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Good morning, Mr. Chairman and members of the Subcommittee. I am Stephanie Bailey, MD, MSHSA. I am Director of the Metropolitan Health Department serving Nashville and Davidson County, Tennessee. I am pleased also to serve as President-Elect of the National Association of County and City Health Officials (NACCHO). NACCHO is the organization representing the almost 3000 local public health departments in the country. I am here today to explain how local health departments serve on the front lines in battling bioterrorism, as well as public health crises of all sorts. I will explain the state of our preparedness in Nashville, what we need to become more prepared, and why we need a nationwide infrastructure of local public health agencies trained and equipped to respond to public health disasters. My most important point is that the very capacities needed by local public health departments to deal immediately and effectively with the consequences of an act of bioterrorism are the same as those needed to prepare them better to identify and respond to outbreaks of other diseases and to protect the overall health of their communities. Local health departments are challenged as never before by new threats and we are struggling to find the resources to meet them.
Outbreaks of disease can occur for many reasons -- because one child infected with infectious bacterial meningitis spends a day going to classes in a school before his illness is diagnosed -- because one shipment of frozen strawberries from Mexico arrives at a grocery store infected with the Hepatitis A virus -- because a hurricane, tornado or flood disrupts water and sewer lines and causes a public water supply to become dangerously contaminated -- or because someone introduces a lethal biological agent, such as anthrax or smallpox, into the air. Whatever the reason for an unusual outbreak of illness, the local public health authority - whether it is governed by the city, the county, or the state - has the local responsibility for detecting that outbreak, tracing it to its source, and stopping its spread. I strongly submit to you that, when these events happen, they happen at the local level and it is localities that respond first.
The potential public health threats we all face are growing in number, complexity and severity. Rapid air travel means grave infectious diseases can be spread from one country to another simply when an infected person takes a plane flight. Our food supply has become globalized, and we are more vulnerable to food-borne diseases from imported food than ever before. Insidious bacteria that have mutated so that they are no longer easily treatable with existing antibiotics are multiplying in number. Virulent new viruses, such as hantavirus and Ebola, have emerged. And reports of instances where persons have access to biological weapons are increasing. We rely on law enforcement to prevent and deal with criminal acts, but when those acts pose a threat to health, we rely on the public health system. Just as our military needs to keep up a defense against new weapons development, so our public health system, which has been taken for granted, must maintain a defense against new diseases and new ways they are manifested.
We had an anthrax scare in Nashville just three weeks ago. A letter was delivered to the Southern Baptist Convention (SBC) building in downtown Nashville. It was opened by an employee, who found a note that said, "Congratulations, you have been exposed to Anthrax." SBC called the alternative 911 emergency telephone number asking for assistance. The police responded, followed by the Nashville Fire Department's Hazardous Materials (HazMat) unit. They secured the area and turned off the building's heating and air ventilation system. The envelope and its contents were immediately sealed in an airtight container. I was notified by the city's Office of Emergency Management and went immediately to the scene to provide onsite public health direction. We identified five people who had been most closely exposed to the letter. It was necessary to set up a decontamination area in which the individuals were disrobed and washed down with a ten percent bleach solution. The Hazmat team, which has breathing apparatus and protective suits, conducted the bleach wash. Eighty other persons were isolated in the building offices. Then I met with each of the exposed individuals, described the signs and symptoms of anthrax, answered questions, and prescribed prophylactic antibiotics.
In Nashville we have proactively communicated the public health role in disasters to other city agencies. Therefore, emergency personnel knew to contact the public health department, so that we could provide essential guidance on decontamination procedures, release of victims, containment of any potential exposures, and prescribe further treatment for exposed persons.
A similar incident occurred in Asheville, North Carolina, on February 18, 1999. The situation was handled very differently. Had the hoax been real, a real and unnecessary disaster would have occurred. A note purporting to contain anthrax was sent to an abortion clinic, which called in the police. The FBI and CDC were notified, but the local emergency management team and the local health department were not notified. Exposed persons were told to go home and take a shower. The note and envelope were sent via Federal Express to Fort Detrick in Maryland. The state and local health departments did not learn of this until the next day. If it had been necessary to use traditional epidemiologic methods to trace contacts of exposed persons, guide their isolation and give post-exposure instructions for prophylaxis, many exposures would have taken place and there would have been casualties.
Nashville-Davidson County is thirty-third on the list of cities that are potential targets for nuclear, biological and chemical terrorism. We began training in September 1998 as part of the Domestic Preparedness initiative established by the Nunn-Lugar legislation, under which the Department of Defense trains first responders. Nine health department staff received training, alongside representatives of the fire and police departments, hospitals, emergency management and the medical examiner's office, and we are presently training others in the city. All members of my staff are being trained on basic awareness of the threats of biological and chemical terrorism.
One result of this effort has been the recognition by other city personnel that public health expertise is essential in responding to terrorist incidents. Our responsibilities include:
We are fortunate to have excellent cooperation from the medical community in Nashville, as well as some funds to establish an epidemiology division in our health department. However, major gaps in our preparedness include access to bulk supplies of vaccines and other medical supplies, bulk protective equipment, and timelier field detection and monitoring capability. We also learned from our training that localities are "on their own" for 24 to 48 hours after an attack by any weapon of mass destruction, before federal assistance can arrive and be operational. This is the critical time for preventing mass casualties and we need more help to be ready.
Disease surveillance capabilities are critical to early detection of a release of a biological agent. When people get sick, they seek care from their doctor or a hospital. No single physician or hospital will necessarily notice that anything unusual is occurring -- but if they all report any one case of unusual infectious disease or symptomatology that they observe, local health authorities can put that information together to discern a pattern. Disease surveillance is a fundamental function of public health at the local, state and federal levels. Surveillance is our early warning system that something is wrong.
In order to participate effectively in disease surveillance and response, local health departments must be able to send and receive information quickly to and from local doctors and hospitals, to and from health departments in neighboring jurisdictions, to and from the state health department, and to and from the Centers for Disease Control and Prevention in Atlanta. The local health department does the work on the ground, such as tracking down who has been exposed to a disease, sometimes obtaining laboratory specimens for accurate diagnosis, and taking whatever measures are necessary to prevent further spread. The local health department also is responsible for giving accurate and timely information to the media and the community. In order to do its job, the health department needs not only local expertise, but also immediate access to higher levels of expertise that are available at the state health department, laboratories, and CDC.
Every day, my colleagues in other jurisdictions face outbreaks of illness caused by salmonella, E. Coli bacteria, the hepatitis A virus, meningococcal bacteria, and a frightening array of new antibiotic-resistant bacteria. None of these diseases respects boundaries -- we all must be well prepared to share information about suspicious incidents of disease, deal with outbreaks and communicate about them to our neighbors. Agents of biological terrorism are highly similar to other agents of disease in that they may be insidious in onset and difficult to recognize. We won't recognize them promptly enough to save lives if we can't trade information with each other instantaneously.
Currently, electronic communications are the best way to send and receive data quickly, and the Internet is the best way to share data and get access to current information about a disease. In the military and in law enforcement, these methods of emergency communication are a given. But in public health, we are way behind. Most health departments still rely on the phone, the fax machine, and paper and pencil to track down the information needed to evaluate reports of disease, identify who may have been exposed, analyze data to determine whether there is a threat of an epidemic, and call in expert advice. If they need to send or receive information quickly, a fax is too slow. If the threat is real and preventive measures such as immunization of the population at imminent risk is the protocol, saving time means saving lives.
Nashville is fortunate to have some of these communications capacities and is way ahead of many jurisdictions. But if anything were to happen just 30 miles away that had regional implications, we would all come up short.
Preliminary data from a 1999 NACCHO survey show just how far behind public health is in its access to the information superhighway. In at least one-half of local health departments, staff who would coordinate the responses to a bioterrorist incident or other imminent public health threat do not have continuous, high-speed access to the Internet. One-quarter of these staff do not have electronic mail. Almost twenty percent of local health departments have no e-mail capacity at all.
If my staff in Nashville needed to trace contacts of persons exposed to a suspected biological agent, we would need the cooperation of neighboring jurisdictions. Our own systems wouldn't be helpful if other local health departments still relied on the phone and fax. There is no system for communication between local health departments in Tennessee. We also don't have full electronic communications to and from the state health department, which would be highly involved in any mass disaster, or with other Nashville government agencies. Our electronic connections to the state health department exist only for certain categorical programs, such as immunization and HIV prevention and reporting. And for all the sophistication of the categorically funded systems, they cannot communicate with each other. It would make much more sense to have a uniform, department-wide connection to the state health department, but the categorical nature of our funding prevents this.
Even where some type of electronic communications capacity exists, a huge problem remains. The capacity is useless unless people are trained to work with it effectively. Training in the use of on-line data and services is essential. The skills and competencies we will need to apply 21st century technology to public health are sorely lacking. Moreover, the experience and skill in dealing with complex infectious disease problems is widely variable across the country. Additional training is needed to improve local public health surveillance and response.
The knowledge gap is particularly alarming with respect to biological and chemical terrorism. Few of us in public health are familiar with the prevention, diagnosis or treatment of the health effects from agents of biological warfare. We need quick access to authoritative guidelines for implementing emergency measures, as well as an ability to communicate instantaneously and securely with other government agencies that would respond to an instance of terrorism. We also need to train our own personnel. The NACCHO survey found that 94 percent of health departments do not have fully trained staff in bioterrorism preparedness, and almost half serve jurisdictions whose emergency response plans do not address incidents of bioterrorism.
NACCHO strongly supports all aspects of CDC's current efforts to address bioterrorism and we believe that a total of $263.5 million is needed for the next fiscal year. We are particularly concerned about continued and adequate funding for the component that will help local health departments develop the technology and training that they need to deal with bioterrorism, as well as any other public health crisis. This component, known as the Health Alert Network, will fill the huge gap in knowledge and communications capacities that now handicaps many of us in our ability to recognize and deal quickly with public health emergencies. It will provide those of us on the front lines in public health, local health departments, with essential electronic information tools and the training to use it well to improve public health surveillance and response. Bioterrorism response will not work effectively or efficiently without a high level of attention to preparing the most likely first responders.
The same local public health infrastructure of trained personnel, equipment, and communications and data analysis capacities that will equip us to cope with an act of terrorism, such as an intentional release of anthrax, will also better equip us to deal with the threats that occur even more frequently, when contagious diseases or contaminated food or water threaten our communities.
Building this infrastructure requires sustained planning and resources and close cooperation between local and state health departments. The infrastructure cannot be dismantled simply because no crisis has occurred. We would never permit fire departments to lapse when there hasn't been a fire, but we have sorely neglected local public health departments.
We believe that CDC needs more funding than the Administration has requested to carry forward a multi-year process to equip local public health agencies, working with their state health departments, to fulfill their governmental responsibilities. The categorical nature of our funding permits us to address specific public health problems, but it does not leave enough room to build the underlying infrastructure to support comprehensive public health protection. In addition to recommending funding of the Health Alert Network in the amount of $40 million, we hope the Subcommittee will use this opportunity to examine the needs of local public health agencies that cut across all their activities and explore mechanisms for helping us improve our capacity and our performance.
My colleagues in public health and I are accustomed to using scarce resources efficiently and creatively, but operating as we are is simply unacceptable. A strong public health infrastructure is important to the defense of this nation. We just cannot afford to get any farther behind. Whether the cause of a public health emergency is an innocent cook at a church supper or an international terrorist, our need to respond quickly and skillfully remains the same. Saving time means saving lives.
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