3 October 1998

    Source: http://www.hhs.gov/progorg/asl/testify/t980602c.txt

    1998/06/02; OPHS Testimony; Preparedness for Epidemics and Bioterrorism

      STATEMENT OF
      ROBERT KNOUSS
      DIRECTOR
      OFFICE OF EMERGENCY PREPAREDNESS
      U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
      BEFORE THE
      SENATE SUBCOMMITTEE ON LABOR, HEALTH AND HUMAN SERVICES,
      EDUCATION AND RELATED AGENCIES
      COMMITTEE ON APPROPRIATIONS

      JUNE 2, 1998

      Good afternoon.  I am Dr. Robert Knouss, Director of the Office of Emergency
      Preparedness in the Department of Health and Human Services (HHS).
      I am pleased to have the opportunity to appear before the Senate Appropriations
      Subcommittee on  Labor, Health and Human Services and Education on the very
      important topic of the Nation's Public Health Infrastructure Regarding Epidemics and
      Bioterrorism.

      The Office of Emergency Preparedness is responsible for coordinating HHS' continuity
      of government, continuity of operations, and the provision of public health and medical
      services following emergencies and disasters that sufficiently degrade local capacity as to
      require national assistance.  In this role we also work with other federal agencies and the
      private sector to develop capabilities and capacities for responding to the health and
      medical needs of affected populations.

      HHS is actively participating in the Department of Justice led effort to develop a Five-Year
      Inter-Agency Counter-terrorism and Technology Plan.  This effort will address
      specific strategies and requirements for all agencies involved in the counter-terrorism
      effort.

      I am also the Director of the National Disaster Medical System (NDMS) which is a
      partnership between the Department of Defense, the Department of Veterans Affairs, the
      Federal Emergency Management Agency, HHS and the private sector.  This system can
      provide medical response to an affected area, evacuate patients, and provide definitive
      care if local and state resources are overtaxed.  Under the Federal Response Plan, NDMS
      assets are incorporated into Emergency Support Function #8, Health and Medical
      Services, and have been deployed to a wide variety of emergencies such as natural
      disasters, plane crashes, and terrorist incidents.

      The Sarin gas attack on the Tokyo subway system and the Oklahoma City bombing of the
      Alfred P. Murrah Federal Building left the world shocked by these senseless and horrific
      acts of terrorism.  One of our greatest challenges is addressing the complex preparedness
      issues posed by a terrorist use of a WMD on civilian populations.  The human health
      impact of such a release or detonation is the primary consequence of such an attack.

      HHS is taking a "systems" approach to building response capability and capacity at the
      local, state and federal levels.  Our counter-terrorism strategy includes the following key
      elements: Enhancing local resources because disaster response in this country begins at
      the local level; developing partnerships to improve local and state health and medical
      system coordination and capability to respond effectively; and improving federal health
      and medical capability to rapidly augment state and local responses.  Our resources
      include those of the National Disaster Medical System.

      As part of this system, we have developed specialized national medical response teams
      (located in Washington, D.C., Winston-Salem, Denver and Los Angeles) that can
      augment local resources in the event of a WMD threat or event.  Instances where these
      teams have been used include: (1) in response to the bombing in Centennial Olympic
      Park; (2) pre-positioned to respond if needed during the Summit of the Eight last year in
      Denver; (3) during the Inauguration in 1997; and (4) in the Capitol during the State of the
      Union  Address this year.   It was also one of these teams, the one in Winston-Salem, that
      responded under State auspices, to the event that occurred earlier this year in Charlotte,
      North Carolina.

      In creating these resources, we have not been alone.  Some of the key HHS agencies with
      which we have been working very closely to address counter-terrorism issues include the
      Centers for Disease Control and Prevention, the Agency for Toxic Substances and
      Disease Registry; the Food and Drug Administration, and the National Institutes of
      Health.   External to HHS we have been working with other federal departments and
      agencies, the National Academy of Science's Institute of Medicine, and local and state
      governments, as well as with nationally recognized individual experts.

      We have also supported 27 major metropolitan areas for the development of local
      Metropolitan Medical Strike Team Systems.  These enhancements to existing local
      response systems are designed to provide initial on-site response and provide for safe
      patient transportation to hospital emergency rooms for treatment in the event of a WMD
      terrorist attack.  These MMST Systems are characterized by specially trained responders
      for on-site triage and initial medical treatment; specialized pharmaceuticals and
      decontamination equipment; enhanced emergency medical transportation; definitive
      hospital care; and the provision of assistance from the National Disaster Medical System,
      if needed.  Our plans are to continue developing local MMST Systems in conjunction
      with the Domestic Preparedness Program's 120-city initiative.  Further system
      development is necessary to assure adequate surveillance, laboratory support and
      pharmaceutical distribution systems in the event of a biological weapon release.

      The program of enhanced preparedness that the President called for in his Naval
      Academy commencement speech on May 22nd, and his recent signing of Presidential
      Decision Directive 62, will strengthen our nation's defenses against the growing threat of
      unconventional attacks against the people of the United States.   This directive designates
      HHS as the lead Federal agency, in support of FEMA, to plan and prepare a national
      response to medical emergencies arising from the terrorist use of weapons of mass
      destruction.  We will be supported by other Federal agencies in this effort.  Together we
      plan to continue to provide enhanced local response through the strengthening of local
      systems   and the provision of Federal supporting teams, if necessary -- for the
      prevention, detection, identification and public health response to the release of a weapon
      of mass destruction.

      Of significant concern is how best to protect our civilian population from biological
      weapons.  In response to the President's directive, HHS is exploring a range of
      approaches for upgrading our public health systems for detection and warning and for
      providing medical care for massive numbers of affected people.    We are examining a
      broad spectrum of needs that includes research and development, pharmaceutical
      stockpiles, public health surveillance, and response capabilities.

      Secretary Shalala recently requested that the Assistant Secretary for Planning and
      Evaluation convene a working group to develop a HHS strategic plan for strengthening
      and expanding our role in the Government-wide bioterrorism effort.  Implementation of
      the plan and oversight of the resulting activities will be the responsibility of the Assistant
      Secretary for Health and Surgeon General.

      Thank you for this opportunity to discuss our counter-terrorism initiatives with you.  I
      would be glad to answer any questions .

    Source: http://www.hhs.gov/progorg/asl/testify/t980602a.txt

    1998/06/02; CDC Testimony; Preparedness for Epidemics and Bioterrorism

    STATEMENT OF
    JAMES M. HUGHES, M.D.
    DIRECTOR
    NATIONAL CENTER FOR INFECTIOUS DISEASES
    CENTERS FOR DISEASE CONTROL AND PREVENTION
    U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
    BEFORE THE
    SENATE SUBCOMMITTEE ON LABOR, HEALTH AND HUMAN SERVICES,
    EDUCATION AND RELATED AGENCIES
    COMMITTEE ON APPROPRIATIONS

    JUNE 2, 1998

    I am Dr. James M. Hughes, Director, National Center for Infectious Diseases, Centers for
    Disease Control and Prevention (CDC).   With me today is Dr. Richard Jackson, Director of
    CDC's National Center for Environmental Health.  We are here to discuss a very important topic:
    the public health response to disease outbreaks caused by biological and chemical terrorism.
    Our testimony summarizes the present system of public health surveillance and control at the
    state, local, and Federal levels.  I will focus primarily on terrorist events that involve biological
    agents, and Dr. Jackson will address events that involve chemical agents.

    U.S. Vulnerability to Terrorism
    The bombings of the World Trade Center in New York and the Federal building in Oklahoma
    City taught us how vulnerable we are to terrorist attacks within our own borders, even in times of
    peace.  We know that in addition to bombs, today's terrorists can choose among many highly
    dangerous agents, including biological and chemical agents.

    An attack with a biological or chemical weapon used to be considered very unlikely, but now
    seems entirely possible.  Many experts believe that it is no longer a matter of "if" but of "when"
    such an attack will occur.  They point to the accessibility of information on how to prepare
    biologic and chemical weapons (on the Internet and elsewhere) and to activities by groups such
    as Aum Shinrykyo, which, in addition to releasing nerve gas in Tokyo's subway, experimented
    with botulism and anthrax.  Moreover, the Federal Bureau of Investigation (FBI) recently
    investigated a situation in Las Vegas where an individual was in possession of the organism
    causing anthrax.  Although the individual had an attenuated strain of anthrax used in an animal
    vaccine rather than a virulent strain, the incident provided another reminder of how easily a
    terrorist might cause serious illness and panic in a U.S. city.

    The release of a biological agent or chemical toxin may not have an immediate impact because of
    the delay between exposure and onset of illness, or incubation period.  For example, when people
    are exposed to a pathogen like anthrax or smallpox, they will not know that they have been
    exposed, and they may not feel sick for some time.  The incubation period may range from
    several hours to a few weeks, depending on the microbe and the dosage.   If a group of people in
    an airport were exposed to the organism that causes anthrax in an aerosolized form, some of them
    might be far away -- perhaps even overseas -- by the time they experienced the first symptoms.

    Moreover, if an attack involved an organism like those causing plague or smallpox that is spread
    from person to person, there could be a second or third wave of illness, and health care workers
    treating patients would be at risk of infection.  Each wave of illness could be larger than the one
    before, as more and more people were exposed.  In the best-case scenario, an observant health
    worker would recognize that something out of the ordinary has occurred and alert public health
    authorities.   In the worst-case scenario, the first wave of cases may not appear to be connected --
    or may be mistaken for other diseases -- and the outbreak would continue for some time before
    the diagnosis is made and action is taken to contain it.  We may have only a short window of
    opportunity -- between the time the first cases are identified and a second wave of people become
    ill -- to determine that an attack has occurred, to identify the organism, and to prevent further
    spread.

    Most people agree that investing in defense is imperative, even at a time when the average
    American is not threatened by war, but defense is not solely through military means.  As the
    anthrax example illustrates, the initial response to a bioterrorist act is likely to be made by the
    public health community rather than by the military.  Protection against terrorism requires a
    strong public health system at the local, state, and national levels.

    Planning and Preparedness
    Many Federal agencies are working together to formulate policies and strategic plans to ensure
    prompt and effective responses to terrorist attacks that employ biological or chemical agents.  In
    his commencement address at the U.S. Naval Academy on May 22, 1998, President Clinton
    announced his intention to upgrade our public health systems for disease detection and early
    warning, both to improve our preparedness against terrorism and to help us cope with naturally
    occurring infectious disease outbreaks.  CDC and other agencies are assessing what is necessary
    to implement such an upgrade.

    CDC also is participating in a working group on domestic and international surveillance for
    bioterrorism, conducted under the auspices of the Emerging Infections Task Force of the
    Committee on International Science, Engineering, and Technology (CISET), National Science
    and Technology Council.  The Task Force is based in the White House Office of Science and
    Technology Policy (OSTP).  In addition, CDC works on bioterrorism issues with the Office of
    Emergency Preparedness (OEP), OSTP, and the National Security Council.

    Interagency planning will be especially important to ensure the availability of medical supplies
    needed to respond to terrorist acts.  In addition, CDC, the National Institutes of Health (NIH),
    DOD,  and other agencies need to collaborate on a  research agenda to address scientific issues
    related to bioterrorism.

    CDC's Role
    To respond effectively to the threats of bioterrorism and epidemics, CDC and State and local
    health departments must act together as they do in other areas of public health.  CDC and State
    and local health departments are the Nation's three-part shield of defense against public health
    threats of all kinds.  Public health response to terrorism requires recognition of the unique, yet
    interdependent, roles that local, State, and Federal agencies play.

    As the Nation's prevention agency, CDC's mission is to monitor the health of the U.S.
    population and investigate and contain disease outbreaks, including those that are due to
    deliberate acts of terrorism.  In 1994, CDC issued a strategic plan, Addressing Emerging
    Infectious Disease Threats: a Prevention Strategy for the United States, which launched a major
    effort to rebuild the component of the U.S. public health system that protects U.S. citizens
    against infectious diseases.  The plan focuses on four goals, each of which has direct relevance to
    preparedness for bioterrorism:  disease surveillance and outbreak response; applied research to
    develop diagnostic tests, drugs, vaccines, and surveillance tools; disease prevention and control;
    and infrastructure and training.  Through fiscal year 1998, $59 million has been appropriated to
    implement the plan incrementally, with the help of many partners, beginning with the most
    critical areas and programs, and the President's fiscal year 1999 budget includes an additional
    $20 million to continue this effort.

    CDC intends to issue an updated version of the plan later this year.  Like the 1994 plan, the new
    plan emphasizes that we must always be prepared for the unexpected --  whether it be a naturally
    occurring influenza pandemic, multiply antibiotic resistant infections, or the deliberate release of
    anthrax by a terrorist.

    Investigating Diseases of Unknown Cause
    CDC is often asked to assist State public health authorities or foreign health ministries when the
    cause of an outbreak is unknown.  Early in an investigation, it may not be possible to know
    whether an outbreak is caused by an infectious agent or a chemical toxin.  For example, a recent
    outbreak of acute kidney failure in children in Haiti was thought to be infectious, but
    investigation revealed that the illnesses were caused by chemical contamination of a medication
    used in children.

    In recent years, it has become more common for outbreak investigators to consider the possibility
    of a terrorist event when they investigate the cause of an outbreak.  This possibility arose during
    the investigations of the 1993 outbreak of hantavirus pulmonary syndrome in the United States,
    the 1994 outbreak of plague in India, and even the 1995 outbreak of Ebola hemorrhagic fever in
    the Democratic Republic of the Congo (then Zaire).

    Whether an outbreak has a natural or man-made cause is not always clear in the first stages of an
    epidemiologic investigation.  This point is well illustrated by what happened during the first days
    of the hantavirus outbreak in 1993.  In May of that year,  a physician at the Indian Health Service
    (IHS) in a southwestern State reported that two previously healthy young people had died from
    acute respiratory failure.  Over the next few days, additional cases were identified by the State
    medical examiner's office and by other IHS physicians.  The epidemiologists ruled out leakage
    of an air-borne toxic chemical from a nearby munitions depot.  Microbiologists conducted
    laboratory tests for pneumonic plague, inhalational anthrax, and pulmonary tularemia, and were
    able to rule out these diseases.  These three infections, though rare, occur sporadically in the
    southwestern United States, where they are endemic in the local animal populations.  All three
    could have been biological weapons.  Throughout the investigation, there were rumors that a
    biological agent had been released as an act of genocide against the Navajo people who lived in
    the affected area.

    As public health investigators proved, the outbreak was not caused by a chemical or biological
    weapon, but by a newly identified, highly lethal virus spread by rodents.  Fortunately, CDC's
    application of sophisticated molecular biologic techniques led to the rapid identification of a
    previously unrecognized hantavirus as the cause of this illness five months before the virus was
    finally cultured using conventional techniques.  The investigative skills, diagnostic techniques,
    and physical resources required to detect and diagnose this outbreak were similar to those that
    would be needed to identify and respond to a bioterrorist attack.

    Our experience with the hantavirus outbreak shows that a strong public health system for disease
    surveillance, outbreak investigation, and laboratory diagnosis is essential to protect the nation.
    With each outbreak investigation, public health personnel become better trained and more
    experienced in addressing cases of unexplained illness.

    Public Health Response to Terrorism
    Four components of the public health response to disease outbreaks are important to U.S.
    preparedness to address acts of terrorism in a coordinated fashion: detection of usual events,
    investigation and containment of potential threats, laboratory capacity, and coordination and
    communication.

    Detection of unusual events.  The public health effort to combat infectious diseases in the
    United States is based on the early detection of unexpected cases or clusters of illnesses, so that
    small outbreaks can be stopped before they become big ones.  In its recent interim report,
    "Improving Civilian Medical Response to Chemical or Biological Terrorist Incidents," the
    Institute of Medicine (IOM) cites public health departments' existing mission to promptly
    identify and control infectious disease outbreaks.  The IOM report recommends expansion of
    CDC's emerging infections initiative as a means of improving State and local surveillance
    infrastructure.

    In the case of a bioterrorist attack, the initial detection of a disease is likely to take place at the
    local level.  It is essential to work with members of the medical community who may be the first
    to recognize unusual diseases, and with State and local health departments, who are most likely
    to mount the initial response -- especially if the intentional nature of the outbreak is not
    immediately apparent.  Strong communication links between clinicians, emergency responders,
    and public health personnel are important.

    As mentioned, an astute physician -- on the basis of only two unusual cases -- alerted health
    authorities to what turned out to be an outbreak of hantavirus pulmonary syndrome.  In contrast,
    during the 1995 Ebola outbreak in Zaire, there was no surveillance system in place, and the
    outbreak was not detected until at least two waves of infection had passed and many people,
    including a large number of health care workers, had died. Thus, early detection and response is
    critical.

    As part of the implementation of CDC's plan for emerging infections, CDC has established the
    Epidemiologic and Laboratory Capacity (ELC) program to help State and large local health
    departments develop the skills and resources to address whatever unforeseen infectious disease
    challenges may arise in the twenty-first century.  One of the specific aims of the ELC program is
    the development of innovative systems for early detection and investigation of outbreaks.  By
    July, thirty State and large local health departments will receive support from the ELC program.
    CDC has also entered into agreements with seven State health departments, in collaboration with
    local academic, government, and private sector organizations, to establish Emerging Infections
    Program (EIP) sites that conduct active, population-based surveillance for selected diseases, as
    well as for unexplained deaths and severe illnesses in previously healthy people.

    CDC has also helped establish sentinel surveillance systems that involve local networks of
    clinicians and other health care providers.  One such network includes emergency departments at
    eleven hospitals in large U.S. cities.  Another includes fourteen travel medicine clinics in the
    United States, plus seven overseas.  A third network includes over 500 infectious disease
    specialists throughout the country.  CDC is using these and other provider-based networks to
    alert and inform the medical community so that health workers can help recognize and assess
    unusual infectious disease threats.

    Investigation and response.   As is the case for any naturally-occurring infectious disease
    outbreak, the initial response to an outbreak caused by an act of bioterrorism is likely to take
    place at the local level.  In the most likely scenario, CDC -- as well as DOD and security
    agencies -- will be alerted only after a State or local health department has recognized a cluster of
    cases that is highly unusual or of unknown cause.  CDC is working with State and large local
    health departments through the ELC program and other efforts to provide tools, training, and
    financial resources for local outbreak investigations.

    CDC's Epidemic Intelligence Service (EIS) trains personnel to respond to outbreaks and other
    disaster situations to aid state and local officials in the identification of potential causes and
    implement appropriate solutions.  It is interesting to remember that the EIS was established
    during the Cold War in response to the threat of biological warfare.  In addition, CDC trains
    Public Health Prevention Service (PHPS) specialists who can provide on-site programmatic
    support to extend the manpower of state and local public health staff.

    Once the cause of a terrorist-sponsored outbreak has been determined, specific drugs, vaccines,
    and antitoxins may be needed to treat the victims and to prevent further spread.  However,
    depending upon the pathogen that causes the outbreak, appropriate medical supplies may not be
    readily available since these organisms are uncommon causes of disease in the United States.
    This is an important issue that is being addressed collaboratively by a number of Federal
    agencies, including CDC, OEP, FDA, and other parts of the Department of Health and Human
    Services; DOD; FEMA and the Department of Veterans Affairs.

    In his May 22 speech, the President also announced that the United States would create
    stockpiles of medicines and vaccines to protect our civilian population against biological agents
    our adversaries are most likely to develop.  A number of Federal agencies are working
    collaboratively to address this important issue as well.

    Laboratory Support.  In the event of a bioterrorist attack, rapid diagnosis will be critical to the
    immediate implementation of prevention and treatment measures.  However, because none of the
    biological agents considered most likely to be used as bio-weapons are currently major public
    health problems in the United States, we have limited capacity to diagnose them, either at the
    State and local or Federal level.

    We must also prepare for the possible use of other agents as bioterrorist threats.  This was
    illustrated by a 1984 foodborne outbreak of salmonellosis in Oregon caused by followers of
    Bhagwan Shree Rajneesh and a 1996 foodborne outbreak of shigellosis in Texas caused by a
    single perpetrator.  Future events could involve organisms that have been genetically engineered
    to increase their virulence, manifest antibiotic resistance, or evade natural or vaccine-induced
    immunity.

    In recent years, CDC has helped State health departments acquire the capacity to detect naturally
    occurring outbreaks of foodborne diseases.  In 1997, the success of that effort was underscored
    when the Colorado State Health Department, using DNA fingerprinting techniques
    developed/standardized at CDC,  detected a small cluster of cases of E. coli infection caused by
    consumption of a single brand of frozen hamburger patties.  Twenty-five million pounds of
    ground beef were recalled, and a potential nationwide outbreak was averted.  Providing state
    health departments with the capacity to detect outbreaks of diseases caused by terrorists may
    avert disasters with even greater potential to devastate our country.

    Coordination and Communications.  One of the major objectives in CDC's emerging infections
    plan is to improve CDC's ability to communicate with State and local health departments, U.S.
    quarantine stations, health care professionals, other public health partners, and the public.  In the
    event of an intentional release of a biological agent, rapid and secure communications will be
    especially crucial to ensure a prompt and coordinated response.  Each hour's delay will increase
    the probability that another group of people will be exposed, and the outbreak will spread both in
    number and in geographical range.

    CDC may also need to communicate with WHO and with the ministries of health of other
    nations, especially if persons exposed in the United States have traveled to another country.
    Because of the ease and frequency of modern travel, an outbreak caused by a bioterrorist could
    quickly become an international problem.

    Conclusion
    In conclusion, a strong and flexible public health infrastructure is the best defense against any
    disease outbreak -- naturally or intentionally caused.  CDC's on-going initiatives to strengthen
    disease surveillance and response at the local, State, and Federal levels can complement efforts to
    detect and contain diseases caused by the biological agents that might be used as weapons.

    Thank you very much for your attention.  I will be happy to answer any questions you may have.

    Source: http://www.hhs.gov/progorg/asl/testify/t980602b.txt

    1998/06/02; CDC Testimony; Preparedness for Epidemics and Bioterrorism

    STATEMENT OF
    RICHARD JACKSON, M.D., M.P.H.
    DIRECTOR
    NATIONAL CENTER FOR ENVIRONMENTAL HEALTH
    CENTERS FOR DISEASE CONTROL AND PREVENTION
    U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
    BEFORE THE
    SENATE SUBCOMMITTEE ON LABOR, HEALTH AND HUMAN SERVICES,
    EDUCATION AND RELATED AGENCIES
    COMMITTEE ON APPROPRIATIONS

    JUNE 2, 1998

    I am Dr. Richard J. Jackson, Director of the National Center for Environmental Health of the
    Centers for Disease Control and Prevention (CDC).  I appreciate the opportunity to summarize
    CDC's role in responding to chemical terrorism.  As a former State public health official, I have
    experienced first hand the panic, fear and chaos associated with disease outbreaks and disastrous
    events.

    As Dr. Hughes summarized, CDC's mission is to monitor the health of the U.S. population and
    investigate and contain disease outbreaks, including those that are due to deliberate acts of
    terrorism.  As with biological terrorist threats, CDC's response to chemical terrorism includes
    four components:  surveillance and outbreak response; laboratory capacity to measure toxicants
    in the blood, serum or urine of people; disease prevention and control; and infrastructure and
    training.  Whereas the Environmental Protection Agency has the lead for the effects of chemical
    toxicants on the environment, CDC's role pertains to the effects of chemicals on human health.

    CDC responds to chemical emergencies, whenever and wherever they occur,  whether the
    emergency is caused by an act of terrorism or an accidental release.  Television has given us all
    the opportunity to see a glimpse of the serious impact both of these types of emergencies can
    have on the population of a city or country.  Two such examples in recent years are the chemical
    plant explosion in Bhopal, India and the terrorist attack in the subway in Tokyo, Japan.  In
    December 1984, an explosion at a chemical plant in Bhopal, India caused an extremely toxic
    substance to be released into the air in an area surrounding the plant -- a densely populated part
    of the city.  In this  incident, an estimated 30-40 tons of the substance were released into the
    atmosphere during a 2- to 3-hour period, resulting in over 3,000 dead and 60,000 seriously
    injured of the more than 200,000 people exposed.  In the second example, in March 1995, a
    terrorist group in Japan released Sarin gas (a nerve agent) into the air of Tokyo's subway system.
    Within 24 hours of the attack over 5,000 people had sought medical attention.  By the end of the
    crisis almost a thousand people were identified as experiencing some health effects and 12
    people died. In the end, it was only the inefficiency of the mechanism used to disperse the
    chemical agent that prevented casualties from being far worse.

    The reason I have chosen to cite these two examples today is to point out the variability of the
    types of chemical emergencies that have occurred elsewhere and that could occur in the United
    States.  There are three points I would like to make about the emergency response responsibilities
    and capabilities at the various levels of government:  1) the nation's public health system, health
    officials at the local, State, and federal levels, is a critical resource aimed at protecting the health
    of U.S. residents whenever a health emergency occurs; 2) CDC has the expertise and capacity to
    respond to many types of chemical emergencies; and 3) the Federal agencies tasked with
    responding to chemical emergencies are discussing ways to improve our response capabilities to
    better triage exposed populations and communicate with our partners, the media, and most
    importantly, the public.

    Public Health Role in Responding to Chemical Emergencies
    Terrorism is a community problem.  Health decisions for the community in response to a terrorist
    event require the involvement of public health professionals from the local, state, and Federal
    levels.  State and local public health officials will be among the first to respond to any chemical
    weapon attack, long before any Federal units are on the scene. It is these local public health
    professionals with whom CDC has had a long term relationship.  It is CDC that State and local
    officials call upon for help and advice in any kind of public health emergency.  And, it is the
    State and local public health professionals who work along side the local police, firefighters, and
    emergency medical personnel and who have the greatest  impact on the health and safety of
    people in affected areas.

    We,  in public health, also have the responsibility to protect the community of emergency
    responders - so that they do not become victims as well.  We have the responsibility to protect
    the community of exposed people - to carry out surveillance, to determine who has been exposed
    to toxic chemicals and at what level they have been exposed, to ensure that they receive
    appropriate care and treatment, and to create registries during the early stages of the event to
    allow for appropriate long term follow up.  Lastly, we have the responsibility to protect the larger
    community impacted by a terrorist act - to calm the panicked and worried well with good
    scientifically based but understandable information and to help communities recover from the
    trauma of a terrorist act or chemical emergency.  Experienced public health doctors,
    laboratorians, and epidemiologists are essential in helping communities to respond quickly and to
    sort out questions of exposure, treatment, and recovery.

    CDC's Emergency Response Capabilities
    CDC has considerable experience working on all types of chemical emergencies.  When a
    disaster or emergency occurs, CDC responds to requests for assistance from state or local
    agencies by helping to:

         Make a preliminary assessment of the situation either by telephone or by sending an
         emergency response coordinator or team to the site;

         Coordinate our activities with those of the local, state, and other federal personnel,
         including assistance to help protect the health and safety of emergency response teams;

         Provide assistance to help protect the health and safety of emergency response teams;

         Develop a strategy for dealing with the public health aspects of an emergency;

         Provide technical assistance in areas such as epidemiology, toxicology, and laboratory
         science;

         Perform any necessary laboratory tests, most of which are currently beyond the capacity
         of local, state, or university laboratory;

         Determine when protection, treatment, and prevention objectives are achieved; and

         Set up a program to deal with the recovery process.

    Throughout the response process, CDC makes resources available to use in aiding both the short
    term response and the long term recovery of the community involved.  We have state of the art
    communications equipment that allows us to provide a link between on-site and off-site
    responders.  CDC has a staff of health communicators and educators, who are invaluable to our
    communications with the media and the affected and worried public.  CDC has the experienced
    professionals, including doctors and epidemiologists, needed to triage victims, ensure medical
    treatment for those who are ill, and  provide follow up for those who are at risk of disease.  And,
    CDC's  laboratory capacity is unique in the world in that it has the technology and highly trained
    professionals necessary to make measurements of chemical exposures in people.

    One common thread in the laboratory component of the public health response to these tragedies
    is to determine what chemical agents were used, who has been exposed to the agents and to how
    much.  This information is critical for appropriate medical treatment for those who have been
    exposed, and to allay the fears of those who have not been exposed.

    CDC's Laboratory Capacity
    CDC's environmental laboratory is unique in that it is the only laboratory that can accurately
    measure more than 200 toxicants (chemicals) in people, not simply in the environment.  Such
    measurement is known as biomonitoring.  Let me provide an example of the value of this
    information and how CDC's scientific capacity helped to address a recent chemical emergency
    involving the pesticide methyl parathion.

    Methyl parathion is illegal for indoor pesticide use because it acts as a nerve agent.  Though not
    as strong as the nerve agent used by terrorists to kill people on a Japanese subway in 1995,  it
    affects people the same way.

    Starting in the fall of 1996, seven states -- Mississippi, Louisiana, Texas, Arkansas, Tennessee,
    Alabama, and Illinois -- became aware that methyl parathion was being used indoors to control
    indoor pests.  Two children died.  Thousands of homes were affected.  In order to take
    appropriate action, public health officials had to determine who had been exposed and to what
    extent.  They also had to respond to a flood of calls from people who feared that methyl
    parathion had been sprayed in their homes.

    State and local health officials asked CDC, the Agency for Toxic Substances and Disease
    Registry, and the Environmental Protection Agency to help with this emergency.  To quantify
    human exposure to this deadly pesticide, CDC's Environmental Health Laboratory developed a
    mass spectrometry assay to measure a metabolite of methyl parathion in urine.  Through this
    unique test, it was possible to determine the amount of exposure a person had to this nerve agent.
    State and other federal officials used CDC's test to determine who had been exposed, how
    much, who was at greatest health risk, and whether homes needed to be evacuated and
    remediated.  To date, more than 14,000 persons in these seven states have been tested  - 4,000 of
    whom were assured they had no significant exposure.  In the absence of CDC's unique
    laboratory capacity and diagnostic test, there would have been be no way to obtain this personal
    exposure and health risk information.  In addition to the public health benefit, CDC's test
    provided precise exposure information which averted more than $50 million in unnecessary
    home remediation costs.  The methyl parathion emergency just described illustrates the
    importance of precise measurements of chemicals in people, not simply in the environment.
    Similar laboratory and epidemiologic capability and response would be needed to respond to an
    act of terrorism.

    Having such measurements means that in any chemical emergency persons truly exposed can be
    identified, and persons not exposed could be reassured they were not at risk.  Emergency
    response and medical personnel can then focus their limited resources in the most efficient and
    effective ways possible.

    Additional Strategies Being Considered
    In addition to the current capabilities that I have just described, CDC is working with other
    Federal agencies to define improved systems and technologies for responding to these types of
    emergencies.  Some of the strategies being considered include:

         The development of the laboratory capacity to more rapidly provide critical
         measurements chemical agents in people.

         The provision of additional training for local health professionals in order to assure that
         there are an adequate number of highly-trained professionals at state and local levels who
         know how to address and manage these chemical emergencies, including physicians who
         know the proper medical treatment for victims.

         The provision of training, laboratory capacity, quality assurance and quality control,
         along with the development of technology that can be transferred to Regional or State
         laboratories to aid in the response to chemical emergencies.

         The enhancement of current information and communication systems at the local, state,
         and Federal levels.

     In closing, I would like to reiterate that public health at all levels - local, State, and Federal - is
    the integrating factor in our response system to all types of health emergencies.  One of the most
    critical components of the public health response to a chemical weapon terrorist attack is the
    capability of state and local public health agencies.  Personnel working at state and local public
    health institutions will be among the first to respond to any act of terrorism.  Whether natural or
    intentional, health emergencies require an immediate response, capacity to triage victims,
    medical treatment for those who are ill, follow-up for those who are at risk of disease, and
    assistance to help communities recover from the crisis.

    Thank you for the opportunity to testify today.  I will be happy to respond to any questions you
    may have.