Mr. Chairman and members of the Committee, thank you for the opportunity to testify
today. I am accompanied by colleagues who have responsibility for implementing various
parts of our anti-bioterrorism initiative: James Hughes, M.D., Director of the National
Center for Infectious Diseases, Centers for Disease Control and Prevention; Robert Knouss,
M.D., Director of the Office of Emergency Preparedness, Office of the Assistant Secretary
for Public Health and Science; John Taylor, Esq., Senior Advisor for Regulatory Policy,
Food and Drug Administration; and Anthony Fauci, M.D., Director of the National Institute
for Allergy and Infectious Diseases, National Institutes of Health. The Department of
Health and Human Services (DHHS) welcomes your interest in our efforts to develop
effective counter-measures for possible uses of biological weapons against the civilian
population.
I will outline for you the overall strategic approach that DHHS is pursuing in our
anti-bioterrorism activities - emphasizing our efforts to strengthen the public health
infrastructure for infectious disease surveillance related to potential bioterrorism
agents and our efforts to enhance capabilities for medical and public health response
should a bioterrorist attack occur. Following that, my colleagues and I will be pleased to
respond to questions.
I begin by noting that bioterrorism presents a special set of challenges to our
emergency preparedness systems, public health organizations, and consequence management
capability. Unlike a bomb or discrete chemical exposure, a terrorist incident involving a
biological agent may not be detected or even suspected until people begin to present with
serious illness. This may occur at considerable and varying distance from the site of
initial exposure, both in terms of onset of disease (incubation periods can vary) and
geographic location (e.g., if exposure occurs in a transportation terminal, people can
spread out widely before becoming ill).
With a bioterrorist event, there is also the possibility of concentric, spreading
circles of communicable disease exposure, extending significantly the damage caused by the
agent released. This kind of threat will also dramatically increase the level of public
fear and potential for major civil disruption.
Increasing the urgency of the need for our nation to prepare for the potential threat
of bioterrorism is the fact that the agents most likely to be used in this type of attack
are pathogens not commonly experienced in this country or routinely dealt with by our
medical system. This has a number of significant implications: (1) the population
generally has little or no immunity to the pathogen and hence is more vulnerable (e.g., no
longer vaccinated against smallpox); (2) medical providers generally are not familiar with
the diagnosis and treatment of these disorders (which they may even fail to initially
recognize); and (3) routine scientific research into the pathogenesis and treatment of
certain of these disease conditions has been at very low levels compared to other agents
of infection because they have not been perceived to be high priority or because they
require levels of biological containment that are not available at most research centers.
For these reasons, a sound strategy for addressing bioterrorism will be quite different
from one that targets other types of terrorist acts.
The DHHS initiative features activities in five distinct but related areas:
- Deterrence of biological terrorism
- Surveillance for unusual outbreaks of illness
- Medical and public health response
- Development of a national pharmaceutical stockpile
- Research and development
I will comment briefly on each.
Deterrence. The Centers for Disease Control and Prevention (CDC) has the
responsibility mandated by the Antiterrorism and Effective Death Penalty Act of 1996 to
regulate the shipment of certain hazardous biological organisms and toxins (hereinafter
called "select agents"). Organizations such as research universities,
pharmaceutical manufacturers, and microbiological archives often have occasion, as part of
their routine work, to send or receive samples of dangerous pathogens or toxins. DHHS
regulations (42 CFR 72.6) require that all facilities sending or receiving shipments of
select agents register with the CDC, maintain records of such transfers, and otherwise
document their compliance. CDC's administration
of the select agent rule is part of the Administration's
multi-agency effort, led by the Department of Justice, to combat terrorism.
CDC also fosters safe design and secure operation of laboratories that handle select
agents. This involves consultation with laboratory officials to help ensure that new,
renovated, or proposed facilities meet standard guidelines for the infectious organisms
that will be handled. Development of guidelines and training materials for use by
laboratory personnel and provision of technical assistance to states as requested
regarding their inspection programs for BSL 3 facilities also are part of CDC's responsibilities..
Surveillance. Terrorist use of biological weapons against the civilian population
is likely to be surreptitious. Absent an explosion, other immediate evidence of an attack,
or notification of authorities by a perpetrator that an attack has been made (i.e., people
have been exposed), the first responders will be health-care workers rather than fire or
police personnel (as would be expected for a conventional emergency response scenario).
The first indication that a silent attack has occurred probably will be an outbreak of
some uncommon illness or an abrupt, significant increase in the incidence of commonly
observed symptoms. How quickly the outbreak is detected, analyzed, understood, and
addressed will determine the timeliness and effectiveness of the medical and public health
response and hence the extent and severity of the impact upon the health and well-being of
the affected community.
For example, most infectious agents have an incubation period measured in days or
weeks. A silent release of a biological agent capable of producing a highly communicable
disease, therefore, could afflict hundreds - if not thousands - of individuals over a wide
geographic area during a period of several weeks before the need for a full medical and
public health response could be identified and the response designed and mounted.
CDC is working to upgrade public health capability to counter bioterrorism through
complementary, simultaneous improvements in the bioterrorism-related expertise,
facilities, and procedures of state and local health departments and within the CDC
itself. The emphasis areas are (a) preparedness planning by state and local health
departments; (b) prompt reporting of cases of illness that might have been caused by
terrorists; (c) epidemiological analysis of outbreaks to identify the source and mode of
transmission; (d) laboratory identification and characterization of the agents causing the
outbreaks; and (e) electronic communications among public health officials regarding
occurrences of outbreaks and responses to them. CDC recently issued a competitive program
announcement soliciting applications for cooperative-agreement awards whereby states and
major metropolitan health departments can receive financial and technical assistance to
effect desired improvements in one or more of the five emphasis areas. CDC will make these
awards this summer.
Medical and Public Health Response. Much of the initial burden and responsibility
for providing an effective response by medical and public health professionals to a
terrorist attack of any kind rests with the local governments, with support from state and
federal agencies. Local public health systems almost inevitably will be called on to
provide protective and responsive measures for the affected populations, including:
- mass patient care -- including the establishment of auxiliary, temporary treatment
facilities or procedures for the movement of overflow patients to other geographic areas
for care;
- in the case of a bioterrorist event, mass immunization or prophylactic drug treatment
for groups known to be exposed, groups who may have been exposed, and populations not
already exposed but at risk of exposure from secondary transmission and/or the
environment;
- mass fatality management to provide respectful and safe disposition of the deceased,
including animals; and
- decontamination of the environment.
Presidential Decision Directive 62 designates DHHS as the lead federal agency to plan
and prepare for a national response to medical emergencies arising from the terrorist use
of weapons of mass destruction. Within DHHS, this responsibility rests with the Office of
Emergency Preparedness (OEP) within the Office of Public Health and Science.
OEP seeks to develop complementary medical response capabilities at local and national
levels. It works closely with other agencies
especially the relevant components of the Department of Defense (DOD), the Department of
Justice, the Department of Veterans Affairs, the Federal Emergency Management Agency, and
others with a view toward ensuring that plans
for managing the medical consequences of terrorist acts are well integrated with other
emergency response systems. To date, the anti-terrorism focus across the federal
government has been on the prospect of nuclear or chemical attacks. Future preparedness
efforts must focus on the prospect of bioterrorism as well.
In particular, OEP contracts with local governments for the creation of Metropolitan
Medical Response Systems (MMRSs) and, within these agreements, is placing new emphasis on
preparedness for mass patient care and other consequences of biological terrorism. Also,
OEP is working to strengthen its four National Medical Response Teams and the National
Disaster Medical System overall with respect to the bioterrorism threat so that they can
augment local capabilities as needed in the event of an attack. To date, OEP has
contracted with 27 municipalities to develop MMRSs. Another 8 MMRSs are to be initiated
this year; plans to fund 12 more with redirected Fiscal Year (FY)1999 funds have been
provided to the Subcommittee (bringing the total to 47); and the budget request for FY
2000 includes $16.5 million for contracts with an additional 20 cities for MMRSs -
bringing the total to 67. The long term goal is to establish MMRSs in all 120 metropolitan
areas specified in The Response to Weapons of Mass Destruction Act of 1997.
National Pharmaceutical Stockpile. A release of biological, and some chemical,
weapons of mass destruction will require rapid access to quantities of pharmaceutical
antidotes, antibiotics and/or vaccines that will not be readily available in the locations
in which they would be needed unless special stockpiles are created. Because no one can
anticipate exactly where a terrorist will strike and each local government does not have
the resources to create sufficient stockpiles on its own, special stockpiles must be
created and maintained as a national resource.
The initial focus will be on acquiring antibiotics useful in treating anthrax, plague,
and tularemia; enhancing the utility of the existing supply of smallpox vaccine; and
developing a cache of drugs and equipment for countering chemical attacks. Once research
and development have yielded improved vaccines against anthrax and smallpox and new
antiviral drugs effective against smallpox, they will be included in the stockpile.
CDC has responsibility for developing the stockpile. Fifty one (51) million dollars has
been appropriated for this purpose this fiscal year, and a comparable sum is requested for
FY 2000.
Research and Development. Capability to detect and counter bioterrorism depends to
a substantial degree on the state of relevant medical science and technology. Without
rapid techniques for accurate identification of pathogens and assessment of their
antibiotic sensitivity, planning for the medical and public health response will be
compromised significantly. Without efficacious prophylactic and therapeutic agents, even
the best planned responses are likely to fail. The current base of science and technology
is strong in some areas (e.g., certain classes of anti-bacterial drugs) and weak in others
(e.g., rapid diagnostics, anti-viral drugs, and vaccines). Strong, sustained research and
development in relevant scientific disciplines is the only proven way to remedy such
deficiencies in knowledge and technology.
The National Institutes of Health (NIH) is reinvigorating its research related to the
pathogenesis of - and host immune responses to - infectious organisms likely to be used in
terrorist acts - e.g., the organisms that cause anthrax, tularemia, and plague. This
research would be greatly facilitated by the acquisition of genome sequence information on
these and related pathogens. The results of such genomics research - coupled with other
pathological, immunological, biochemical, and microbiological information - are expected
to facilitate pursuit of a variety of critical goals including the development of rapid
diagnostic methods for the most likely biological weapons, the development of antiviral
therapies for smallpox and Ebola virus, and the development of new vaccines for anthrax,
cholera, and smallpox. NIH also will undertake an array of basic and targeted studies
oriented toward development of new or improved methods to diagnose chemical exposures and
determine their effects upon the nervous system.
Building upon the rapid advances of recent years in the molecular and cell biology of
infectious organisms, the Department has requested $30 million in FY 2000 specifically for
developing improved vaccines for the highest priority bioterrorism threats: anthrax and
smallpox.
Other DHHS agencies are engaged in relevant research and development as well. CDC, as
part of the surveillance initiative I described earlier, is expanding its in-house Rapid
Toxic Screen project to develop methods for measuring, within 48 hours, toxicants in human
blood or urine samples. The goal over the next three years is to devise methods to
identify and measure 150 different toxins and to achieve an in-house analytic capacity of
200 samples per day. As new methods come on line, CDC will disseminate them to state and
local laboratories as appropriate for incorporation into their analytic repertoires. Also,
FDA proposes to expand its research on detection and characterization of toxins that might
be used by terrorists.
Looking more generally at the entire civilian medical response to chemical and
biological terrorism, DHHS contracted in May, 1997 with the National Academy of Sciences' Institute of Medicine (IOM) to provide specific
recommendations for priority research and development activities to improve that response.
The IOM's report, delivered this past January,
examines a wide range of research and development needs - including not only the medical
response areas described above but also topics such as environmental detection of chemical
or biological agents, personal protective clothing and equipment, and decontamination. My
colleagues and I have found this to be an excellent and helpful study; and the Office of
Science and Technology within the Executive
Office of the President is using the IOM
report as its framework for assessing and coordinating counter-terrorism-related research
and development throughout the Executive
Branch.
Expedited Regulatory Review. The development of new or improved diagnostics,
antibiotics, antivirals, and vaccines needed to combat bioterrorism must go hand in hand
with efforts to streamline the regulatory process that new products must undergo
successfully to be approved for marketing. FDA will work closely with sponsors and
manufacturers to ensure effective and timely reviews of investigational new products. For
example, NIH has created an Anthrax Vaccine Working Group, which brings together
representatives of the NIH, FDA, and DOD to advance research and development relevant to
developing a new anthrax vaccine. Also, FDA intends to accelerate the pace and increase
the efficiency of its reviews by ensuring the availability of experts to guide sponsors
through the regulatory process not only for new products but also for new uses of existing
products.
In conclusion, Mr. Chairman, I believe that DHHS is off to a good start toward
protecting this nation from those who would use biological weapons against the civilian
population. Thanks to the leadership of President Clinton and the strong support of the
Congress, the funding for the anti-bioterrorism initiative this fiscal year totals $158
million. Moreover, the President's request for
FY 2000 includes $230 million to continue, expand, and strengthen the activities begun
this year. The medical and public health communities clearly have the skill and the will
needed for this task. We seek your help in ensuring that they also have the means.