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.