Edward L. Baker, M.D., M.P.H.

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Testimony
Before the Subcommittee on Technology and Procurement Policy, Committee on Government Reform
United States House of Representatives

Bioterrorism Preparedness:
CDC Efforts to Improve Public Health Information at Federal, State, and Local Levels

Statement of
Edward L. Baker, M.D., M.P.H.
Director, Public Health Practice Program Office Centers for Disease Control and Prevention
Department of Health and Human Services

For Release on Delivery
Expected at 10:00 am
on Friday, December 14, 2001

Good morning Mr. Chairman and Members of the Subcommittee. I am Dr. Edward L. Baker, Director of the Public Health Practice Program Office at the Centers for Disease Control and Prevention (CDC). With me today is Dr. Kevin Yeskey, Acting Director of the Bioterrorism Preparedness and Response Program, National Center for Infectious Diseases, CDC. Thank you for the invitation to discuss CDC's public health response to the threat of bioterrorism, specifically our role in building a strong public health infrastructure to improve public health information at the local, state, and Federal levels.

As has been highlighted recently, increased vigilance and preparedness for unexplained illnesses and injuries are an essential part of the public health effort to protect our citizens against bioterrorism and other health threats. The terrorist events on and since September 11^th have been defining moments for all of us - and they have greatly sharpened the Nation's focus on public health. Even before the September 11^th attack on the United States, CDC was making substantial progress to define, develop, and implement nationwide a set of public health capacities required at all levels-local, state, and Federal-to prepare for and respond to deliberate attacks on the health of our citizens. Since September 11^th we have worked very closely with our public health partners to accelerate our efforts, share critical lessons learned, and identify seven high priority areas for immediate strengthening. We are committed to increasing our efforts ever further in the coming months to ensure that every health department is fully prepared and every community better protected against such threats.

Public Health Leadership

The Department of Health and Human Services' (DHHS) antiterrorism efforts are focused on five key strategies: (1) improving the nation's public health surveillance and electronic communications systems to quickly detect and identify the biological or chemical agents that have been released; to track and map the spread of disease; and to report and disseminate information as rapidly as possible; (2) strengthening the capacities for medical and public health response at both the state and local level; (3) expanding the stockpile of pharmaceuticals for use when needed; (4) regulating the shipment of hazardous biological agents or toxins; and (5) expanding research on disease agents that might be released, including rapid methods for identifying biological and chemical agents, and improved treatments and vaccines.

As the nation's disease prevention and control agency, it is CDC's responsibility, on behalf of DHHS, to provide national leadership in the public health and medical communities in a concerted effort to detect, diagnose, respond to, and prevent illness and injury, whether occurring naturally or as a result of a deliberate act. This task is an integral part of CDC's overall mission to monitor and protect the health of the U.S. population and has been described in detail in such reports as CDC's 1998 plan, Preventing Emerging Infectious Diseases: A Strategy for the 21st Century. This plan, developed with input from state and local health departments, disease experts, and partner organizations such as the American Society for Microbiology, the Association of Public Health Laboratories, the Council of State and Territorial Epidemiologists, and the Infectious Disease Society of America, emphasizes the need to be prepared for the unexpected - whether it is a naturally occurring influenza pandemic or the deliberate release of smallpox by a terrorist.

Fundamental to this plan-and to all preparedness efforts-is a strong national public health infrastructure. Like our military system, our public health system must be at a constant state of "battle readiness," with a skilled professional workforce, robust information and communication systems, and a strong network of local, state, and Federal agencies and laboratories, effectively linked and working together.

Recognizing the importance of the nation's public health infrastructure as our first line of defense, Congress requested in FY2000 that CDC assess the current state of the infrastructure and make recommendations on possible actions that could be taken to strengthen key components. In response, in March 2001, CDC released the report Public Health's Infrastructure: A Status Report, developed in collaboration with national and international public health associations and officials at the local, state, and Federal levels. This report outlined 10 key recommendations for improving the public health infrastructure, building on the goals previously identified in Healthy People 2010. As the Committee requested, I will describe CDC's approach and strategies for achieving these goals with our public health partners, with a special emphasis on improved information and communication systems.

One of the anchors of our defense against bioterrorism continues to be accurate information regarding how to recognize a potential threat and knowledge of appropriate actions. CDC serves as a trusted source of scientific information on emerging infectious diseases and other public health threats and works with our private and public partners to communicate disease prevention information to state and local health departments, health professionals, and the public. Since September 11^th, CDC has issued more than 175 updates on the response to the terrorist attacks and the anthrax investigations through a variety of communication channels, reaching an estimated 7 million health professionals and the public.

This level of communication and collaboration with our public health partners has been crucial to the investigation and response to these events, but improvements can still be made to the nation's information and communication systems, as called for in the Infrastructure Report. To maximize the effectiveness of the public health response, key communications recommendations must include:

1) All health departments should have continuous, high-speed access to the Internet and standard protocols for data exchange. Integral to this recommendation is the ability to detect cases and track and map disease occurrence in order to manage the public health response to an outbreak;

2) All health departments should have immediate, online access to current health information, such as public health interventions and treatment guidelines;

3) All health departments should have the capacity to send and receive sensitive health information via secure electronic systems and to broadcast emergency health alerts among hospitals, medical centers, and other community partners.

These recommendations are being achieved by a State and Federal partnership through three major initiatives, which form the core of a comprehensive, nationwide health information system. These three initiatives are the Health Alert Network (HAN), the National Electronic Disease Surveillance System (NEDSS), and the Epidemic Information Exchange, or Epi-X. As the events of September 11^th highlighted so dramatically, these three initiatives are critical to our nation's emergency response now-and for the future-and must be fully implemented as quickly as possible by States with Federal assistance. They must be fully implemented as quickly as possible, in a seamlessly integrated system that supports rapid and effective public health action. I will describe each briefly.

Health Alert Network

The Health Alert Network, or HAN, is designed to be the nation's rapid online system for health communication, information, and training. When fully deployed, the Health Alert Network will link local, state, and Federal agencies with their community partners, private health care providers, and others, and will serve as the electronic platform for NEDSS, Epi-X, and other applications. The Health Alert Network is being developed in three Phases, incorporating the three key recommendations of the Infrastructure Report. The three phases are:

Phase I: Ensure that each county health department has 1) continuous, high-speed Internet access, 2) the capacity to receive emergency broadcast health alert messages, and 3) online access to Satellite and Web-Based distance-learning programs for just-in-time training and health updates.

Phase II: Extend HAN to the full range of community partners; enhance information security and redundancy at each node in the network; ensure 24/7 operation and reach through expanded HAN Operations Centers at state and large city headquarters; and deploy mobile phones, pagers, and new communications devices to state and local health officials.

Phase III: Provide time-saving and innovative information tools and resources for public health practice in the field, including model emergency plans and protocols; pictures, maps, and diagnostic reference images; health communication and media materials; and lessons learned from peer communities. Many of these resources are under development in three City-County Health Departments-Dekalb County, GA, Rochester/Monroe County, NY, and Denver City/County, CO-which serve as HAN Exemplar Sites and laboratories of innovation.

On the morning of September 11^th, the Health Alert Network was fully activated for only the second time since its inception. Within four hours after the attack on the World Trade Center the Health Alert Network was in put into full operation at one of CDC's offsite facilities and began transmitting health messages to the top 250 public health officials in the 50 states, Guam, and 7 large cities. Over the course of the ensuing 12 weeks, some 60 health alerts, advisories, and updates have been transmitted directly from CDC, and the Network has been extended to potentially reach an estimated 1 million recipients in the first wave, including 1,500 local and county health officers and a wide range of frontline public and private practice physicians, nurses, laboratorians, environmental specialists, health communicators, and other professionals.

In addition to this first "tier" of communication transmitted directly from CDC, states with CDC funding and guidance have established their own statewide Health Alert Networks for retransmitting and augmenting CDC information. Through August 2001, 40 states and cities had received Health Alert Network awards. In September the remaining states, the District of Columbia, and Guam received small planning grants to get started. To date:

Thirteen states have directly connected 100% of their counties (924) to the Health Alert Network via high-speed continuous Internet access; the remaining 37 states have reached an additional 1,217 counties, for a total of 2,142 counties, or two-thirds (68.1% ) of all U.S. counties.
Forty-two states are extending the Health Alert Network to reach private providers; these currently include approximately 2500 hospitals and 6,000 physician offices.
All 50 states are developing full-function distance-learning systems for access to CDC training courses and broadcasts; since September 11^th, CDC has reached 1.1 million public and private health professionals through a series of 12 Satellite and Web Broadcasts.
All 50 states are developing Health Alert Network Web Sites; many of these are fully operational and have been used since September 11^th to communicate with health professionals, the media, and the public, and to link directly to CDC's Web Site for Public Health Emergency Preparedness and Response.

The Epidemic Information Exchange (Epi-X)

The Epidemic Information Exchange (Epi-X), is CDC's secure web-based communications system that provides intelligence sharing capabilities for CDC, state and local health officials, and select military health personnel regarding newly identified disease outbreaks and health events, particularly those suggestive of bioterrorism. Epi-X is intended to provide secure, moderated communication to help public health officials prepare for, and respond to, epidemics and other emerging health events, including bioterrorism. Epi-X serves as an important portal for private, electronic exchange of epidemiologic information, including early notification of suspected cases of disease, online discussions of presumptive diagnoses and laboratory reports, and rapid requests for onsite epidemic assistance. Epi-X also facilitates the rapid submission, review, and publication of timely updates for CDC's premier weekly health bulletin, the Morbidity and Mortality Weekly Report (MMWR), which provides definitive and citable articles for the scientific literature.

In response to the attacks on September 11^th, Epi-X immediately provided secure communications among state and large city epidemiologists and CDC programs, including the Epidemic Intelligence Service. Since the identification of the first anthrax case in Florida, CDC and state and local health authorities have posted over 80 Epi-X reports on bioterrorism-related threats, investigations, and responses. Epi-X has also been used to notify health authorities by telephone and/or pager about urgent information on the anthrax investigations and to initiate telephone and on-line conferences to coordinate the ongoing public health response. In operation since December 2000, medical personnel review all content before distribution on Epi-X and they monitor the site on a 24/7 basis. Currently, 731 health officials at the local, state and Federal level have access to Epi-X. To improve intelligence gathering and sharing across agencies, CDC plans to gather information from additional sources such as international health agencies, and to include additional Federal agencies, military installations and local public health and safety authorities in Epi-X. CDC will also assist other organizations in using standard reporting tools, developing editorial policies, and training users in online features. These expansions will further enable state and local health departments to identify and report public health threats, including those suggestive of bioterrorism. Epi-X represents an important, specialized application built upon the platform of the Health Alert Network.

National Electronic Disease Surveillance System (NEDSS)

Public health surveillance is a crucial monitoring function for CDC and its partners. It is these ongoing data collection activities that help us detect threats to the health of the public. Without our public health surveillance systems, we might not identify outbreaks or other important problems in time to prevent the further spread of disease. We cannot investigate problems, identify their causes, and implement control measures if we have not detected them. Surveillance systems also let local health departments map the location of cases, track whether cases are increasing or decreasing over time, and link laboratory data with case reports, to either confirm them as cases, or provide prompt reassurance if tests are negative. These surveillance data are critical to target resources appropriately for public health response. Recent events have underscored this essential role of public health surveillance.

The traditional operation of our surveillance systems generally consists of paper or facsimile reporting by providers to health departments. If a case of illness is particularly unusual or severe (such as a case of anthrax or rabies), the provider will call the local health department immediately. CDC and its partners have recognized the need to build more timely, comprehensive surveillance information systems that are less burdensome to data providers. Several years ago, we initiated the development of the National Electronic Disease Surveillance System (NEDSS). The ultimate goal of NEDSS is the electronic, real-time reporting of information for public health action. NEDSS includes direct electronic linkages with the health care system; for example, medical information about important diagnostic tests can be shared electronically with public health officials as soon as a clinical laboratory receives a specimen, or makes a diagnosis.

NEDSS is designed to facilitate the development of an integrated, coherent, national system for public health surveillance that will have the flexibility and capacity to support emergency response, as well as handle ongoing public health surveillance needs. NEDSS standards provide an "architecture" which can support a wide range of surveillance activities. Ultimately, NEDSS will support the automated collection, transmission, and monitoring of disease data from multiple sources (clinicians' offices, laboratories, etc.) to local and state health departments and to the CDC. NEDSS will replace current systems used by public health agencies for collecting disease surveillance data, which rely on multiple, disparate, independently designed and supported systems. All 50 states, 6 cities and 1 territory have received funding for NEDSS; 21 jurisdictions have received funds for assessment and planning. Thirty-six state and metropolitan health jurisdictions are receiving funds for NEDSS compatible systems development, including 20 jurisdictions receiving support to deploy in 2002 the NEDSS Base System, a NEDSS-compatible system developed for state use.

State and Local Efforts

CDC has been working to ensure that all levels of the public health community - local, state, and Federal - are prepared to work in coordination with the medical and emergency response communities to address the public health consequences of biological and chemical terrorism.

State and local health departments are able to respond in part because of CDC's support of their bioterrorism preparedness. We have seen the results of these investments in the rapid public health responses to anthrax in Florida, New York, New Jersey, Washington, DC, and Connecticut. CDC has made awards to all states and three large cities--plus Washington, DC and Guam--which are now better prepared not only to identify and respond to bioterrorist acts, but also to provide enhanced communications with Federal, state, and local public health agencies.

CDC will continue and expand support to states, as well as enhance CDC's own preparedness for future attacks.

Public Health Infrastructure Development

In addition to these efforts, CDC has also worked with ASTHO, NACCHO, and other public health partners to implement the new law enacted last November, the Public Health Threats and Emergencies Act of 2000. This landmark legislation calls for three important milestones to strengthen the nation's public health infrastructure:

Development of a set of consensus public health infrastructure capacities required for national, state, and local public health systems and their workforces;
Assessment of the current state of the nation's public health systems using these capacities to identify critical gaps in the infrastructure; and
Technical assistance and funding to state and local health agencies to fill those gaps, beginning with the highest priority areas.

To date, CDC, HRSA, ASTHO, NACCHO, and state and local public health officials have jointly developed the set of public health infrastructure capacities and have identified seven priority areas for immediate strengthening. These seven areas build on the findings and recommendations of the Infrastructure Report:

System Readiness: Public health systems with the ability and surge capacity to effectively respond to public health threats and emergencies.
Information Systems: Secure, accessible information systems for rapid communication, acquisition, analysis and interpretation of health data, and public access to health information.
Communication: Swift, secure, two-way communication mechanisms to distribute scientific and health information to communities and policymakers; provide timely, accurate public information and advice to policymakers during emergency events; and coordinate logistical communication within the response community.
Epidemiology and Surveillance: Public health systems with the capacity to monitor health events, to identify patterns or aberrations, to track and respond to outbreaks, and to investigate underlying causes.
Laboratory: Public health laboratories with the ability to produce timely and accurate laboratory results for diagnostic and investigative purposes.
Workforce: A public health workforce capable of delivering the Essential Public Health Services during routine and emergency operation.
Policy, Laws, & Evaluation: Utilization of community assessment findings to establish priorities, ensure proper legal authorities, and improve the effectiveness of programs and policy decisions.

The President's budget for FY2002 recommended funding to get this important work started. The Administration's emergency request after September 11^th included funding to make further progress on these and other priorities.

Lessons Learned

The events of this fall are unprecedented. Like every organization and every individual, CDC has learned many lessons. As we work through the current anthrax threats and prepare for the next challenge, whatever it may be, we take forward a deeper understanding of bioterrorism and of how we share information.

We learned that the linkages we have helped forge between clinical and public health communities are strong and that these linkages saved lives by detecting illness early. We learned how to shorten the time lag between acquiring new knowledge, communication and action. We confirmed that close collaboration of local, state, and Federal public health personnel builds confidence in local response. We are newly aware of the challenge that changing science presents to clear communication. As we learned about the health risks of this outbreak, we had to modify recommendations, refocus investigations, and change our message. We put new scientific information into action with great speed. We also learned more about what information is valuable to the public and our partners, which will help us craft messages and materials in the future.

Conclusion

In conclusion, CDC is committed to working with other Federal agencies and partners as well as state and local public health departments to ensure the health and medical care of our citizens. We have made substantial progress to date in enhancing the nation's capability to prepare for and respond to a bioterrorist event, but there is much more to be done. The best public health strategy to protect the health of civilians against biological terrorism is the development, organization, and enhancement of public health prevention systems and tools, including enhanced communications mechanisms and messages. Other priorities include strengthened public health laboratory capacity, increased surveillance and outbreak investigation capacity, and education and training at the local, state, and Federal levels. Not only will this approach ensure that we are better prepared for deliberate bioterrorist threats, but it will also enable us to recognize and control naturally occurring new or re-emerging infectious diseases. A strong and flexible public health infrastructure is the best defense against any disease outbreak.

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