandemic or acts of terrorism. Public health also globalize is as you know during Natural Disasters like storms, hurricanes, tornadoes, floods, wildfires, etc. 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 through mechanisms like Emergency Management assistance compact, even uninfected jurisdictions are frequently called upon to assist neighbors. Public health and Emergency Preparedness response and recovery is a responsibility, discipline and service that we have to get right. Lies physical health depend on if it is something we do every day. In the matter of local resiliency. All disasters play out locally. It is also a matter of National Security. In a few moments i will share my perspective of you being directly involved in certain roles at all levels with military and civil capacity. What is healthy and medical Emergency Preparedness response and recovery . It is not stuff for equipment for plans. It is people. Shelters do not staff themselves. A firetruck cannot put out a fire without firefighters. And people like Public Health nurses or firefighters cannot be hired and trained after the alarm sounds. They need to be there ready to go before the threat ever emerges. If they are to be effective in responding to it. Preparedness is about the people involved and the interconnected networks. To be truly prepared we need three key things. One is to train people with knowledge and all connected by relationships built on trust. Number two, expertise in leadership at all levels. Local, state and federal. And three, communication and shared Situational Awareness among responding leaders, people on the ground and experts. Try to create these three things after an event begins, takes the one commodity that is most precious in an emergency, time. We do not have time to create this network after the event starts. Anyway the Public Health and Emergency Response and Recovery Network is like a safety net for a performer. It has to be in place before the show starts anchored and inspected and in good shape to do the job. Many people think equipment or supplies are the net. But, if you remember nothing else from my testimony today, i would like you to remember this. People, people, not things are. Net. People are in that. Anchors matter but people run the response. The relationships, knowledge and trust over time is what strengthens the chords, holds it together and keeps them adaptable and resilient. The more chords, the more capable we are. Things like durable medical equipment, medical countermeasures and Communications Infrastructure are essential anchors for that net. Without that the network of people cannot be as effective. But the people are the net. Our accomplishments and successes over the last 15 years illustrated in my written remarks can be directly attributed i believe to the pandemic and all hazardous preparedness act. This act in its first form has provided the requisite direction authorities, authorization resources and the accountability that have become part of the culture of Public Health and enable us to do our job in the best way possible. As you consider reauthorization, the priorities and resources must be lined up with the demands of an earth spending environment given the front line defense and safety net ability. The scale of speed it needs to protect the Public Health and safety are critical to the ability. Congress and especially the committee, should be applauded for the continued work on laws like states and 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 Security as you know. But consummately and essential. Sometimes depending on the hazard, Public Health is the only responder. We ultimately need as a nation to ensure a strong citizen is sufficient funding to keep the people, the net, the knowledge and networks, trust intact. Thank you again for the opportunity to speak with you today about this fundamental issue. And for caring about preserving our ability to respond to any hazard or threat for generations to come. We appreciate the opportunity to present to you. Happy to take questions. Thank you. Good morning senators, members of the committee. My name is brent mcgregor. Commercial operations, i appreciate the opportunity to appear before you today. And to prepare for the second reauthorization of the pandemic and all hazards preparedness act. I like to focus my remarks on the importance of preparedness against pandemic influenza and the Critical Role played by the Biomedical Advanced Research and Development Authority and its industry partners. There are three issues i would like to highlight from my testimony. First the pandemic influenza is one of the most urgent Public Health threats we face as a nation. And must be a priority of the bile defense enterprise. Second, the Pandemic Influenza Program must be in this years the decision. And the Congress Must provide sustained funding to strengthen partnerships with the private sector to ensure the nations preparedness. Regarding my first point, preparing against pandemic influenza. This is critical to the national and economic security. It secures the partnership to supply one third of the nations needs when the next pandemic strikes. Thanks to leadership of the senator burr and senator casey, members of the committee, and a dedicated team at barta, we have one of the best examples of a successful Publicprivate Partnership in bio defense. Second regarding the Pandemic Influenza Program. Despite representing vp, funding has never been included in the legislation. As a result funding like stockpiling advanced research and development has been largely since 2009. The emergency Supplemental Fund during 2005 and 2009 pandemics are not fully exhausted. Having a program authorized by congress will provide a clear signal to the private sector, that the Us Government is committed to preparing against pandemic thats in the future. The most recent fiveyear budget outlines 630 million in pandemic influenza funding needs. For fiscal year 2019 alone. We believe an annual authorization release 535 million is needed to support the most critical pandemic influenza activities. Finally, regarding the funding. Over the last 12 years, this enterprise has greatly improved our nation security. And while they have improved communication with industry partners, better coordination from the government to provide more and to and certainly in the development process. Procurement funding provided by the project special fund, the stockpile and the Pandemic Influenza Program provides manufacturers with market certainty after investing many years. Because there is no commercial market for this companies can only rely on the commitment provided by hhs to make investments in research. Unfortunately, over the last several years, the private sector has become skeptical of the government commitment to bio defense big lack of multiyear funding has created uncertainty in the longterm sustainability of programs. Publicprivate partnerships must be sustained over time. There he demonstrated commitment by the federal government. There are dozens of companies both large and small, that have committed to the mission and made significant new investments in mcm development. Authorization of the authorities and renewed commitment to mcm funding will ensure that they yield more countermeasures. The church strongly supports the reauthorization priorities. Identified by the alliance for bio security to which im privileged to be a cochair. And biotechnology organization. I would like to thank members of the committee and in particular senator burr for the commitment to the reauthorizing of pahpa. We want to make sure americans are better protected of the threat of pandemic influenza and were excited about the future of our partnership. This is a critical opportunity for congress to ensure that they have the resources it needs to prepare against one of the most predictable threats that we face as a nation. Look forward to serving as a resource for the committee during the reauthorization of pahpa. Im happy to understand questions and i thank you for inviting me here today. Thank you for the testimony. Stephen, the floor is yours. Good morning. Chairman burke, Ranking Member casey comet established members and staff of the health committee. I am doctor steve head of medicine at the Childrens Hospital in chicago and professor of pediatrics at the Northwestern University Feinberg School of medicine. I am the chair of the American Academy of pediatrics Disaster Preparedness Advisory Council and on behalf of the 66,000 members of the aap, thank you for holding todays hearing and for inviting me. In the last reauthorizations three authorizations. Those changes that help to make the needs of children in much higher priority in Emergency Planning response. As we heard last week from cdc and fda leadership these changes have a distinct role in ensuring our Health Care System is better prepared to meet the needs of all americans including of course children during and after a disaster. The leader of these federal agencies and countless hardworking dedicated federal employees that they oversee really are the bad one of our nations 24 7 federal Emergency Response. By most accounts a frequency severity of disasters meaning they will remain a significant threat to the health and safety of our communities and our nation. As such maintaining and expanding the federal government to Strategic Focus on all hazards approach is that address routine and how security needs are critical. The sore choir continuing engagement of all stakeholders including Public Health medical and Mental Health services academia industry and daytoday Emergency Trauma Services printer nations elements of preparedness including Emergency Medical Services for Children Program and our nations Childrens Hospitals must be strong. It is evident that Health Care Health care and other systems that are regularly tested will be the most reliable and effective during the response. Regular exercises and drills along with the continuing education for daycare providers and First Responders in order to be ready for all populations when they disaster strikes. This is important to meet the meet needs of children. We should strive for healthy and more resilient when teen predisaster this will reduce the burden on the Health Care System during and after disaster. It ensures access to Affordable Health care and Preventative Services and reducing Health Care Disparity in all populations. Financial drivers in Todays Health Care environment are not aligned with the need for facilities to be prepared for Public Health emergencies. Cost reduction measures have resulted in leaner stockpile to supply medications and equipment at a substantially smaller workforce but the daily operations particularly impatient operations functioning much closer to full capacity but this is what Emergency Department overcrowding where i work in poor and poor capacity during seasonal epidemics and pandemics like the one we are going to right now. The capacity is particularly precarious than pediatrics. Disaster plan does not equal integrate primary care. These clinicians are largely operating a small set or businesses that provide Vital Services before during and after disasters. In the absence of mechanisms provide assistance to impact a providers and disruptive practices. Many have been forced to leave. Given this is not hard to see why so many communities have responded and struggled to respond in why so many never fully recover after disaster that Community Resilience allies have leaving on the resilient to the health care sector. Children account for 25 of the population and their unique vulnerability is remain preparedness and response activities at all levels. Children are not little adults. I concur with the comments of my esteemed colleague but i would offer free conditional thoughts to the recommendations. First reauthorizing the strength of the hhs National Advisory committee on children in disasters with subject Matter Experts from the public and private sector has provided insightful ideas. Authorize the cdc childrens preparedness unit which is proven to be an invaluable resource of the cdc pediatrician Community Schools and child serving institutions during recent emergencies such as zika. This unit is a vast best practice example of an effective public and private Sector Partnership that has brought tremendous value to preparedness preparedness. Finally to reiterate the comments that have been made lets maintain the Grant Programs that are distinct programs with strong pediatric measures and increased funding biggest disasters in universal wristwatches influence at can occur anywhere in the nation is essential all jurisdictions have a baseline level of preparedness aided by each of these programs. I want to thank the committee for the opportunity to testify and i look forward to your questions. As evidenced by the fact that im not sure we have in the past had a pediatrician in related hearings it shows that we understand the need to get it right. I might say its probably one of the most challenging areas because its hard to incorporate pediatrics and the cuttingedge technologies that on one side but that will always be a challenge and would be more subject better to help us navigate through this. I will recognize members of the five minute starting with myself and move on a seniority basis. Mr. Macgregors security has worked for many years to make us better prepared in the event of an outbreak and facilities in Holly Springs North Carolina is both a promise and a partnership between your company and the federal government that is needed. We can flip a switch from the manufacturing for seasonal flus to the manufacturing what are the Lessons Learned from this partnership and how can we improve the partnership . Thank you for the question. I think the lessons we have learned is the partnership is a very good one. What has happened really in recent years is the commitment that has been made and for which secures companies have delivered delivered. The funding has not kept up. Whereas there was a period of time and even though the funding for the pandemic flu was not part of the original legislation there were Supplemental Funds provided for the flu. I think the big lesson we have learned since that time is the funding has declined particularly since 2009. You start to question the commitment and the partnership forward with barda. Sometimes we feel the funding that is dedicated or earmarked to preventing the flu suggests theres not a seriousness or interest taking to this particular threat Going Forward. I think thats one of the Lessons Learned. I think ongoing communication is another lesson. I think for the most part the communication between barda and our companies that arent partnership with the government have been good but there is always opportunity for improvement across the sector from na i. D. All the way to the s and mask sns. The jurisdictional lines were to go at the beginning. I hope my colleagues on the committee will remember this years flu and the severity of it we dont know yet. As we get smarter protecting what the thread is going to be this is a great example of where not smart enough to get it better than 32 right based on current numbers and we have got to look at technology that allows us to address the seasonal flu in the way that encompasses all of the above options. You mentioned florida. Part of his advance new and Innovative Technologies to better combat Health Threats. Its been extremely successful in an advancing innovative approaches and medical countermeasures such as platform technologies. What d. C. Is the greatest challenges to bring in these newest Innovative Technologies through the medical countermeasure pipeline . I think one example that you mentioned senator burr is new Platform Technology and the plant in Holly Springs is an example of this. This is cellbased technology and its more conventional which i think most people are aware of of. The interaction with barda is very strong and not only allowing us to continue to advance the effectiveness of cellbased knowledge and most recently through the partnership their efforts to improve cellbased technology that cannot only benefit in a pandemic setting but potential benefit in the seasonal setting as well and the bandit at the will come will not only be hopefully sooner to market but the other promise and cellbased technology is an example of a Platform Technology that is suggested by government. It offers the potential by providing a better match in the event of a mismatch. , me turn to you if i can. Innovation has drastically improved the Situational Awareness to monitor and identify publicHealth Threats in as timely a fashion as is possible. Though this potential exist the federal government lags behind in its ability to leverage these technologies. How can we improve the federal programs to create more cohesive and realtime surveillance capability for Public Health threats and as an aside to that do you believe that we use enough open Source Information outside of the mechanisms we have set up domestically and internationally . Senator burr thats a very good question and we have been working on that for a long time. There are many Surveillance Systems in the country that have that goal. They are not all brought together under one roof which is very difficult to do and its been a goal of the federal government to try to consolidate them bring those together. One of the things that we could do better is to get more information out of the Health Care System. Public health during emergencies we have a lot of advances in Electronic Health records but for the most part Public Health agencies dont have any resources or analytics to be able to see whats going on in Health Care Records around the country. So if we could do more to bridge that divide through Public Health and medicine thats where the signals are going to come in outbreaks from doctors and nurses seeing unusual things in reading that information to Public Health getting diagnostics, getting that information together. In closing that divide a little bit in bringing together sources of information like whats going on in the animal systems and combine that with Human Systems being able to trace back when big food outbreaks arise. Thats a very big challenge for us right now. Where a lot better than many. Much better. John is on the frontline and i felt confident that mechanisms are in place for that transmission of information. All we need is one break down and it does make one wonder in the overall scheme of things why we are not layering on top of that a review of scripts on a daily basis that gives us either confirmation of what we are hearing from the Public Health arena or potentially a sign of an outbreak of something we picked up in prescriptions that were administered the day before and the unusual thing is that gives us great clarity as far as the geographical location of something all the way down to the nine digit zip. Seems like its all of the above above. Thank you senator burr. That her supple and i will start with you. Senator burr talked about the flu. This year we are told one more than 17,700 cases of the flu have been confirmed just in pennsylvania. 32 people including one child have passed away because of that that. While this is a particularly bad flu season it doesnt come close to what we would see on a much larger scale Infectious Disease emergency or of course in a pandemic flu scenario. Or health care or his art in capacity with this flu season so we are woefully unprepared to respond to a mass casualty biological event. So for both. Or inglesby inductor six how can we begin to prepare hospitals, lets just focus on hospitals for mass casualty biological event and i know thats a lot to bite off but as best as you can. Thank you for the question senator and i welcome dr. Capitol udpates ands comments as well. As has been said funding to its prior levels would be huge hugely hugely in terms of the financial incentives of the Current System just in time for supplies and for staffing and limited surge capacity. We are seeing that right now and act i did town hall with her hospital couple weeks ago and some of the challenges. This is a flu season that is more severe than we typically see. We dont know exactly what this will look like in comparison to other seasons. One thing that is true many states are reporting all of that that. Senator alexander pointed out some tragic preventable deaths and as we hear about those things theres a perception of greater severity and winners of perception of greater severity people go to places like emergency room so one of the things we have been doing is if you are ill you may need to call your Health Care Provider but you may not need to go to Emergency Rooms all those types of things are part of what we deal with in a flu season where theres heightened awareness. In terms of assuring we are prepared the amount of funding available through the grant has been adequate for some time and as you pointed out in your comments theres a need to bolster that. I dont think it takes a great deal more patzert made were tending to funding levels will be extremely healthy. Dr. Inglesby. I agree with everything said and if if theres anything more we can develop our flu technologies modernization and rapid acceleration of the process being the interim goal the less we will have in hospitals but in the meantime we need a strong Health Care System system. It could be other facets of that program like having more Regional Centers back and shoulder more responsibility in crises and take care of more patients. We need a level 1 trauma system works very well but we dont have one for Infectious Disease. Rebuild biocontainment units in response to ebola. Most of those containment units can only take care of two or three patients at most. You want to raise the level of preparedness and we might think about creating regional strength strength. Most hospitals need to have proficiency personal protective equipment and relationships with the other hospitals and Public Health agencies and surgery clinics and medical clinics through a network of care as opposed to relying on acute care hospitals. You have to distribute that burden out to the community when their major epidemics flu and pandemics. A level 1 Trauma Center model is what i hear i hear. How do you think we incentivize that in the context of your testimony. On page three are for two specialized Disaster Resource hospitals. I am out of time but then i will come back later to dr. Subtwo six and get his comments on it. You would have to provide resources for it we wont be elected build programs unless the government says we can years out. Thank you very much. Thank you chairman burr. Dr. Inglesby you wrote on the National Security agenda for Global Health agenda. That was in 2014. Where is it now . Multiple agencies of government particular ac dc and usaid. What is the quarterback . The quarterback is the directors. When the Ebola Outbreak took place and he referred to some places around the united states. From a modest standpoint we were able to meet with every university and nih and a couple of other places and doctors who came back from liberia. How much of that was enough at the time but how much should be dealt simpler preparation in case anything like that happen again. Maybe not for a bowl up at some cases . Every National Leader in that program and you speak to leaders in a program they would say would be difficult for them to take care of more than one or two patients in the current units. I think we need to get better cost information about how much the units cost. It would be difficult to scale those by orders of magnitude by 10 or 100 but we could build more capacitance systems share the lessons that have been learned in those units see if we can spread that responsibility a bit further because right now its a pretty small number of units that can care for any patients. In most cases capital. Exactly told training in specialized people. You talked about funding. [inaudible] the Contingency Fund . If you base Contingency Funding on what we have spent in Infectious Disease emergencies we typically spend 500 million to 1 billion as a country in response to things like zika. Sometimes much more so a fund that was somewhere in that range in the Public Health agency and others outside of our center have called her to billion dollar Contingency Fund closer to femas Disaster Relief funding. I think that would be, provide a lot of acceleration in response to emergencies. The biological threats and disease with oceans and berries is something the roe World Community has to get together on. Tonight yes, absolutely. The cdc is great and so is usaid and they did a great job on ebola but the International Agenda ought to be a coalesced game plan. One of its successes is that it brings in different parts of government including finance sides of government securities that the government so the u. S. There is participation by security and finance and economics and thats the model they are trying to get other countries to represent as well. Mr. Macgregor. Has North Carolina manufactured the flu vaccine . Yes. How are we doing on back . Do we still have enough . We have been constantly enhancing the capability so from a seasonal perspective looking at seasonal perspectives we have more than tripled our capacity into the market this year. I mentioned in delivering one third of the requirement in the event of a pandemic and responding within a six month period. Is itself based . In a cellbased, that is correct. What is the shelf life . The shelf life of the vaccine from a pandemic in perspective is five years but unfortunately we do have antigen in the stockpile right now thats older than that and from a cell perspective but thats the state of affairs right now is far as its concerned to have promised by the way senator as i said it offers the potential of being a better match so as an alternative form of manufacturing for initial Publicprivate Partnerships that is a promise that are companies trying to deliver on on behalf of the government. Thank you very much and thanks to all of these for your testimony. Thank you. Thank you senator burr and senator casey thank you for your leadership on this issue and to our panelists. Good morning and thank you for being here. Dr. Inglesby i wanted to start with a question for you. As you all know puerto rico was devastated by Hurricane Maria and the island is still trying to rebuild from a disaster. The effects of that disaster are widespread. Hospitals in New Hampshire and around the country dealing with among other effects medical products and equipment such as i. V. Saline bags because the storm devastated some of the manufacturers on the island. What does this say about a future vendor of their emergencies where a emergency playas can plies camp easily replenish and what can we do in congress to reauthorize . Senator hassan i agree with you completely that puerto rico hurricane and other storms have revealed how are wonderful our supply systems are and one possibility to consider would be to consider whether there are some critical supplies such as saline bags if they are single sourced or some active products or pharmaceuticals that are single sourced whether or not this should be included in the pharmaceutical stockpile. That is not how the stockpile is configured or resource now so would need to be Additional Resources for an Additional Mission but the stockpile has had Great Success in acquiring medicines to be able to deliver them to locality so that would be one possibility in funding for the stockpile. The time wont count against you but Holly Springs is a great example in the other two facilities that when faced with a pandemic we thought what can we do to me what we dont know and we went into partnership with three Different Countries where we funded threequarters of the facility implant but with conditions written into it that at any point we could turn it into whats in the nations best interest and all three owners that participated. It may be a model that we look at as we identify the things that we have shown a degree in the past. I think thats very helpful and i think what happened after maria hopes us focus on the next things we should be doing. I also wanted to ask all of you and i start the question with you. There dreyzehner nh funds a statewide coalition that works with Public Health and Emergency Management professionals to ensure that health care across the spectrum of care from hospitals to home care to longterm care and beyond. Other states rely on this funding to make sure the peers for all kinds of emergencies and hurricanes. Unfortunately like many other states New Hampshire seen a significant decrease in hospital preparedness funding. We dont know when the next emergency will happen or what cicely it will entail so we need to make sure the coalition in New Hampshire is not only collaborating regularly but its hard to do that when funding is dramatically reduced. I will start with you dr. Dreyzehner by from all of you do you believe the need to increase the hospital Preparedness Program 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 it, go response . In my written testimony i talk about three tears for professionals. We have people that are highly trained and they are called upon and their National Emergency but they typically have different duties on a daytoday basis. One of our emergency coordinators director board of Emergency Medical Services but when we have an emergency she is in apperson center in and we have a third tier which is everybody else in the people you are talking about in the Public Health nurses and the clinicians in the hospital. Their hospital nurses and people who are called upon whenever there is a need and they are training and the training and exercising and responding creating relationships and the knowhow what do i do where to ride who do i talk to those at the critical things. Those are relationships built on trust and the funding really helps solidify. Unfortunately when we reduce that funding thats one of the first things that goes. You try to preserve positions in you try to preserve but the more fungible assets are the very things you need more of and i think you spoke to those. To nick thank you and in the interest of time i would ask the panel anything you would disagree with or add to what dr. Dreyzehner just said about the founding . Just to point that it is about people. Nearly question about how do we get the hospitals better prepared, they have to train and if you dont have trained people your response will not be affected. Thats been shown in many other Industries Including health care and with the focus evolving from hospitals to Health Care Coalitions which actually an appropriate mode its not just the hospitals that need to be trained if the entire community that needs to be trained. If as an emergency physician after oxygen the elixir of life and how we care for patients as saline so but do you have sepsis because of the high consequence of infection or youve been in the explosion or a bus crash and you dont have saline you lose your life. There could be nothing more fundamental to our Emergency Response after oxygen than saline. Thank you and senator i know im over and i will submit a question about Behavioral Health needs especially for children in disasters and traumas and disasters. They concern me greatly and lastly thank you for pointing out the importance of focusing on special needs populations. On the mother of a special needs young man and thank you for your testimony very much. Thank you very much senator burr and senator casey and the other members of this committee for your work and focus on Emergency Preparedness and also to our test the fires here today. In 2015 when i was Lieutenant Governor of minnesota minnesotas hit by an avian flu outbreak which ended up costing somewhere in the neighborhood of 1 billion with the largest and most expensive animal disease response in the history of this country. Of course it hit poultry growers incredibly hard so if. Or dreyzehner i was relating to what you are talking about about how the safety net they have is about people. Certainly as we responded to this catastrophe we needed stuff but we also really needed the people and their relationships that made our response work and function incredibly quickly which was such an important part of it. I am quite interested in this idea of a one Health Approach and how we can build that kind of approach when thinking about Emergency Preparedness. I know senator young from indiana has raised this question just last week and probably two weeks. You probably been talking about for much longer but it raises this question about whether we need additional approaches or resources to do this. I would like to turn to. Or inglesby it also dr. Dreyzehner. Could you talk a little bit about what tweets we might need to the legislation to address this question has one Health Approach and what we ought to be doing better on . Yes. First of all i completely agree there are strong protections between animal and Human Health Disease and out rakes and i do think those principles and federal agencies people believe there is a lot of acceptance and belief in one health but youre also right that its housed in a particular program. If there arent large efforts underway to bring one Health Together i do think theres a National Strategy that is now being written or completed by the white house and its purpose is to bring together animal health, plant health and human health and this is the first time the strategy has been written that way. I do think there was a lot of coming together in agencies over the last year on this and its improving animal Surveillance Systems. We dont have strong animal surveillance and we talk about shortages in the workforce, the human health and Public Health workforce is trapped in the Public Health workforce is even more strapped. Taking a look at those things im not sure its in the scope of pop are not that we dont have a lot of information coming from our animal systems and we dont have enough information and doesnt cross over to human health very easily so it to create a bridge between these systems would be a good step. Thank you very much. Dr. Dreyzehner. We think about primary prevention with the flu and stopping it in the first place. I think we have to look at ourselves and how do you primarily prevent the flu from ever occurring in the population or another disease such as ebola occurring in your population while doing things around animal sources are critical. In stamping out Avian Influenza in poultry we had to make sure we circle the workers encircle their families because thats the primary prevention of a influenza strain in the human population. One health is an essential perspective and i think from my perspective and the association of Health Officials perspective id be interested in that and id be very happy to work with you on crafting in papa how to specifically as dr. Inglesby mentioned bringing ag recessionals and Health Professionals and the health world together to do the better job in animal populations. And ill make one other point. We came to Congress Years ago and said you know we need some money to teach people how to properly peer prepare in africa and how to properly gather food. When you consider the money we have spent on the Ebola Outbreak from those practices and lack of education around that risk is a relatively small investment. Tonight thank you very much and i look forward to working with this committee and senator young on this issue of one health. I appreciate it appreciated him and then im out of time but i might also submit later to dr. Crowd and miniatures to do and how respond to what is another epic comic of the Opioid Epidemic especially in indian country. That will be for later time but i would very much appreciate your thoughts on that. Senator roberts. Thank you mr. Chairman. I want to thank you for this committee and both the Ranking Member and our distinguished chairman for focusing on this issue. Last month in the Agriculture Committee we held a on safeguarding american agriculture in the globalized world. Dr. Inglesby you really hit the nail on the head with your comments. One of our witnesses was general Richard Meyers of fourstar Kansas State University national bioand defense facility called it mpac for sure. General meyers notes because there were two Homeland Security president ial directives hspds in 2004 and that spend some time ago one for people and one for animals. There does not seem to be a strong focus at the executive level wants livestock and suggested reasons why this is surprising and i went to the full testimony in the record at this point if thats all right mr. Chairman. The reasons are essentially every country that ever developed a bio Weapons Program including the u. S. And agriculture as well as people. I would like to insert at this time with a lot of interest in this by former senators sam nunn and dick lugar and the nunnlugar program on pandemic threats and also by tom ridge and Joe Lieberman with regards agritourism. I myself was when charged at one time is a member of the Armed Service committee. It was called the subcommittee went to a place just north and west of moscow. Thereby seeing one of the sacred cities and we are not allowed there now of course but we were then. We were focusing on security but in that area i was a little stunned with regards to mass warehouses of pathogens that they were making ready and attacking the countrys food supply. At that particular time its a misnomer because you dont want the bird carcasses or anything like that but by the time texas figured out shipping to oklahoma or to texas they say dell shipped any we have an epidemic on our hands. We had to terminate thousands if not millions of cattle. All of our exports stopped. All of our exports stopped. There was a run on Grocery Stores throughout the country. People discovered their income from Grocery Stores. Took us years to get back to a situation where we could literally feed not only this country but the world. That was quite an experience for me. The general said as i have indicated every country ever developed a bio Weapons Program also targeted agriculture to almost every pandemic that can spread from animals to people. The department of Homeland Security has issued a material threat determination all except for smallpox are synodic meeting they reach humans or animals. The foreign animal disease threats could devastate Public Health as well according to general meyers testimony. Tell him path is operational i regret that its taking that long there is no u. S. Laboratory to be good on ebola, swine being opposed to animal for both. As chairman i would like to work with you and all of our colleagues on this reauthorization to ensure we are addressing and preparing for the threats. I have 25 seconds to ask dr. Inglesby if you would like to respond. In leading the countermeasure and to praise this is supposed to be for all the coordinating agencies in advance of the Homeland Security Homeland Security lung with all of the First Responders involved along with our strategy to implement implement from your perspective are we doing the job . I think we have a lot more work to do in the realm of agriculture food and crop safety safety. I agree with what you said about the importance of animal vaccines and a shortage. With the lack of animal vaccines to protect herds from some of the most serious diseases on the planet i agree with what you said about the threat to agriculture which i think both animal and plants have been relatively neglected over the last 15 years. We have got to do other things from a biological defense. I dont have a strong sense of how it should be organized. I think its complicated and usda is responsible for the promotion of food and the business of food and they could perhaps be difficult to have all the protection in the same exact place where they have seen signs of life in the past six months abound around the program lasts five or 10 years. Secretary perdue and the Agricultural Research obviously would run the department of Homeland Security and they are responsible for an attack on its face. Been difficult to focus on this. Some years back in the Intelligence Committee in which my distinguished friend is the chairman we are able to determine what keep shoe up at night at least in the top 10 in our food supply thats not the case today talking with our director mike pompeo from kansas so we are trying to at least reassess that threat. I think its very real and i thank you all for your service and im over my time i yield back. Thank you mr. Chairman. I knew there would be a question somewhere in that. Thank you chairman burr and Ranking Member casey. This discussion today is important and timely and to focus the sobering fact that we have experienced at least one Health Emergency every year in the five years that i have been serving on this committee from ebola to zika two 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 capability. We are also in the middle of a particularly severe in deadly seasonal flu year so i wanted to focus specifically on readiness for a pandemic flu outbreak. I am concerned with the lack of sustained and predictable funding for the pandemic vaccine stock pile and im committed to working with my colleagues to advance a specific authorization for pandemic flu activity. Mr. Macgregor and your testimony i was troubled that are pandemic flu stock pile doesnt match the current strain of influenza and is full of expired vaccine components due to underfunding and its especially concerning as we have the age seven and nine bird flu circulating in china that continues to evolve in ways that have potential to trigger a Global Global pandemic that we adequately prepared for now right of pandemic flu that could strike in the near term and how would a pandemic in the middle of this severe flu season complicate our Vaccine Readiness . Thank you for the question senator. At the start of your statement portable would be my answer, think your question your comment about the stockpile as it exists today is the result of the underfunding that is occur particularly since 2009 so the ones that were provided and balances for Emergency Funds would provide from 2005 to 2009 it allows the stockpile of bearing pandemic strains, three of pandemic strains allowing us to test and understand how they manufacture and this is in a Good Partnership with barda and was fundamental to our preparation at that time. Since then the funding is dropped off as you commented mats behind the point i was making. There is a product that sits in the stockpile today that was manufacturing sometime ago. Some of them seven or eight years ago and our ability and the ability of the country to replenish the stock pile whether it be with antigens or whether it be with adjuvant which is also a stockpile has been diminished by the lack of sustainable funding in its efforts. In answer to your question because of that i dont believe they sit in the great state of readiness today. We are in fact working with barda in developing 87 and nine and other partners are as well but we need that sustainable funding Going Forward to sustain readiness. This next question is for you mr. Macgregor and you dr. Inglesby use dr. Inglesby. My home state of wisconsin has long been a leader in medic innovation that helps grow our economy. Not only are we home to renounce flu scientists working to develop a universal vaccine but also by medical companies producing the technology. A company in Madison Wisconsin cassini were janitors to scan technology to treat severe burns to her contract with barda to develop their tissue as a medical countermeasure. Through several skin grafts they are producing skin graft to mimic human skin and promote tissue for generations. Dr. Inglesby and mr. Macgregor can you discuss the federal investment in medical countermeasure research and development for two foster innovation involving an increasing chemical and biological threat and why dont we start with you dr. Inglesby. I think the reason its so important to continue investment is for problems like the one you described for patients with burns, for pandemic influenza and other kinds of outbreaks there isnt necessarily a commercial market for those products so Companies Face a different challenge in planning and a lot of uncertainty and if the government can provide more parity both in the early stages of the research and Development Stage and potentially an acquisition phase for a particular Product Companies can then plan and decide to make investments as opposed to other commercially valuable opportunities they might pursue otherwise. I think it will continue to play an Important Role for the government. I would certainly echo that comment of dr. Inglesby. Its a mechanism that needs to exist and Innovative Companies like the one you mentioned for bio security and more broadly bio, to be able to continue innovating in the states a sustainable funding in the state. Alas, that would make its interesting to hear from a number of colleagues that when you look at institutional advances and the like and the attraction for them when the funding was more certain that attraction has gone the way and the new value is placed in the current context because of the lack of sustainable funding. Senator saxby. Thank you jill meant that i enjoyed your testimony, all of you. I enjoyed it so much because you would rewith me. Perhaps one of you spoke about the need to have Health Care Professionals to be able to build go across lines and have liability protection. I was a practicing physician when katrina hit. The fema people would not allow him to assess someones broken bones because he was from out of state and they were written about liability. If you are from out of state in Good Standing with your state you have protection but when you get on a federal level is and ive introduced a bill with senator king entitled the Good Samaritan Health Professionals act and secondly dr. Krug and dr. Inglesby the need to have a Public Health Emergency Fund and senator schatz and ive introduced something that just as fema has dollars it doesnt mean a special preparations but when an emergency hits the dollars are appropriated in it cannot be encumbered and put in escrow by another effort. Those dollars are there. You have to come back to congress and get approval. Gao will eventually do it at it would also take care of contracts. The previous director said of ebola he had to get 10 travel vouchers for people to go to west africa. He had to contract with ngos for them to contract to get transportation for people and goods. Senator schatz and ive put something together with guards of that. Let me ring up something thats perhaps will more provocative. The need to maintain the International Network theoretically world health is doing that. Im not sure we are getting our bank for our buck with world health. You probably have relationships with them so dont mean to put in a bad position but the cdc is doing it separately. At the same in a time of scarce resources a wise use of resources. Thoughts . The World Health Organization has some of the best experts in the world and around the world and they are the normative agency for setting policy and guidance around the world but they are not a Strong Operational agency. They dont have resources for going to train the world. They have some money for that but their budget is constrained as well. Do they have the capability of doing it . Not right now. Were having to supplant an International Organization with the centers for Disease Control. Its almost as if we are compensating for something which has responsibility already. I would say 65 other countries are contributing in some way some of them with a lot of money and some of them with experts but the Global Health care agenda was a way of getting a Large Consortium of countries. I get that but it seems like world should be doing that. Now you mentioned having regional areas of expertise. Let me go back to my former experience with hurricane katrina. When the material hit the fan it was just overwhelmed. When i went to haiti as a private citizen after the earthquake there i was struck that the israelis came in and they plop down the hospital and unfolded it in every capability they need was there, a field hospital. I most think is Public Health emergencies in baton rouge shreveport or topeka or you name it how does every region have that expertise as opposed to a Public Health hospital set up in your local va which is a government boom we have commandeered aware taken over. Better way to understand respond is we truly have expertise and we can respond. I do think we should be able to rely on local institutions. Fee azar greats source of strength in some cities but they disaster medical system and the d teams are the teams that some teams responded to katrina. Lets go back to you bolo which is very the u. S. Was not prepared to send doctors and nurses for ebola. We spent health specialists. My point is would be better to have that expertise that truly could go to a community and we are going to be the Expeditionary Force. And Expeditionary Force that will be able to manage this and we dont have a lot of inservice for the people in the door right now. We will give you in service but in the meantime we will provide direct care and whether its baton rouge or topeka or new york we know we have expertise. I do think it would be very valuable. We have Something Like that on a smaller scale. D is more generic. I agree with you. We dont have ebola or contain just disease oriented teams and internationally would be good for us to build those teams. I yield that. I would like to show North Carolina after katrina delivered an affordable hospital portable hospital and was the governor of the wooden sign the liability. We have this incredible capacity. We have hurdles in the way that stopped the dead in its tracks if it ever starts the motion of addressing collectively the problem. These are things we can work out. We continue to be indebted around the nation who are deployed. Senator kaine. Its an observation want to ask each of you to address the workforce question. The observation is when we reached a deal yesterday so the government would open there really two components and neither one a guarantee but permanent protection for dreamers which is very important the second half was we have got to get out a continuing resolution and get that budget to fund those priorities and others. When the funding questions where grappling with is the question of what a terry caps because of those of earlier congresses that would impose such caps. When the caps are imposed they were imposed equally on defense and nondefense. All of your testimony and the testimony last week was about as security. I just came from a closed hearing about Americas Nuclear posture and the armed interNational Security. One of the proposals floating around is it would increase caps on the defense accounts but not on the nondefense accounts. You guys are nondefense. Your National Security but youre not defense. The lynchburg virginia economy is based heavily on companies that build Nuclear Reactors that build carriers and subs but those under control of the department of energy so thats the nondefense expenditures. The point that im making as we grapple with these caps would be foolish to raise defense the nondefense caps because if we are not raising superbly to fund Emergency Response or where not raising superbly to fund the programs that build Nuclear Reactors we are not taking care of her National Security. Thats my observation. Second dr. Dreyzehner your testimony about people and it is about people with things i love about this Committee Health education and labor pension so in the context of our labor we are having Senate Hearings about approaching the rewrite of education act. Programs such as public loan forgiveness. This is on education site pretty well approached your jobs from a different background of expertise but share any concerns you have about the current Public Health workforce in this country as you look forward. And we do need more stuff but we really need more people and the budget environment today constrains the number of people you can employ which is why there is this going on in healthcare and we dont have a lot of capacity but in the end there are not enough nurses to staff of hospitals or clinics in some of those limitation limitae greater in certain communities than others and there is a Public Health force issue as well and what we need to do in education and maybe through some incentive is to direct more of our future young people towards these important carriers because these are in addition to taking them a paycheck, you are making a difference serving the community and the public. To redirect the flow we would be better prepared to deal with the calamity. Others who would address it. We both go down the line quickly. My only response would be some of the restraint is the need to respond in an emergency and i feel like a big part of the reauthorization discussion into the notion of sustainable funding has at its core the avoidance of having to respond d that puts an undue strain on the Public Health system so it is a bit drifted from your question about workforce but i think it gets to the sustainability. Thank you, senator. Folks that are engaged in this area are highly committed and compassionate people that they need certainty in the profession being there tomorrow. Theres been a lot of question marks raised about the area that i devoted my life to a. Many of them are becoming senior and are retiring. Will there be a profession if i decide to enter the field so all of these things are important to sustaining funding is important. You reference that briefly so i think your points are important. The threats to the Public Health workforce is the will decide to go do Something Else and possibly they will retrain into healthcare with a little bit more stability. They have other options, but they really like these jobs. They are good jobs and in portland in the areas they exist in the rural and urban environments and i think that the nations National Security would be well served to recognize the experience that they gained and relationships and the lives and property they saved in the last 15 years since this regime was authorized. I would just echo the comments and say that the program that supports so much of the work force has come down pretty substantially since the start since they began the effort after 9 11 i think theres great excitement in the field. They leave schools with pretty substantial loan and there are some loan forgiveness programs that need to be attended to the. Right now a lot of it does come from the federal government. It supports jobs directly. Thank you for that. Thank you chairman and Ranking Member for the second in the series of hearings. In the last hearing we heard from the admiral from the center for Disease Control and prevention. Its been a reactive strategy and so it made me think are there any strategies that goes from the reactive stance to use the term proactive . 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 the pandemic influenza and something called the corona viruses and others. According to the world bank, the pandemic emergency Financing Facility would provide over 500 million of coverage against pandemics in the last five yea years. You think congress should experiment in similar financing structures like the pandemic emergency Financing Facility or some other type of insurance mechanism to protect against pandemics and regardless of your thoughts on that, if there are other proactive strategies that you think we should turn to first if you could volunteer that to me i would appreciate it and we will start with doctor ingles. What we talked about already but be to establish Contingency Fund that would only be used for congress or the secretary of health. It would be ready to go kind of like an insurance policy. Ive done work like this in the new financing mechanisms related to the number of healthcare social policies so i respectfully am on th of the opn this wouldnt be that complicated. Im not sure that i know what insurance means anymore but yes, back to the prior levels it is insurance to make sure the people that need to go there when the balloon goes up are able to do what they do and in the Contingency Fund that could be a very important piece of ensuring the unknowns are insured against so i would echo what was said and i would say that our best insurance is making sure that we have adequate people and relationships and networks and experts available at a moments notice to respond. I would add its mechanisms is such as these when you first mentioned in the event of protecting against the cost of the pandemic i would be more inclined to work in the financing mechanisms that allow it to be more prepared than not having it deal with the tragic aftermath and maybe what the world bank is proposing is something that could be more of a global effort and could not only benefit the u. S. But other countries as well and by benefiting it actually contributes. Its good to be last. All of the comments made by my colleagues i would offer a hopeful perspective. If we could avoid the disease, that would solve a lot of problems and so that gets back to a proactive vaccination. Early on to prevent the diseases before they spread in the end, it is pretty clear to me theres not enough money to go around to make this all work. 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. In the threats we face the reality of the resources and how we can collectively make a difference i think most americans share some common values and i think that 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 calvary arrives whether it is the federal, state or local government to meet the needs of everybody. If citizens were better prepared and if he began in a discussion about the values and culture with personal readiness and the strong helping the weak and making sure that thats okay then we went and maybe this sort of rescue everybody. Maybe we would be dressed using a few and in doing so there will be citizens cant do that for a variety of important reasons. But if we get back to the culture that 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 some other issues as well. I threw a Novel Concept at you if you have any additional fun adult leader i would be appreciative and mr. Chairman, i would note that point on community is something that has been consistent whether it is the Opioid Epidemic or the need for more community to address the range of public issues we are dealing with, so not an easy one to tackle, but an important reminder. Thank you mr. Chairman. Public Health Emergency hits and the headlines are about what happens on a minute by minute and hour by hour basis. The hard work that went into making the Disaster Work when everything was on the minds of all of the drills and training, but i understand that these are the investments that we have to make in the nations preparedness and response capabilities if we are going to be ready when the emergency strikes, so i want to talk about one specific type of investment today and that is investing in the therapies into the measures that save lives when disaster strikes. So vaccines for anthrax or influenza nextgeneration antibiotics, and i think the senator referred to this earlier and senator baldwin and i want to be again a little bit by investing in medical research you are an expert on bio security. When a Company Develops a new drug or device usually they get a lot of funding from private investors. Why do the medical countermeasures need Public Investment from a program like the project by ocean of the. Even in the event of a pandemic its going to be difficult for people to access the funds without the help of government they would be in stockpiles so we need sustained investment to get them to do this work. And a guaranteed funding over ten years it was called and advanced appropriation and that Means Congress decided in advance that it was going to spend that amount of money to decide whether or not they would put the money in as promised. Now, that changed when the initial plan ran out and projects bio shield hand to get its funds set aside just like everyone else through the appropriations process. You work in the bio security field in a company that makes flu vaccines. The authorization levels have stayed the same since 2013 is that right . There was the authorization. Authorization stays the same, but appropriations levels did Congress Actually get that money out the door to you . No, i think that the authorization was 2. 8 from fy 14 and about 1. 5 billion was actually appropriated so there was a shortfall relative to what they had been experiencing. 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 . Call into question again with the commitment is and i think for a lot of companies it is difficult in this space to do longterm planning and forecasting the way you would typically granted in a commercial space so that makes it difficult to plan. I think as well what has happened in this uncertainty and i know i mentioned it before but during that initial tenyear period their of private investment in companies that were in this space because there was the value that was seen and ive heard from a number of colleagues investment has dried up and there is very little that is put in this space. Youre telling me it is a market that only works if the market makes the investment and event data yearly appropriations process isnt working in this field. I think thats what im hearing from the two of you. But it seems to me keeping the nation safe from these threats is the most important investment or one of the most important thing can make. You cannot break ground overnight on this once the threat is at your doorstep. We have to be in this for the long haul. I hope we can discuss robust and Stable Funding to the researchers who are working to help us with the next Public Health emergency. I think that we have been in the trenches for a long time with more letters to appropriators. Definitive changes when the budgets and ask for the full pivotal point. It was the lack of request and here and senator casey and i found in the letters to the appropriators van with a president ial budget request was. I can say on behalf of the chairman we all ought to appropriate at the authorization levels. You probably hit on the key thing that is the toughest to recognize and that is where is the role of the federal governments responsibility at creating the incentive for people to create something that iis not a commercial art before and i would say now as one of the authors has feverishly been writing notes, so everything youve said today is going to find its way back. I will tell you how difficult this was when it was originally designed, try to find somebody to be the spokesperson for the disaster created i a new positin of the emergency secretary for preparedness because nobody wanted to raise their hand and be in charge. So this is something that the committee has to be absolutely vigilant on from the standpoint of what the needs are because i would say mr. Mcgregor is a good example. Who wants to be in the vaccines they come at th the same reasone have a shortage of antibiotics today. Its millions and millions of dollars of development and its not only addressing this i would say its also technologically trying to come into the century and the regulatory reimbursement as you look at the platforms, the genebased platforms that make the genetic depictions in children on one side and the diseases that we havent been able to endure tomorrow today that the consumer. How did you reimburse for that . You can do it based on how much you put into it. Youve got to look at it from the standpoint of how much we are saving. This is for him to the government but something that we have to tackle in a bipartisan way to get it done. We have just a couple more questions and if senator warren has some bibles per pound as long as the two. Identifying an emerging is difficult in how to treat and mitigate its effects. One of the best tools we have to gain the information is the diagnostic test in the midst of combating, determining the individuals in need of treatment help to inform providers and those on the frontlines of the outbreak. How do with our rapid point worked to better inform those preparing for the Public Health emergencies . Thank you. That is a great question. They help immeasurably. Imagine for a moment that you were in a scenario with several sick victims and is one of my colleagues pointed out, they could take care of the patients that he will admit to the unit but the Older Technology that we have took over 24 hours back when we dealt with the treatment center. We had no other choice but to treat them until we make sure they didnt have the disease. It came during the time in the year that we are not operating at peak hospital upgrading capacity. If that was today, i wouldnt know what to do with the problem because i wouldnt know who to treat and by treating somebody that doesnt have the disease and the need for treatment essentially defend somebody else and that care team meeting their needs, so both in the hospital setting and also in the field, these diagnostics are terribly important. The resources are even less limited and so the fundamental decisions made in that setting are also vital. I want to turn to you. As the statement correct we learned enough with the ebola crisis to understand our limitations, but we have done nothing to increase our capacities 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 havent really changed resources that are available for the mission. We learned enough to know that we have a little capacity for the Infectious Disease of that magnitude. Let me come back to you from a pediatric standpoint. Thereve been a number of news reports, i dont know the accuracy of them, thats just young adults taking a tamiflu have had so loose ahallucinations. How is that expanded the new treatments to the pediatric population . Youve hit the nail on the head and its not just tamiflu. The bigger issue is on vaccination. With the exception of a glass of water there will be side effects with potentially anything that you prescribe or give to a patient. Whether you use something or not is driven by evidence and that ratio of the cause and effect versus the side effect. And thanks in part to the social media everything that occurs that maybe didnt occur the way it should have with reports of adults that are having hallucinations with timoth tamie their way to places so the average family i care for a already know about this and when i try to advise them that their child should have something driven they say to me this medication will cause my child [inaudible] i dont know if that is true and if it is, the likelihood of that is probably much more likely than those youve are worried about, so the point is it does make it more difficult and i will say that the partnership that we have been able to have and its not just the American Academy of pediatrics, theres others as well in terms of partnering with a group like the cdc indicating guidance not only to practitioners that information to families so that at least on a reliable website there is perhaps counter information that makes it clear that if your child has an underlying medical problem and that they are in their first day of illness that tamiflu is probably a good idea. The challenging thing is to fulfill your wish to increase the pediatric indication. Youve got to have kids going to join Clinical Trials and that means a pair and that is willing to allow a child to do that. We have done some unusual thing by the emergency use order but i think you would agree when you take somebody that is physically different than what a dose or drug might be approved for you just dont know the reaction youre going to get. There is an interest in the community to make sure that pediatric indications is a normal process in the future. And it should be part of the process. There are ethical concerns that are substantially greater than adults and so again recalling this other half that i have, a very interesting discussion about since we dont know if its going to work should we try to test the anthrax vaccine in children before the event occurs and this is back when it was high on the radar screen, and in the end, we deferred to the president ial commission of bioethics which the subject came to the conclusion that probably wasnt ethical to do that, so thats the dilemma. How do you do that an and in an industry where it is tough to convince people to develop things for which there is a market it is even smaller for kids and the risk to the industry to do something that is substantially greater so it is a steep hill to climb. I want to turn to you just real quick i think it is safe to say the countermeasures are difficult things to develop. Those studies are not feasible in some countermeasures, so the fda finally in 2015 set the wayy forward with the animal google. My question is what are the challenges in successfully bringing forward a medical countermeasure by relying on animal rule as the pathway . Its a different approach from what we are accustomed to so you are reliant on the data you generate from that rule being something that you have to extrapolate from being of use so i think it is beneficial in that it allows us to bring the medical countermeasures forward so in that regard its good. Its a rule and individual would adapt to Going Forward but it has been a good step forward. Senator casey. Thank you very much. I wanted to continue on the topic of children. I know we are almost out of time. In the last reauthorization, we were able to place a new Advisory Committee on the children disasters and appreciate your work and testimony today. The only question i have for you is what are the areas of the preparedness plannin planning tu see the need for greater attention in the needs of children and i know youve answered different parts of this, but [inaudible] arguably, we have made tremendous progress in the committee and its certainly contributed to the direction. From a healthcare perspective because the whole process is bigger than health care, the Health Care Industry is primarily for together to take e care of somebody like me, somebody not a child, somebody with underlying medical problems toward the end of their life they hope not and complaint is with the exception of the facilities and a smaller number of us with a specialized with kids, the rest of the system does not and theres nothing within it works like that on a daytoday basis. We can build the Specialty Centers for the Disaster Response that ever but every co, every institution, every clinic because thats where the care needs to be prepared. You put them in the ambulance and send them to the hospital but is it going to work first of doesnt permit transportation or everything is fine but they already are full so the challenge we have into the goodd thing is everybody likes kids, so that is our little thing in our pocket. Weve got to get everybody better prepared to take care of kids and one of the most important ways to get there is through training i think this would make us better for all populations i and certainly children. Thanks mr. Chairman. Thank you to the witnesses. I do want to highlight once again in the 24 years ive done a lot of hearings. I found it almost impossible to have an agency with this at the table who testified into the private panel came up to give an Agency Person to stay i to staye room took us into the private sector this may be the first time ive looked and weve not had a government witness that weve had agency folks that have attended this year with the members and the sector say about the reauthorization of the program. I think all of you for your willingness to be here and the insight that he provided to the committee and the hearing is adjourned. [inaudible conversations] [inaudible conversations] [inaudible conversations] Kevin Mcintyre a the chair of te federal trade commission and assistant Energy Secretary bruce walker were among a panel of government officials testifying before the Senate Energy and Natural Resources committee. They looked at the impact of major weather events on the power system. This is about two hours and 15 minutes