STATEMENT OF SCOTT R. LILLIBRIDGE, M.D.

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STATEMENT OF
SCOTT R. LILLIBRIDGE, M.D.
SPECIAL ASSISTANT TO THE SECRETARY
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FOR
NATIONAL SECURITY AND EMERGENCY MANAGEMENT
BEFORE THE
COMMITTEE ON GOVERNMENTAL AFFAIRS
UNITED STATES SENATE
July 20, 2001

Mr. Chairman and Members of the Committee, thank you for inviting me here today to discuss activities of the Department of Health and Human Services (HHS) in responding to Bioterrorism, other emergencies, and acts of terrorism. I am Scott Lillibridge, Special Assistant to the Secretary of HHS for National Security and Emergency Management. I have a long history of emergency management experience with this Department that ranges from service to victims of civil wars in Africa to terrorism response following the Sarin attack in Tokyo. Domestically, I have worked with the Federal Emergency Management Agency (FEMA) at the state and local level during Federal mobilizations to more than a dozen states. Prior to this new assignment, I served as the Director of the Bioterrorism Preparedness and Response Program, National Center for Infectious Disease, Centers for Disease Control and Prevention (CDC).

On July 10, 2001, Secretary Tommy Thompson appointed me to this position and directed me to begin creating a unified HHS preparedness and response system to deal with these important issues. I would like to discuss that effort with you today, highlighting some of the ways that HHS works with the Federal Emergency Management Agency, other Federal Agencies, and our partners at the state and local level.

Among weapons of mass destruction, Bioterrorism features several characteristics that set it apart from other acts of terrorism involving, for example, explosives or chemical agents. First, biological agents are easy to conceal. A small amount may be sufficient to harm large populations and cause epidemics over a broad geographic region. Second, the contagious nature of infectious diseases means that once persons are exposed and infected they can continue to spread the disease to others. Third, in the most worrisome scenario of a surreptitious attack, the first responders are likely to be health professionals in emergency rooms, physician offices, outpatient clinics, public health settings, and other health-care activities rather than the traditional first responders. The longer the terrorist-induced epidemic goes unrecognized and undiagnosed, the longer the delay in initiating treatment and other control efforts to prevent further infectious outbreaks.

The Special Assistant for National Security and Emergency Management is located in the Immediate Office of the Secretary (IOS) and I have been tasked to coordinate and provide executive leadership and organizational direction for HHS budget, policy and program implementation related to these important issues. Within HHS, the Office of Emergency Preparedness (OEP) coordinates emergency response preparedness activities and works with other federal agencies, including the Federal Emergency R Managementesp Agency (FEMA) and the Departments of Justice (DOJ) and Defense (DOD). Other Agencies within HHS that play a key role in our Department’s overall Bioterrorism preparedness include the Centers of Disease Control and Prevention (CDC), the Food and Drug Administration (FDA), and the National Institutes for Health (NIH). HHS is the primary agency responsible for the health and medical response under FEMA’s Federal Response Plan (FRP). This plan provides HHS with a framework to respond with FEMA and 26 other Federal departments and agencies, along with the American Red Cross.

HHS also coordinates and provides health leadership to the National Disaster Medical System (NDMS). NDMS is a partnership that brings together HHS, DOD, FEMA, the Department of Veterans Affairs (VA). It was envisioned to provide medical response, patient evacuation, and definitive medical care for mass casualty events. This system addresses both disaster situations and military contingencies. More than 7,000 private citizens across the country volunteer their time and expertise as members of response teams to support this effort. This system also includes approximately 2,000 participating non-federal hospitals. VA and DOD’s expertise and resources are critical to many key aspects of NDMS response, and I would note that these Departments have distinguished themselves on many occasions.

Bioterrorism Preparedness and Response

The Department of Justice, acting through the FBI, is the overall Federal lead agency for managing the Federal response to a terrorist incident or threat, as well as the lead agency in charge of crisis management during a terrorist event or a credible threat to public safety. HHS provides technical assistance to the FBI during all phases of threat assessment and alerts law enforcement if the threat first appears in the health arena in the form of unexplained illness or death. FEMA is the lead federal agency in charge of consequence management. As in other types of disaster responses under the Federal Response Plan, FEMA would request HHS to provide necessary health, medical and health-related services to the victims. This occurs most often through the use of key components of the National Disaster Medical System I have just described.

The broad goals of national response to Bioterrorism, or any epidemic involving a large population will be to detect the problem, control the epidemic’s spread and treat the victims. The Department’s approach to this challenge has been to strengthen public health infrastructure to deal more effectively with epidemics and other emergencies, and to hone our emergency health and medical response capacities at the federal, state and local level. HHS has also worked to forge new partnerships with organizations related to national security.

As an example of building a public infrastructure, HHS has awarded grants to states to enhance the key elements of detection and control of infectious diseases. Other HHS efforts have included the development of a national pharmaceutical stockpile, the development of a CDC Bioterrorism Preparedness and Response Program, and the efforts of OEP to improve local medical readiness. In most localized disasters, HHS organizes its medical field response through the Office of Emergency Preparedness, using a team structure. Teams can include Disaster Medical Assistance Teams, specialty medical teams (such as burn, pediatric, mortuary), and Disaster Mortuary Teams. In addition, National Medical Response Teams are able to deploy to sites anywhere in the country with a supply of specialized pharmaceuticals to treat up to 5,000 patients. Currently, HHS can draw on 27 such teams that can be federalized and deployed to assist victims. Such teams have been sent to many areas in the aftermath of disasters in support of FEMA-coordinated relief activities. HHS, through OEP, will mobilize NDMS resources, the Public Health Service’s Commissioned Corps Readiness Force, as well as enlist the support of other federal agencies, such as DOD and VA, to help provide the needed medical and public health services to ensure the continued health of the disaster victims. In the last few years these assets were deployed to New York, Florida, Texas, Louisiana, Alabama, Mississippi, the Virgin Islands and Puerto Rico in the aftermath of hurricanes and tropical storms.

However, regional or national response to a health emergency involving Bioterrorism will also require that additional capacities be in place at the state and local level before the disaster strikes. HHS, primarily through CDC, is supporting state and local governments to strengthen their surveillance, epidemiological investigation and

laboratory detection capabilities, as well as continuing development of a national stockpile of critical pharmaceuticals and vaccines to supplement local and state resources.

The Office of Emergency Preparedness is working on a number of fronts to assist local hospitals and medical practitioners to deal with the effects of Bioterrorism and other terrorist acts.

Since Fiscal Year 1995, HHS through OEP has been developing Medical Response Systems (MMRS). This initiative enhances the existing local and city systems capability to respond to a chemical or biological incident and provide triage, medical treatment, and patient decontamination. The city systems that have been developed to help address the medical needs of victims from terrorism and to facilitate the transport of patients to hospitals. Affiliated hospitals are developing procedures to ensure that arriving patients would be decontaminated before entering the facility. To date, OEP has contracted with 72 of the Nation’s largest metropolitan areas for MMRS development and will initiate an additional 25 contracts during this fiscal year. OEP is working with entities such as the American College of Emergency Physicians and the American Hospital Association to enhance the clinical preparedness.

Training

HHS to prepare the health and medical community for contingencies such as Bioterrorism and other terrorism events has used classroom training, distance learning, and hands-on training activities. For example, in Fiscal Year 1999, Congress appropriated funds for OEP to renovate and modernize the Noble Army Hospital at Ft. McClellan, Alabama, so the hospital can be used to train doctors, nurses, paramedics and emergency medical technicians to recognize and treat patients with chemical exposures and other public health emergencies. Expansion of the Bioterrorism component of Noble Training Center curriculum is a high priority for HHS. In addition, the Department envisions a strong linkage to the adjacent Department of Justice, Office of Justice Programs (OJP) training facility for first responders. We have been working closely with the OJP’s National Domestic Preparedness Consortium and we will continue our excellent relationship with them. OJP and HHS have teamed together to develop a healthcare assessment tool and have also delivered a combined MMRS/first responder training program. CDC has participated with DOD most notably to provide distance-based learning for Bioterrorism and disease awareness to the clinical community. CDC is now moving to expand such training with organizations such as the Infectious Disease Society of America (IDSA) and schools of public health such as the Johns Hopkins Center for Biological Defense. HHS is also aware of the fine training programs that currently exist within FEMA. The recent FEMA-CDC initiative to expand the scope of FEMA’s Integrated Emergency Management Course (IEMC) will serve as a vehicle to integrate the emergency management and the health community response efforts in a way that has not been possible in the past. It is clear that these communities can best respond together if they are able to train together toward realistic scenarios that leverage the best of both organizations. FEMA’s leadership and collaboration has been critical to success in this effort.

National Preparedness for Bioterrorism

An indication of the Nation’s preparedness for Bioterrorism was provided by the congressionally mandated Top Officials (TOPOFF) 2000 Exercise in May 2000. This national drill involved scenarios related to a weapons-of-mass-destruction-attack against our populations. However, the exercise’s simulated plague outbreak in Denver is most important to our discussion today. This exercise involved state and local community, FEMA, DOJ, HHS, DOD and many other vital community sectors that would play a role in such a response. While much progress has been made to date, a number of important lessons from that event have begun to shape our planning notions about Bioterrorism preparedness and response in the health and medical area. They are as follows:

- Improving the public health infrastructure remains a critical focus of the Bioterrorism preparedness and response efforts. Such preparedness is indispensable for reducing the Nation’s vulnerability to terrorism using infectious agents and other potential emergencies through the development of broad public health capacities.

- In this Nation, we have extremely limited surge capacity in our healthcare system. Local health care systems must be able to expand their health care capacity rapidly in the face of mass casualties. This must be part of our overall preparedness effort for infectious diseases and other major health emergencies.

- Local communities will need assistance with the distribution of stockpile medications and will greatly benefit from additional planning related to epidemic response.

- It will be extremely important to link emergency management services and health decision making at the state and local level for the purpose of rapidly addressing the needs of large populations affected by an epidemic. Training health workers to understand emergency management tools like the Incident Command System (ICS) is an example of the type of effort that will be important in closing this gap.

- Ensuring that the proper legal authorities exist to control the spread of disease at the local, state and Federal level and that these authorities can be exercised when needed. This will be important to our efforts to control the spread of disease.

- Lastly, Federal "response partners" in the health and medical arena need to design response contingencies that specifically address the needs of victims of large-scale epidemics

Priorities for HHS

HHS is moving to develop a system of emergency management, communications, planning and training to ensure an efficient "One Department" emergency response to states and local communities. Our Secretary is committed to this task. Once these capacities are in place we will build better linkage with the interagency community and our state and local partners as we move toward these preparedness objectives.

HHS, through CDC, needs to expand its cooperative agreements to health departments to enhance state and local preparedness for Bioterrorism. Our Nation’s surveillance networks need to extend beyond the boundaries of the public health departments if we are to ensure the timeliest, most effective detecting and reporting of disease outbreaks. The strategy to accomplish these tasks should be better defined and expanded to include non-traditional sources of information about the community, such as 1) reasons for emergency department visits, 2) more detailed information about the nature of 911 calls, 3) timely data concerning health services utilization such as the number of hospital beds that are currently in use, and perhaps, 4) information concerning the purchase of specific products or commodities at pharmacies that suggest an increase in certain types of illnesses within the population.

Expansion of the Laboratory Response Network (LRN) will augment our effectiveness in dealing with Bioterrorism. This network is a partnership among the Association of Public Health Laboratories (APHL), CDC, FBI, State Public Health Laboratories, DOD and the Nation’s clinical laboratories. This will include additional training in laboratory methods, the development of new rapid assays, and the implementation of new technologies in public health and clinical laboratories. The communication and training capacities of the Health Alert Network will be needed for distance-based learning and the rapid notification of health departments. In the near future, as part of its responsibility associated with the National Disaster Medical System, HHS must begin to broaden its perspective to address issues related to health facility preparedness in civilian communities. It is also time to review the roles and responsibilities between NDMS partners to see how they match against the new threats facing our Nation.

Conclusion

The Department of Health and Human Services is committed to ensuring the health and medical care of our citizens. We are prepared to quickly mobilize the professionals required to respond to a disaster anywhere in the United States and its territories and to assist local medical response systems in dealing with extraordinary situations, and we are actively preparing for the challenge posed by acts of Bioterrorism. At the end of my first week at this new post it is clear that close ties between HHS, FEMA and DOJ will be paramount in addressing the consequences of Bioterrorism and other terrorist incidents. I look forward to this challenge. HHS Secretary Thompson is

Mr. Chairman, that concludes my prepared remarks. I would be pleased to answer any questions you may have.

Last revised: July 24, 2001