AVIAN INFLUENZA: Pandemic Influenza: Progress Made and Challenges Ahead

CDC Congressional Testimony

Committee on Appropriations Subcommittee on Labor, Health and Human Services, Education, and Related Agencies United States Senate

Statement of:
Julie L. Gerberding, M.D., M.P.H.
Director
Centers for Disease Control and Prevention
U.S. Department of Health and Human Services

Mr. Chairman and members of the Subcommittee, I am pleased to be here today to provide an update on cross-cutting preparations the Centers for Disease Control and Prevention (CDC) and our many partners, collaborators, and other organizations are undertaking for the next influenza pandemic. Secretary Michael O. Leavitt, Secretary of the Department of Health and Human Services (HHS), is strongly committed to preparing for a pandemic. An influenza pandemic would have a profound impact on almost every sector of society, both in the United States and globally. I would like to emphasize the importance of this consolidated approach not only within the realm of public health but across all sectors of society in readiness for the next influenza pandemic. CDC is committed to improving the health of our Nation and the world. Our longstanding emphasis on cooperative action has allowed the public health community to accomplish a great deal since I testified before the Subcommittee last January, and much more needs to be done. I will focus my testimony today on three areas: ongoing domestic and international surveillance, other preparedness initiatives in 2006, and examples of CDC actions planned for 2007 and beyond. I will also describe the agency′s progress towards the President′s National Strategy for Pandemic Influenza.

Before continuing my testimony, I would like to thank this Subcommittee and the Congress for providing Fiscal Year 2006 Emergency Supplemental funding for pandemic preparedness.

CDC recognizes the continuing threat of avian influenza A/H5N1 as well as other influenza strains that could evolve into a pandemic, and we are committed to take steps necessary for effective preparedness and response. Work clearly must continue to ensure sustained actions that will minimize the morbidity, mortality, economic burden, and social disruption that an influenza pandemic could cause. To put this imperative into perspective, I′d like to share a few comparisons between 2005 and today.

In January 2005, 10 countries that had reported detection of highly pathogenic avian influenza A (H5N1) viruses in wild birds or domestic poultry to World Organization for Animal Health (OIE) (including both China and the Hong Kong Special Administrative Region of China). By January 22, 2007, 56 countries had reported H5N1 in birds had grown to 56 (including both China and the Hong Kong Special Administrative Region of China). In January 2005, the World Health Organization (WHO) confirmed 47 human cases with 34 fatalities in two countries. As of January 22, 2007, WHO had confirmed 269 human cases with 163 fatalities in 10 countries.

Ongoing International and Domestic Surveillance

One of CDC′s most important roles in protecting the nation′s health is to provide an ongoing assessment of the threat of an influenza pandemic. We collect and disseminate surveillance information for influenza strains circulating throughout the world, including those with a high possibility of evolving into an influenza pandemic. As one of four World Health Organization Global Collaborating Centers for Influenza, CDC is responsible for detecting and reporting predominant influenza strains and coordinating development of annual influenza vaccines for the Northern and Southern Hemispheres.

Our agency is especially focused on monitoring changes in the avian influenza A/H5N1 virus. We are carefully monitoring changes in the H5N1 virus that might allow it to evolve into a strain that could result in a pandemic. Our work in this area is highly collaborative, involving global and regional non-governmental organizations, ministries of health in countries across the world, CDC offices in selected countries, and other United States Government agencies such as Naval Medical Research Units (NAMRU). This extensive surveillance network has made it possible for CDC to closely track the geographic spread of the H5N1 viruses in 2006 and to identify and analyze several subtle changes in the virus. Fortunately, at present, these changes do not appear to have increased the virus′ capability for efficient human-to-human transmission. CDC also has been able to identify changes in the composition of H5N1 virus samples that could affect its susceptibility to antiviral medications. A recent example appeared in an H5N1 virus sample from Egypt, initially indicating a change in susceptibility to oseltamivir, better known as Tamiflu. As WHO has stated, at this time there is no indication that oseltamivir resistance is widespread in Egypt or elsewhere.

Influenza surveillance within the United States is closely linked with seasonal influenza activities. The established domestic surveillance network provides a solid foundation on which CDC and our partners are building the real-time human surveillance that will be vital when an influenza pandemic appears in the United States. We also are working closely with agencies such as the U.S. Geological Survey and the United States Department of Agriculture (USDA) to maintain integrated surveillance of animals infected by avian influenza strains. CDC is cooperating with public and private organizations to monitor migratory wild birds that carry numerous strains of avian influenza. We have strengthened agreements with our neighbors in Canada and Mexico to identify highly pathogenic H5N1 and other potential pandemic strains quickly.

International and domestic surveillance is vital if the United States is to contain viruses that cause influenza pandemics and slow the spread of infection to allow the most time possible for development and dissemination of a pandemic vaccine. If an influenza pandemic expands in the United States, CDC′s surveillance efforts will shift focus to supplying the necessary data to track the extent and severity of infection and inform response and recovery efforts.

Other Preparedness Initiatives in 2006

CDC′s preparedness initiatives can be grouped under the agency′s Health Preparedness Goals. Many of the agency′s accomplishments in 2006 bridge these goals, including the completion and implementation of a comprehensive Pandemic Influenza Operations Plan, an examination by nationally recognized ethicists of ethical issues in the decisions that must be made to achieve preparedness for an influenza pandemic, and the implementation of a cross-cutting Pandemic Influenza Task Force that is focusing on CDC′s responsibilities related to the President′s Pandemic Influenza National Response Plan.

Prevention

In 2006, CDC completed several important preparedness actions related to prevention, in cooperation with parts of the HHS and other organizations.

• CDC played a lead role in most State Influenza Summits coordinated by HHS and has continued follow-up with the States.
• CDC has prepared and disseminated guidance, recommendations and initial funding to 62 States, localities, territories, and tribal nations that are receiving HHS funding for pandemic influenza preparedness. This guidance included templates for operational drills of influenza immunization clinics and table-top exercises for community-based school-closing decision processes as well a model contract for engaging pertinent private-sector entities in receipt, storage and emergency intra-state distribution of antiviral drugs when an influenza pandemic seems imminent.
• To strengthen seasonal vaccination and prepare a foundation for promotion and distribution of a pandemic influenza vaccine upon availability, CDC held two National Vaccine Summits with partners in 2006 and conducted the first National Influenza Vaccination Week.
• CDC completed its Pandemic Influenza Operations Plan in 2006 and began implementing the plan. As part of this initiative, the agency has begun a systematic series of preparedness exercises.
• CDC and other WHO Global Collaborating Reference Laboratories isolated and characterized strains of avian influenza and with this information recommended representative strains for use in avian influenza vaccines.
• CDC laboratories employed reverse genetics methods to rapidly develop safer strains of newly identified avian influenza viruses for use in vaccine production.
• CDC′s 2006 research on the deadly 1918 pandemic influenza increased understanding about the challenges in preventing or minimizing the impact of pandemics.
• As part of United States global cooperation, CDC in collaboration with other parts of HHS, had worked with other agencies to pre-position antiviral regimens overseas to support international containment efforts. This activity is closely coordinated with WHO.

Detection and Reporting

In 2006, CDC made considerable progress in its detection and reporting goals related to pandemic influenza preparedness.

• CDC awarded four contracts to biotechnology companies to develop easy to use rapid diagnostic tests for detecting avian influenza. These tests can diagnose influenza within 30 minutes and will be used at the point of care such as in doctor′s offices, in emergency rooms, or at ports of entry.
• Research accomplishments ranged from development, production and dissemination of new rapid diagnostic tests to development of tests to distinguish H5 viruses from other strains, which now are being used by 113 certified laboratories in the Laboratory Response Network (LRN). These labs have reagents on hand to perform the H5N1 test (assay). Of these, 107 are domestic labs and six are international labs. CDC also conducted extensive research on viral samples to identify changes in the structure of H5N1 subtypes that might indicate greater ability for person-to-person transmission or increased severity of infection.
• To help ensure the prompt identification and containment of people infected by H5N1 and other viruses that could result in an influenza pandemic, CDC and the Council for State and Territorial Epidemiologists (CSTE) continued our cooperative work to make all laboratory-confirmed influenza hospitalizations notifiable. In addition, CSTE recently has recommended that infection with novel influenza viruses be nationally reportable.

Timeliness and Accuracy of Communications

Risk communication planning is critical to pandemic influenza preparedness and response. HHS and CDC are committed to the scientifically validated tenets of outbreak risk communication: comprehensive information shared across diverse audiences, information tailored according to need, and information that is consistent, frank, transparent, and timely.

• CDC developed a comprehensive pandemic influenza risk communication plan based on its nationally recognized risk communications training program. This plan is included in the agency′s Pandemic Influenza Operations Plan and will be modified as needed based in part on scheduled pandemic influenza exercises.
• In 2006, CDC developed preparedness checklists and other practical guidance for targeted groups, including the business community and healthcare facilities.
• CDC has contributed substantial information to the national pandemic preparedness web site, www.pandemicflu.gov, including information, education, or guidance documents.
• The agency also enhanced its speaker′s bureau and hotline to accommodate increased requests for presentations about pandemic influenza preparedness. Since February 2006, the CDC Speaker′s Bureau has recorded as accepted more than 115 presentations to groups in the United States and internationally on pandemic influenza.

Investigation and Control

CDC′s investigation and control efforts focus on decreasing the time needed to identify causes, risk factors, and appropriate interventions for those affected by the threat of pandemic influenza. These efforts include activities that support rapid outbreak response and purchasing and stockpiling of antiviral medications and other materiel.

• Rapid response to international outbreaks has been a part of CDC′s mandate for decades, but recently published work suggesting challenges involved in slowing or containing an influenza pandemic clarifies the importance of such response capabilities. For optimal response, an emerging influenza pandemic outbreak anywhere in the world must be recognized within 1 to 2 weeks and investigated and virologically confirmed within days. An unprecedented and well-coordinated containment effort must be launched in stages in response to pre-planned trigger points, including deployment of dozens of trained teams, public health messages, social isolation measures, movement restriction considerations, treatment of patients, and tracing and prophylaxis of contacts. During an international training meeting in Bangkok, Thailand in July 2006, CDC unveiled a new, one-week standard curriculum to train local rapid response teams throughout the world. This program was developed in collaboration with the University of North Carolina School of Public Health and provides essential response skills to Rapid Response Teams composed of medical doctors, epidemiologists, veterinarians, nurses, laboratorians, communications specialists and other health responders.
• In 2006, CDC awarded a total of 21 new Cooperative Agreements supporting avian and pandemic influenza detection and response to all six WHO regional offices and countries throughout the world, bringing the total number of grantees supported by CDC to 47.
• The agency deployed investigative teams to many countries that experienced H5N1 outbreaks, including Indonesia, Turkey, Azerbaijan, Djibouti, Nigeria, and Sudan. These teams often contributed to investigations coordinated by WHO or requested specifically by ministries of health. Other teams were part of multi-agency U.S. Government initiatives. For example, in Azerbaijan, CDC subject matter experts visited as part of the Department of State visit and advised on outbreak control. In addition, CDC staff that are stationed in China, Thailand, Cambodia, and Laos have participated in investigations.
• CDC also collaborated with USDA and numerous other Federal partners to develop a playbook that systematically addresses scenarios and roles for responding to the introduction of H5N1 and other avian influenza viruses by wild birds and domestic animals.
• CDC developed a comprehensive Global Disease Detection (GDD) strategy and in 2006 expanded its international surveillance, diagnosis, and epidemic investigations, which are integrated with WHO and other international partners.
• In 2006, in collaboration with WHO and other partners, CDC enhanced sharing of influenza virus genetic sequences as part of an international effort to increase information for research into pandemic influenza.
• Last year, CDC significantly increased supplies in the Strategic National Stockpile, including antiviral medications, personal protective equipment, and other vital material, which will be used in the event of a pandemic.
• The agency has worked extensively with sister-agencies, partners, and public groups to develop health guidance specifically for pandemic influenza. This includes development of technical guidance for health-care workers on the use of personal protective equipment.

Response and Recovery

The U.S. healthcare system will be severely stressed by an influenza pandemic. In addition to critical preparation needed to respond successfully to the acute medical care needs of the population, the healthcare system will also need to resume normal services as rapidly as possible. Among its actions, the Pandemic Influenza Task Force in 2006 enhanced planning for recovery of vital public health services.

• CDC has developed, with input from State and local health departments, healthcare partners, and other Federal agencies, guidance to assist healthcare facilities in developing and implementing plans to respond to an influenza pandemic, including guidance on the use of appropriate infection control measures to minimize transmission during patient care.
• Participation in tabletop exercises during the past year has helped facilities identify gaps and improve their readiness to respond and recover after a pandemic, as an integrated part of the overall planning and response efforts of their local and State health departments.

CDC Actions for 2007 and Beyond for Continuing

The following highlights some of the actions in which CDC now is engaged.

1. CDC will continue ongoing activities with State, local, territorial, and tribal nation grantees. These activities will include review and monitoring of preparedness efforts, technical assistance and guidance on exercise programs, analysis of potential gaps in preparedness plans, and promotion of best practices among grantees.
2. A large CDC internal pandemic influenza preparedness exercise is scheduled for January 31 February 1, 2007. Additional exercises that will include other agencies and groups will be scheduled as the year progresses.
3. CDC, building on its successful 2006 National Influenza Vaccination Week, and in collaboration with HHS and others, will make this an annual event for promoting the importance of influenza vaccination.
4. CDC, in partnership with the Council for State and Territorial Epidemiologists (CSTE) is overseeing adaptation of the international Rapid Response curricula for use domestically in each state. CD-ROM and web-based versions of the trainings are in development for use by field staff and other partners as a self-study curriculum.
5. CDC is working with HHS to develop and implement a National Education Campaign for Pandemic Preparedness, which will include a focus on vulnerable populations.
6. CDC will provide training and support to other countries to improve avian and pandemic influenza preparedness and response.
7. CDC laboratories will rapidly characterize avian and other influenza viruses to monitor for emergence of potential pandemic strains and to develop strains for use in vaccine production.
8. CDC will complete the collaborative guidance document on the use of personal protective equipment by the public. CDC also will publish preliminary guidance on community mitigation strategies to educate the public, private sector, and our state and local partners about use of non-pharmaceutical interventions, which will be especially important in the initial months of an influenza pandemic. This guidance will be refined and updated as necessary.
9. CDC continues toward the goal of developing the coordinated quarantine and screening capacity. This will include efforts in a range of areas, including continued strengthening of quarantine stations at major ports of entry, initiatives with border security as part of our discussions with public health counterparts in Mexico and Canada, and addressing possible legal and ethical questions regarding isolation and quarantine measures in communities to impede the spread of viral infection.

Conclusion

Although CDC and its many partners accomplished much for pandemic influenza preparedness and response during 2006, from a public health standpoint much more preparation is needed. CDC greatly appreciates the support of this Subcommittee and others in 2006 and looks forward to working with you to sustain these accomplishments.

Thank you for the opportunity to share this information with you. I am happy to answer any questions.