Oral Testimony Presented by Antonia C. Novello, M.D., M.P.H., Dr. P.H. New York State Commissioner of Health
Senate Hearing on Pandemic Flu Preparation, March 10, 2006
Good morning. Chairman Hannon, Chairman Balboni and Committee Members, thank you for inviting me to speak at this hearing on New York's preparation for a potential pandemic flu.
Currently, planning is occurring at many levels of the federal, state, and local levels to provide for a coordinated response to a potential pandemic. Today I will discuss the New York State Health Department's role in these preparations. Our plan, although strong, is still evolving.
First, I want to make sure we all have the facts when we talk about a potential flu pandemic.
As you are aware, there is concern about the avian flu. It is not the same thing as pandemic flu. Avian flu is an infectious disease that primarily affects birds, caused by a type A strain of the influenza virus. Pandemic flu, on the other hand, is a worldwide epidemic of influenza in humans.
As you are also aware, there is a concern about the particular avian virus known as H5N1 currently present in Asia, Europe and Africa. While it is impossible to know for sure what will happen, health experts are concerned that this H5N1 virus spreading primarily among birds may mutate into a strain that could easily be passed from person to person, resulting in a pandemic. This has not happened yet, and it may never happen.
While H5N1 is currently the virus of greatest concern, we cannot discount the possibility that other avian influenza viruses, which are known to infect humans, might be the eventual cause of a pandemic.
We know that there were three influenza pandemics during the 20th Century – in 1918, known as the Spanish flu, in 1957, known as the Asian flu, and in 1968, known as the Hong Kong flu, and most experts believe it is only a matter of time before we have another.
Several human cases of the H5N1 virus have been reported, mainly in Asia, with a few recent cases also reported in Turkey, and one case reported in Iraq.
To date, the H5N1 virus has not been identified anywhere in New York State or the rest of the United States -- neither in birds nor in humans.
As of March 6th, 2006, there have been a total of 175 human cases of avian flu reported, mainly in Asia, resulting in 95 deaths.
It is important to note that the 175 human cases that have occurred to date have resulted mainly from very close human contact with infected poultry and not from human to human transmission.
There have been a handful of possible person-to person cases reported, but the transmission has never spread beyond that.
Over the last several months, the avian flu has been spreading westward through migrating birds from Asia into Africa and the Middle East. Most recently it has been identified in some migrating ducks, geese and swans in Europe.
While there are no migratory bird pathways from Asia or Europe to the United States, migratory birds from those parts of the world could mix with migratory birds from North America in Siberia, Alaska or Greenland. Since ducks and geese are reservoirs for avian influenzas, it is conceivable that the H5N1 virus could show up in migratory birds from one of these areas.
Aware of such a possibility, the federal government has a surveillance program in place to monitor the migratory bird population for avian influenza, especially in key areas, such as Alaska, where bird migratory pathways from Asia and the United States overlap.
Because the huge numbers of bird deaths that have occurred from the H5N1 virus in Asia and other countries occurred primarily in domestic chicken flocks, in the United States currently state and federal programs are conducting surveillance for avian influenza among domestic poultry.
This early warning system gives the United States a level of advantage that not every country has.
With regards to this, in New York State for several decades, the Departments of Health, Agriculture and Markets, and Environmental Conservation have had a joint task force -- called the Task Force on Zoonotic and Emerging Disease Surveillance, or ZEDS, to focus on and coordinate surveillance for zoonotic diseases – which are diseases that are communicable from animals to humans.
In December, to bring even greater focus to the issue of avian influenza, a special subcommittee was formed to coordinate surveillance.
This ZEDS workgroup was instrumental in developing the chapter in the Department's pandemic influenza plan dealing with pathogenic avian influenza in animals, a component that is currently unique among state pandemic influenza plans.
This group is also continuing to work on avian influenza plans in New York for the state and federal agencies responsible for surveillance and control. In addition to the workgroup, these agencies have distinct, coordinated responsibilities for aspects of avian influenza.
In New York State, the State Department of Environmental Conservation (DEC) is responsible for conducting surveillance and testing for diseases among wild birds, including avian influenza.
And the State Department of Agriculture and Markets is responsible for maintaining an active program to identify and control avian influenza in the domestic bird population.
Ag and Markets is currently testing for avian influenza within the live poultry market system and requires that every flock of poultry be tested and found negative for avian influenza before any bird can be moved into the markets.
In addition, Ag and Markets is actively testing for avian influenza in poultry flocks on both large commercial and other poultry farms.
As I mentioned earlier, in order for a human pandemic to occur, the H5N1 virus must mutate to a form that becomes readily transmissible from human to human. While this has not happened yet, research has shown that it actually did happen in 1918. In 1918, the flu virus that caused the pandemic started from an avian flu virus that mutated to a form that spread easily from human to human.
While we don't know what will happen in the future, clearly we can't wait until a pandemic is underway to figure out what we're going to do.
If the H5N1 virus were to mutate, it could spread from country to country by human travelers over a period of months. Because it would be a new virus, people would have little or no immunity to it and could suffer severe illness.
That is why the New York State Health Department has developed a strong and evolving plan designed to protect the public's health to the greatest degree possible. As new scientific and medical information becomes available, as local plans are finalized, and as other resources and experience grow, federal, state and local plans will become even stronger.
I want to emphasize that the Department of Health's plan is part of the New York State all hazards plan. The Department's plan was developed for specific audiences, most notably our local health department and healthcare provider partners.
The Department's plan, as it stands, will facilitate the development of local health department and healthcare facility plans. The State is developing a Pandemic Influenza Annex as part of the State's Comprehensive Emergency Management Plan, which involves all state agencies.
This is a being undertaken in collaboration with the State's Disaster Preparedness Commission (DPC), the State Office of Homeland Security (OHS), and the State Emergency Management Office (SEMO).
The State Health Department's plan parallels the national strategy for responding to pandemic influenza. It also reflects New York State's unique characteristics, including our diverse population; our urban and rural geography; our position as an international border state; and the fact that we are an entry point for many international visitors.
It is our belief that for effective implementation of the plan to occur, there must be strong collaboration and coordination among New York's public health and healthcare communities and public health officials in other states. This is why, during the development of the plan, the Department sought and obtained input from local public health agencies, healthcare providers, state agencies, the CDC, and public health officials in other states..
And this is why we continue to work closely in collaboration with these partners as they develop their own plan and as our plan continues to evolve.
In February, the plan was reviewed and discussed with New York City and all county public health commissioners and directors, as well as representatives of the healthcare provider community. Over the coming months, we will continue to partner with the City and counties in planning, coordination, and practice drills.
New York's pandemic flu response plan revolves around three key requirements: early detection, prevention, and, health care delivery.
During the early days of a pandemic, the plan specifies:
- Increased and active surveillance for ill persons with recent foreign travel. Identification of individuals who have had contact with ill travelers, including possible limits placed on their movement.
- Triage and isolation of sick people, while ensuring that they get appropriate care.
- Rapid testing of viral samples at the Department's Wadsworth Laboratory;
- Emphasis on early recognition of bacterial pneumonia, with aggressive antibiotic treatment.
- Increase in infection control measures in healthcare and other settings to minimize disease transmission;
As a pandemic becomes more widespread, the Department's plan provides for strong actions meant to slow or stop the progression of the pandemic.
These actions may include "social distancing" measures, such as:
- Closing schools for a period of time;
- Closing businesses, or encouraging businesses to have employees work from home;
- Canceling and prohibiting large public gatherings;
- In addition, providing an orderly distribution of vaccines and antiviral drugs, when these become available.
As I have emphasized, a key part of the Department's pandemic response plan focuses on bringing together local health departments, health care facilities, emergency managers, physicians and other health care professionals to ensure a rapid and coordinated response.
The Department has taken a number of steps to assist county health departments with their preparedness planning effort.
Since 2002, the Department has provided nearly $50 million dollars to these departments to support public health emergency preparedness planning and to enhance their response capacity.
As part of his 2006-2007 Executive Budget, the Governor has proposed the creation of a $20 million dollar emergency fund that county health departments could draw from to help the local response to a public health emergency.
In addition, over the last several years, the Department has taken many actions to strengthen local public health preparedness. For example, the Department hired and deployed additional epidemiologists in each region to assist with local surveillance of communicable disease.
In cooperation with the State Emergency Management Office (SEMO) and the Office of Homeland Security (OHS), last year the Department developed a package of drill and exercise scenarios for use by local health departments, hospitals and emergency managers.
The Department has already met with every county health department to discuss the development of their own county-specific pandemic influenza response plans, which must be submitted to the Department by the end of August.
Department staff are working side by side with the county health departments to assist them in the development of their plans and to ensure that their plans contain all required elements in coordination with the State plan.
Since isolation and quarantine may have a limited role early in a pandemic to slow the introduction of influenza from international travelers, the Department has already clarified and communicated to all local health departments the legal basis and authority for these measures.
The City and county commissioners and public health directors, who lead the 57 county health departments and the New York City Department of Health and Mental Hygiene, have the authority to order isolation and quarantine.
In 2004 and 2005, all 57 county health departments were required to develop and submit a detailed plan for isolation and quarantine. These plans were reviewed and approved.
This year, all 57 county health departments are exercising their plans with their county attorney, local law enforcement, hospitals, and court administration officials participating.
We have also been reviewing the public health system's authority to act in situations such as a pandemic, and we expect to shortly submit proposed legislation that will strengthen our ability to respond.
Among these legislative proposals will be:
- Legislation mandating electronic reporting of disease and submission of clinical specimens by laboratories.
- Legislation to update the definition of communicable diseases that must be reported to health authorities.
- Legislation that authorizes the Commissioner of Health to require reporting from entities possessing medicines, vaccines and medical supplies that may be needed to respond to a public health threat.
- Legislation that authorizes the Commissioner of Health to redeploy medical equipment to respond to public health emergencies; and,
- Legislation that will authorize the Commissioner of Health and local health officers to train and authorize unlicensed persons to give immunizations and perform other necessary functions, in order to increase the pool of persons legally able to assist in the response to a pandemic.
We look forward to working with the Legislature on these issues of law.
Regarding hospital preparedness --
All hospitals have developed detailed emergency response plans and have tested those plans in drills and exercises.
Since 2002, the Department has distributed over $23 million dollars to acute care hospitals located outside New York City.
New York City receives its funding directly from the Federal government.
Additionally, since 2002 nearly $14 million dollars has been provided to eight hospital trauma centers that serve as Regional Resource Centers for emergency preparedness.
These centers include Stony Brook University Hospital, Long Island Jewish Medical Center, Westchester Medical Center, Albany Medical Center, SUNY Health and Science Center in Syracuse, Strong Memorial Hospital, Erie County Medical Center, and Champlain Valley Physicians Hospital and Medical Center.
During a pandemic, the ability of hospitals and other healthcare facilities to handle the expected influx of patients is a major concern.
The Department is working closely with hospitals and other providers to develop "surge capacity" to handle such an increased numbers of patients.
The federal government is requiring New York State to create a system of hospital bed surge capacity that provides for 500 adult and pediatric patients per 1 million population. In collaboration with our hospital Regional Resource Centers, we have created eight regional plans that collectively meet the federal goal.
The Department has also developed an important and effective tool to allow us to quickly communicate with healthcare facilities across the State during a public health emergency.
This tool – called the Health Emergency Response Data System – or HERDS – is a statewide electronic web-based system that provides an emergency communication link to all New York State health care facilities through a secure internet site.
Recognized as a national model, HERDS is a sophisticated data management tool that the Department developed in collaboration with hospitals after 9/11. It has allowed us to track critical information during dozens of emergency incidents, preparedness surveys, and disease surveillance activities, including the 2004 influenza vaccine shortage and the tracking of laboratory confirmed hospital admissions for influenza.
This system provides real time data visualization, including GIS mapping of data.
It tracks inpatient capacity, isolation room capacity, available staff resources, and the availability of drugs and supplies by facility, county and region.
During a pandemic, this system will be used by incident command to manage resources at the state, regional and county levels.
Currently, all hospitals and nursing homes are hooked into the HERDS system. We are now in the process of connecting primary care clinics, adult homes, home health agencies, and physicians.
Despite these measures, we recognize that a pandemic could seriously strain the capacity of our healthcare facilities.
To address this, the Department is working side by side with hospitals to develop pandemic flu plans that will include such measures as postponing elective surgery and the use of alternate health care and other sites to provide additional beds.
An effective pandemic response requires that we have a supply of healthcare workers who could be quickly deployed.
With assistance from the New York State Medical Society and the State Nurses' Association, the Department has developed a database of approximately 10,000 physicians and nurses who have indicated their willingness to volunteer to respond to a public health emergency.
In addition to the State database of volunteers, 19 Medical Reserve Corps – consisting of teams of doctors, nurses and other health care professionals -- have been established.
To further enhance local planning, the State Health Department and the State Emergency Management Office (SEMO) conducted regional planning sessions with local public health officials and volunteer organizations in order to recruit and identify non-medical volunteers that could assist during a pandemic or other public health emergency.
These volunteer agencies include the American Red Cross, Citizen Corps, Special Volunteer Progress, Retired Session Volunteer Programs, and others.
Another key requirement to our Plan is the early detection of disease. Speed and accuracy are a must in detecting a disease outbreak to ensure a rapid response to minimize further transmission.
The Department has upgraded its Communicable Disease Electronic Surveillance System, called CDESS. This is a web-based system by which counties report epidemiologic information on all reportable diseases including laboratory-confirmed influenza cases. This system also has a module to monitor contacts of cases.
During the 2004-2005 influenza season, the Department made laboratory-confirmed influenza a mandatory reportable disease, requiring laboratories to immediately report positive results of influenza electronically to the Department.
In addition, on a weekly basis, hospitals are also required to report confirmed hospital admissions for influenza. During a pandemic, more frequent hospital reporting will be required.
During a pandemic, fast and reliable communication with local health officials, health care facilities and clinicians will be critical. The Department has developed a sophisticated alert system called the Integrated Health Alert and Notification System, better known as IHANS.
The IHANS system allows the Department to send and receive emergency notifications and information messages to all stakeholders through multiple and redundant means of communication, including Blackberry emails, FAX, secure-web postings, and sequential phone calls, including cell, pagers, office and home phones.
IHANS uses automated systems with monitoring to confirm receipt of the message.
As part of a recent drill with the CDC, we sent a health alert message through the IHANS system to local health representatives in 57 counties. During this test, 54 of the 57 counties acknowledged receipt of our message within 5 minutes. The remaining counties responded within 3 hours.
In the event of any disease outbreak, including influenza, we must be able to quickly confirm the identity of the pathogen through laboratory testing.
To accomplish this, the State has enhanced the State's public health laboratory capacity to provide for rapid identification of disease threats.
This includes expanding the capacity of the Department's own bio-defense laboratory in the Wadsworth Center to provide early detection of an emerging influenza strain and to allow rapid testing of large quantities of specimens.
Wadsworth Center has implemented multiple molecular assays for detecting different influenza subtypes, including H5, and has the capability and expertise to also perform molecular sequence analysis from which to assess strain variation. Delivery is anticipated of additional automated devices that will increase capacity for molecular testing by approximately four-fold.
To further enhance influenza testing capacity, the State has provided more than $2.3 million dollars to upgrade public health laboratories in Erie and Westchester counties to Bio-Safety Level 3 category.
In the event of a pandemic or other public health emergency, we will also need to quickly distribute medicines to healthcare providers and county health departments.
To accomplish this, several years ago the Department established a State Stockpile of antibiotics, antivirals and other emergency medications and medical supplies.
The Governor's proposed Executive Budget includes $29 million dollars to purchase and stockpile additional medications and supplies that would be needed in a pandemic. Two-thirds of these funds would go toward the purchase of medications, including the antiviral medicine Tamiflu. The remaining one-third would be used to purchase ventilators and personal protective equipment.
We are awaiting details of the Federal government cost-sharing program for purchase of additional medications. We anticipate ordering additional supplies for the State stockpile based on the federal funding.
The State stockpile is intended to supplement assets from the federal Strategic National Stockpile, or SNS.
The Department's plan provides for moving resources from the State stockpile or from the Strategic National Stockpile to any location in the State within a four-hour time-frame.
The State's operational details for accessing and distributing supplies from the SNS are contained in an Annex to the State's Comprehensive Emergency Management Plan.
The plan identifies the personnel and agencies involved, outlines the roles and responsibilities, and details the procedures for request, receipt, breakdown, inventory management, and distribution of the SNS assets to local governments and treatment facilities.
These operational details have been tested in a full-scale SNS exercise conducted in April 2004. This included the receipt, breakdown and transport of SNS push package assets to the 7 counties surrounding New York City.
The Federal government carefully evaluates and tests each state's capacity and readiness to receive and distribute assets from the SNS. Certification in the program is only achieved when the CDC is assured, by evaluation against rigorous standards measured in on-site inspection and evaluation of drill performance, that a state is ready and prepared. New York State is one of only a few states nationwide to thus far receive a "Green" rating indicating it has met all Federal requirements.
The counties have pre-selected sites to receive supplies from the Stockpile, and they have already pre-selected and trained personnel to break down and distribute the supplies.
Local law enforcement personnel have been assigned to provide security at stockpile sites.
At the local level, these county plans include the identification of receiving sites and Points of Dispensing (PODS). The counties have trained staff to perform these duties and, to date, have conducted at least two drills in each local jurisdiction.
Again, I want to emphasize the importance of drills and exercises. Since 2003, the Department has participated in 15 full-scale emergency response exercises, as well as many other smaller drills.
The Department's plan also provides for mass vaccinations if and when vaccine supplies are available. The federal government is currently testing one H5N1 vaccine, and recently announced that it will begin developing and testing a second vaccine.
In one of these emergency response exercises, the Department administered the flu vaccine to nearly 2,000 state employees in less than five hours to gain valuable experience in mass vaccination.
On the local level, county health departments have participated in 360 emergency response exercises since 2003.
Over the coming weeks and months, we will conduct additional drills and exercises to make sure the State's pandemic flu response plan works.
Each one of these drills is followed by an extensive evaluation of performance, resulting in modifications to response plans and protocols, as needed.
Finally, I want to mention that the Department's plan also includes a strong public education and communication component. We will use the Internet and the media to provide the public with information that will help them protect themselves and limit the spread of illness.
In the coming months, the Department will begin a public awareness campaign to remind the public of common-sense measures they should be taking now to prevent exposure to influenza and minimize transmission of illness.
The more people take these precautions now, the more likely they will be able to avoid infection during a pandemic.
I want to emphasize that many of the most effective measures to prevent illness are those that people can take themselves. These include:
- Recommendations for respiratory hygiene -- including frequent hand-washing, covering your mouth when coughing or sneezing, not shaking hands or sharing drinking cups or silverware; and cleaning contact surfaces like phones and desktops.
- We will urge children and adults with symptoms of illness to stay home from school or work.
- During a pandemic, we will add to these measures the following:
- We will urge the public to avoid crowds.
- We will notify the public about possible closings of schools and businesses.
- We will make the public aware of travel advisories that may be necessary to restrict travel and prevent further transmission.
- And we will advise the public to stockpile at least two weeks' supply of non-perishable food, water, and essential household items, so that they can avoid having to visit public places during the pandemic.
Another very important part of public education – which needs to be done ahead of time – is preparing all New Yorkers for the decisions that will need to be made during an influenza pandemic.
The public needs to understand that there will likely not be a vaccine available early in a pandemic. Other medical resources, like antiviral medications, ventilators, and hospital beds, will likely be in very short supply. This may require changes in healthcare standards of care.
To prepare the public and give them an opportunity to discuss these pertinent issues, the Department will be requiring all counties to conduct "town meetings" and invite the public and other stakeholders to hear and discuss the county's pandemic flu plan.
The goal of our communication plan is to get consistent, accurate information to the public quickly. We as leaders must avoid and prevent misinformation that could cause panic. Above all, we must be honest with the information at hand.
This will be very important, because people who remain calm and knowledgeable will be in the best position to protect themselves from illness and prevent further transmission of the disease.
Again, I want to emphasize that the Department's pandemic flu response plan is a work in progress.
We will constantly update this plan as more medical and scientific information becomes available, and as ongoing planning occurs in conjunction with the Centers for Disease Control, the State Office of Homeland Security, the State Emergency Management Office, and our other federal, state and local response partners.
Let there be no doubt, our number one priority is to protect the health of New York's families, communities, and our State.
We must be prepared to do our very best because the health of our families, our communities, and our state is at stake.
If a pandemic does occur, I am confident that in New York State we will be ready and our response will be strong.
Senators, thank you for your interest and support of pandemic flu and public health emergency planning. Clearly, we all have a role to play in making sure the residents of New York State are as safe and healthy as possible.
This concludes my comments, and now I will be more than glad to answer your questions.