<DOC>
[107th Congress House Hearings]
[From the U.S. Government Printing Office via GPO Access]
[DOCID: f:76304.wais]


 
  A REVIEW OF FEDERAL BIOTERRORISM PREPAREDNESS PROGRAMS: BUILDING AN 
            EARLY WARNING PUBLIC HEALTH SURVEILLANCE SYSTEM
=======================================================================

                                HEARING

                               before the

                            SUBCOMMITTEE ON
                      OVERSIGHT AND INVESTIGATIONS

                                 of the

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                      ONE HUNDRED SEVENTH CONGRESS

                             FIRST SESSION

                               __________

                            NOVEMBER 1, 2001

                               __________

                           Serial No. 107-71

                               __________

       Printed for the use of the Committee on Energy and Commerce


 Available via the World Wide Web: http://www.access.gpo.gov/congress/
                                 house

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                    COMMITTEE ON ENERGY AND COMMERCE

               W.J. ``BILLY'' TAUZIN, Louisiana, Chairman

MICHAEL BILIRAKIS, Florida           JOHN D. DINGELL, Michigan
JOE BARTON, Texas                    HENRY A. WAXMAN, California
FRED UPTON, Michigan                 EDWARD J. MARKEY, Massachusetts
CLIFF STEARNS, Florida               RALPH M. HALL, Texas
PAUL E. GILLMOR, Ohio                RICK BOUCHER, Virginia
JAMES C. GREENWOOD, Pennsylvania     EDOLPHUS TOWNS, New York
CHRISTOPHER COX, California          FRANK PALLONE, Jr., New Jersey
NATHAN DEAL, Georgia                 SHERROD BROWN, Ohio
STEVE LARGENT, Oklahoma              BART GORDON, Tennessee
RICHARD BURR, North Carolina         PETER DEUTSCH, Florida
ED WHITFIELD, Kentucky               BOBBY L. RUSH, Illinois
GREG GANSKE, Iowa                    ANNA G. ESHOO, California
CHARLIE NORWOOD, Georgia             BART STUPAK, Michigan
BARBARA CUBIN, Wyoming               ELIOT L. ENGEL, New York
JOHN SHIMKUS, Illinois               TOM SAWYER, Ohio
HEATHER WILSON, New Mexico           ALBERT R. WYNN, Maryland
JOHN B. SHADEGG, Arizona             GENE GREEN, Texas
CHARLES ``CHIP'' PICKERING,          KAREN McCARTHY, Missouri
Mississippi                          TED STRICKLAND, Ohio
VITO FOSSELLA, New York              DIANA DeGETTE, Colorado
ROY BLUNT, Missouri                  THOMAS M. BARRETT, Wisconsin
TOM DAVIS, Virginia                  BILL LUTHER, Minnesota
ED BRYANT, Tennessee                 LOIS CAPPS, California
ROBERT L. EHRLICH, Jr., Maryland     MICHAEL F. DOYLE, Pennsylvania
STEVE BUYER, Indiana                 CHRISTOPHER JOHN, Louisiana
GEORGE RADANOVICH, California        JANE HARMAN, California
CHARLES F. BASS, New Hampshire
JOSEPH R. PITTS, Pennsylvania
MARY BONO, California
GREG WALDEN, Oregon
LEE TERRY, Nebraska

                  David V. Marventano, Staff Director

                   James D. Barnette, General Counsel

      Reid P.F. Stuntz, Minority Staff Director and Chief Counsel

                                 ______

              Subcommittee on Oversight and Investigations

               JAMES C. GREENWOOD, Pennsylvania, Chairman

MICHAEL BILIRAKIS, Florida           PETER DEUTSCH, Florida
CLIFF STEARNS, Florida               BART STUPAK, Michigan
PAUL E. GILLMOR, Ohio                TED STRICKLAND, Ohio
STEVE LARGENT, Oklahoma              DIANA DeGETTE, Colorado
RICHARD BURR, North Carolina         CHRISTOPHER JOHN, Louisiana
ED WHITFIELD, Kentucky               BOBBY L. RUSH, Illinois
  Vice Chairman                      JOHN D. DINGELL, Michigan,
CHARLES F. BASS, New Hampshire         (Ex Officio)
W.J. ``BILLY'' TAUZIN, Louisiana
  (Ex Officio)

                                  (ii)







                            C O N T E N T S

                               __________
                                                                   Page

Testimony of:
    Barry, Anita, Director, Communicable Disease Control, Boston 
      Public Health Service......................................    18
    Broome, Claire, Senior Advisor, Integrated Health Information 
      Systems, Office of the Director, Centers for Disease 
      Control and Prevention.....................................    12
    Davidson, Arthur J., Director, Public Health Informatics, 
      Denver Public Health Department............................    23
    Russell, John S., Executive Vice President and General 
      Counsel, Quintiles Transnational...........................    60
    Wagner, Michael M., Director, RODS Laboratory, Center for 
      Biomedical Informatics, University of Pittsburgh...........    48
    Zelicoff, Alan P., Senior Scientist, Center for National 
      Security and Arms Control, Sandia National Laboratories....    54

                                 (iii)

  


  A REVIEW OF FEDERAL BIOTERRORISM PREPAREDNESS PROGRAMS: BUILDING AN 
            EARLY WARNING PUBLIC HEALTH SURVEILLANCE SYSTEM

                              ----------                              


                       THURSDAY, NOVEMBER 1, 2001

                  House of Representatives,
                  Committee on Energy and Commerce,
              Subcommittee on Oversight and Investigations,
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 9:40 a.m., in 
room 2322, Rayburn House Office Building, Hon. James C. 
Greenwood (chairman) presiding.
    Members present: Representatives Greenwood, Stearns, Burr, 
Whitfield, Bass, Tauzin (ex officio), Deutsch, Stupak, 
Strickland, DeGette, Rush, and Dingell (ex officio).
    Also present: Representative Harman.
    Staff present: Tom Dilenge, majority counsel; and Edith 
Holleman, minority counsel.
    Mr. Greenwood. Good morning. This hearing of the Oversight 
and Investigations Subcommittee of the House Energy and 
Commerce Committee will come to order, and the Chair recognizes 
himself for 5 minutes for an opening statement.
    Three weeks ago, this subcommittee held a hearing to 
evaluate the effectiveness of Federal programs designed to 
bolster the preparedness of States and local communities to 
deal with bioterrorist attacks. At that time the second and 
third cases of anthrax infection in Florida had just been 
discovered.
    Several hundred people who worked with those individuals 
were being tested and put on Cipro as a precautionary measure. 
It was still unclear at that time whether the Florida situation 
was an isolated incident or part of some broader criminal or 
terrorist enterprise.
    Since that hearing the anthrax scare has spread and the 
death toll has increased. The numbers infected seem to increase 
daily, as do the number of locations with anthrax detected in 
them.
    An anxious Nation is left to wonder if in Emerson's words, 
``Things are in the saddle and ride mankind.'' People are 
afraid and some with good reason. Unlike the 1930's, we have 
more to fear than fear itself. An unscrupulous enemy, with 
access to the most insidious means of human destruction, and a 
demonstrated willingness to use them, is in fact a fearful 
thing.
    But what is truly worrying about the recent outbreak is the 
possibility that this is a prelude to a worse attack, and that 
this effort was designed more to test our capabilities and 
probe our weaknesses than to cause sustained damage.
    Surely there can be little doubt that this mail borne 
anthrax attack was well coordinated and is in fact this 
Nation's first real example of bioterrorism at work. All the 
more reason that this Nation must promptly improve its public 
health surveillance activities, which is the focus of today's 
hearing.
    Sadly for thousands of Americans, the 1993 attack on the 
World Trade Center did not serve as a wakeup call on the need 
to better protect our critical physical infrastructure. We 
cannot afford to let this happen to our critical public health 
system.
    In this new kind of war where terror is the enemy's chief 
aim, the most potent weapons may very well be biological 
agents, and increasingly the battlefront will not be in some 
far off land, but here at home. The anthrax outbreak is our 
fire bell in the night, and we may not get another warning.
    And a very real fear we now confront is the one H.G. Wells 
wrote of in 1920 when he observed that human history becomes 
more and more a race between education and catastrophe.
    This is a race that we cannot afford to lose, nor will we. 
America has always risen to meet the challenge, and our public 
health system, while in need of repair, has more than an 
adequate foundation to begin to wage a successful war at home 
against our enemies, and the diseases that they may seek to 
inflict on us.
    But to do that more of our Nation's leadership, and the 
President, and Congress, must be galvanized by the dangers we 
face and must commit themselves to leading the effort to fight 
this new kind of war in a new kind of way.
    This is about much more than appropriating new money, 
though money is needed. To be successful, we must harness the 
creative genius of the American people in the public sector, 
and in the private sector, and in academia.
    Our traditional public health surveillance system, which in 
many parts of this country still relies on doctors mailing in 
post cards to their local public health departments is too 
limited with regard to what is reported, and too slow to be 
effective, to late in the patient evaluation process, and too 
incomplete to meet our country's emerging needs in this area.
    It is the equivalent of relying on the pony express in the 
age of the worldwide web. Some bioterrorist attacks, like 
sending anthrax powder in the mail, tend to be readily 
apparent, at least to those who open the laced mail.
    Other attacks, such as pumping bacteria or viruses through 
ventilation systems, are more covert, and may not be detected 
until exposed individuals get sick and go to their doctors or 
local hospitals.
    The goal must be to detect these covert releases as soon as 
practicable. The successful early detection regime will enable 
us to identify the exposed population sooner, and get those 
individuals treatment faster.
    Early detection will also allow us to contain the spread of 
disease, which while less important with non-contagious 
diseases, such as anthrax, will prove critical if a terrorist's 
agents were a highly contagious disease, such as smallpox.
    And even after initial detection, a good surveillance 
system will enable our public health officials to more 
effectively manage such outbreaks and quickly intervene with 
appropriate care and guidance.
    While astute and well-trained clinicians will always be the 
bedrock of our health care surveillance system, we need to 
ensure that recent advances in medical infomatics and improved 
health care technology supplement our human intelligence 
system.
    As we will learn in today's hearing, our public 
institutions and our private sector have already begun to make 
substantial progress in developing early warning systems to 
detect outbreaks of bioterrorism, and in developing rapid 
responses to outbreaks.
    This is essential if we are going to protect our Nation and 
our people. We will also hear today about the Federal 
Government's promising, but so far quite limited, efforts to 
improve both the traditional surveillance system and to fund 
pilot projects at the State and local levels to develop and 
test more advanced, more proactive, and decidedly more 
unconventional surveillance systems.
    I have been concerned, however, that our Federal health 
officials have done little to oversee and to better direct such 
activities. In particular, it seems like we lack a national 
strategic plan to test and evaluate these advanced systems, and 
are presently unable to provide clear guidance to State and 
local public health officials as to what we believe a good 
surveillance system would look like.
    The Director of the Federal Centers for Disease Control and 
Prevention recently initiated a working group to review the 
potential of some of the new surveillance techniques that are 
being or already have been developed, and I welcome that 
initiative.
    I look forward to the testimony of all of our witnesses 
today, and I will now recognize the ranking member, Mr. 
Deutsch, for 5 minutes for his opening statement.
    Mr. Deutsch. Thank you, Mr. Chairman. Thank you for having 
this hearing. As I recall this was a hearing that was 
interestingly scheduled before the events of September 11, and 
the work of this subcommittee on this issue has been something 
within our jurisdiction literally from the creation of the CDC.
    I think though since September 11, not has just the work of 
this committee changed, but obviously the work of the Congress, 
and obviously the work of the country has changed.
    And my hope is that as we have talked outside of the 
hearing room, my hope is that we really broaden what we are 
doing, because I think that our jurisdiction is as critical as 
any jurisdiction in the Congress right now.
    I mean, we have the legal responsibility to work on public 
health issues, and work on our jurisdiction regarding the CDC, 
and HHS has responsibility for public health, and I think we 
need to take that job very seriously as we are.
    But I think some of the focus needs to be ongoing in real 
time, and the real time issues that I would focus on as we have 
discussed is right now the HHS is working on trying to develop 
250 million additional smallpox vaccines.
    That is an issue which I don't believe there is a more 
critical issue that the Federal Government is working on today. 
And I know that everyone involved at HHS is incredibly sincere 
and incredibly bright, and incredibly hardworking in the 
efforts to successfully complete that endeavor.
    But I think it is critical that we engage our resources 
working with them toward the same goal of trying to acquire 
those vaccines in as quick a real time basis as possible. And 
we can talk, and we will have some testimony about the ability 
of preparing the systems, in terms of what they can do down the 
road, and what they might be able to more.
    But I think there are some potentially cataclysmic events 
that I will work and help prevent, and I think that is really 
the focus, not just of the subcommittee, but I see the chairman 
of our full committee here as well, and I know that next week 
we have a briefing that both of our staffs are working on 
together toward that goal.
    So I welcome the testimony that we are expecting to have 
today, but I urge us, and I am going to focus even some of 
those questions regarding some of the more immediate 
potentially relevant issues, and again not just smallpox, which 
I think is in fact the more relevant, but as they also relate 
to real time issues on anthrax, and real time potential issues 
on the plague. So I look forward to your testimony. Thank you.
    Mr. Greenwood. The Chair thanks the gentlemen from Florida, 
and looks forward to his specific recommendations in those 
regards. The Chair recognizes the chairman of the full 
committee, Mr. Tauzin, for an opening statement.
    Chairman Tauzin. Thank you, Mr. Chairman, not only for 
today's hearing, but for having the foresight even before 
September 11 to schedule this hearing, and to continue the work 
of our committee in this important area of bioterrorism.
    And I want to particularly thank you because today's 
hearing, as Mr. Deutsch points out, is just the beginning of a 
process, in which our full committee has been now recently 
charged by the leadership to produce a major terrorism/
bioterrorism package for the U.S. Congress to consider before 
we leave here this November, perhaps December.
    The Health Department has already sent to us a food safety 
package that we are now working with Mr. Dingell and his own 
version of food safety, to see if we can come up with a common 
ground document that will enhance dramatically the inspection 
of food at America's borders as part of our oncoming efforts, 
but nevertheless now an emergency need of this Congress and of 
this Nation.
    It is contemplated that now with the events of this anthrax 
attack on American citizens, and we have just seen the fourth 
victim in New York die, that while human toll so far has been 
limited, the havoc brought by these attacks has been rather 
broad.
    And the damage done to public confidence in the mail, and 
to the capacity of the CDC, and our health response systems to 
deal with these, is seriously in question. The bioterrorism 
package that we will design will hopefully answer those 
questions, and begin to move the CDC and the health 
department--and by the way, the EPA, which is now in charge of 
the cleanup of these buildings here in the Nation's capital--
into a position where all of those agencies working in 
conjunction with State and local government agencies, including 
the National Guard, the Veterans Hospitals, and other great 
institutions of that nature, will be more thoroughly 
coordinated.
    Today we will focus on how technology can help us identify 
and react quickly to the evidence of an epidemic or 
bioterrorism attack, and in the process this committee will 
engage in next week, we will look at the CDC more precisely and 
at the Health Department's capacity to respond more precisely.
    We will be looking at such questions as how much and how 
extensive should be our drug stockpile to react to attacks, or 
to the spread of infectious or biological diseases. We will be 
looking at how well we currently incentivize vaccine research, 
and whether or not we ought to do more to encourage not only 
the production, but the research and development of new 
vaccines to protect our country against these new forms of 
attack.
    We will be looking at whether or not the infrastructure of 
the CDC is sound, or whether or not some of the systems of 
communications within the CDC are adequate. We know that one-
third of all the labs and medical facilities in this country 
are not on the emergency alert system of the CDC. They need to 
be connected.
    And every lab, and every medical facility, needs to be part 
of a medical alert when it goes out. We want to look at how 
well we are currently educating hospitals, doctors, and nurses, 
in the special needs of bioterrorism attacks and infectious 
disease spread.
    We are going to look at whether we are doing a good enough 
job in public education to make sure that its citizens 
understand and can deal with some of these threats and 
understand the nature of these threats so that they don't have 
to be afraid. They can deal with them without fear.
    We are going to be looking as I said at EPA and its 
authority to respond quickly and to clean up properly when 
buildings or systems like our mail systems become contaminated.
    We were very blessed to have the Marine Corps response team 
available to us here in Washington when our own buildings were 
contaminated, but we need to make sure that all of that is 
organized and we have proper lines of authority, and proper 
funding for these agencies when they are called upon to act.
    We know that we have four major medical response teams in 
this country established in the four district regions of our 
country. How well are they organized, and how well are they 
prepared to respond if in fact a medical alert goes out to our 
country.
    We are going to be looking at all of that next week and 
through the next 8 to 10 days, and under the instructions of 
the leadership our Energy and Commerce Committee will be 
producing the major package on bioterrorism for the House to 
consider.
    So, Mr. Chairman, the work that you do today examining how 
technology and how improved communications infrastructures can 
assist in our Nation dealing with these problems is a critical 
step.
    And most importantly, I want to thank you for being awake 
at the switch when so many others were asleep, and working on 
this problem even before September 11. Our work now is urgent. 
Our work now is extraordinarily important and the 
responsibilities of our committee are deeply felt.
    Mr. Deutsch, I want to assure you, and I see that Mr. 
Dingell has arrived, and all the members on the other side, 
that in the next 8 or 10 days we are going to have to all be 
working in locked step, and we are going to work as we always 
do in a close bipartisan fashion for a good piece of 
legislation for the floor. This is the first step, Mr. 
Chairman, and I thank you for it.
    Mr. Greenwood. The Chair thanks the chairman of the full 
committee, and notes the diligence with which he attends all of 
our hearings, as well as the other five; I don't know how you 
manage to do it. The Chair recognizes the ranking member of the 
full committee, the gentleman from Michigan, Mr. Dingell, for 5 
minutes for an opening statement.
    Mr. Dingell. Mr. Chairman, thank you for your courtesy, and 
thank you for holding this very important and informative 
hearing. Effective disease surveillance is an essential part of 
the successful operation to protect the public health system at 
the local, State and national levels, whether we are talking 
about disease control or bioterrorism attacks.
    The public health system, which has been functioning for 
more than a century in this country, is grounded in the skills 
and dedicated skills of medical personnel who identify unusual 
symptoms and diseases and then alert the public health 
departments of the Federal, State, and local units of 
government.
    Their information allows the public health system to 
identify and deal with outbreaks of things like salmonella, E. 
coli, food poisoning, flu, HIV, hepatitis, and tuberculosis 
epidemics.
    Just like politics, however, disease surveillance is local. 
Sick people go to doctors or an emergency room and not to the 
Centers for Disease Control and Prevention, or government 
contractors. Doctors go to their local health departments for 
help, and not the Federal Government.
    And that is where the emphasis of our effort must be. Many 
people, especially those who stand to benefit from lucrative 
government projects, say this old system no longer works. A 
Florida State epidemiologist, who talked to our staff, but who 
was not able to be here, vehemently denies that position.
    The traditional system has functioned exactly as it should 
have when anthrax appeared in Florida last month, and an alert 
doctor saw something in Mr. Stevens that looked like anthrax. 
He immediately alerted the State health department.
    The State lab identified anthrax from a blood sample, and 
this became the indicator case that alerted the entire national 
public health system. Fancy syndromic surveillance systems 
would never have alerted the health department to anthrax 
because there was only one case there at that time.
    Hospitals also do not need computers to tell them that 
something unusual is going on if a thousand people show up in 
the emergency room with plague-like symptoms. So we must be 
very careful about developing high-powered surveillance systems 
that provide daily reams of information that cannot be 
analyzed, are not useful, and in the words of one public health 
official, ``wear people out.''
    They will likely cost much, and probably confer little 
benefit. A good public health disease surveillance system is 
not one that sits on the shelf sprewing out endless reams of 
useless information while we wait for another bioterrorism 
attack.
    It is one that is an integral part of a health department's 
day to day operations tracking communicable diseases and 
outbreaks of other diseases, and educating the medical 
establishment and the public as to health risks.
    A good system puts most of the investment into State and 
local systems, and not into inside the Beltway projects that do 
not meet the needs or realities of existing structures.
    That said, however, there are many improvements that can be 
made to our long-neglected public health system to make it more 
effective and timely. It needs quicker electronic reporting 
that link laboratories, hospitals, and medical providers to the 
Public Health Department.
    It needs interactive systems so that alerts and treatment 
information can be sent from the health department back to the 
providers. It needs better trained medical providers and lab 
personnel, and it needs more epidemiologists.
    It needs more staff so that the public health departments 
can be staffed 24 hours a day for a quick response. It needs 
money to upgrade laboratory facilities and to train lab 
personnel.
    This morning, we will hear from public health officials who 
have taken relatively small amounts of money and are using them 
to establish electronic systems to speed up disease 
surveillance, to rebuild their labs, and to train medical 
personnel.
    This is to be commended. Mr. Chairman, we in the Congress 
need to encourage these kinds of efforts and to fund them at a 
higher level than we do today. We can also no longer put off 
rebuilding our public health system. It has fallen into sad 
states of disarray because of neglect by the Congress and other 
agencies responsible for that kind of undertaking.
    This is the first and best defense we could have against 
bioterrorism. I heard the comments of our Chairman just a 
minute or 2 ago, and I am pleased to hear his comments and to 
know that we on this side will be very happy to work with him 
and with the leadership to come up with a meaningful, 
effective, useful, and intelligent program, legislative in 
character, to deal with the problems of bioterrorism. I thank 
you for your courtesy, Mr. Chairman.
    Mr. Greenwood. The Chair thanks the gentleman and 
recognizes the gentleman from Florida, Mr. Stearns, for 5 
minutes for his opening statement.
    Mr. Stearns. Good morning, and thank you, Mr. Chairman. 
Again, like my colleagues, we appreciate holding this hearing 
and the fact that you were going to have this hearing well 
before September 11 is a commendation to you and to your staff.
    And I believe that while it is essential and worthwhile to 
hear from the public health department officials, it is also a 
great opportunity for all of us to hear from those in the 
private sector, in academic health, and in the Department of 
Energy contracted laboratories.
    My colleagues, these witnesses have valuable real world 
experiences in disease surveillance, and now more than ever is 
the time to learn from them. I am particularly interested to 
hear how we might employ data base systems to report outbreaks, 
thereby injecting automation in a system that now is manual, 
voluntary, and not highly complied with.
    As the chairman has mentioned there is a problem that the 
terribly low compliance rate with reporting some diseases. We 
have got to correct that. The system which relies on ``passive 
surveillance'' by doctors often has been criticized as too 
slow, and has been plagued by poor compliance from overworked 
health care personnel.
    And as the chairman of our committee has mentioned, we need 
to correct that. I also read in the Washington Post this 
morning that Dr. Zelicoff, who is one of our witnesses, a 
senior scientist with the Center for National Security and Arms 
Control, Sandia National Laboratories, in Albuquerque, New 
Mexico, he said, Mr. Chairman, ``Investigators need to begin to 
focus less on the microbiology than the physics which is 
impressive.''
    He goes on to say that ``We didn't think that anybody could 
come up with the appropriate coatings for anthrax spores to 
make them float through the air with the greatest of ease. 
Exposing 28 people with a single opened envelope is no mean 
trick.''
    So I think he has pointed out and pointed to all of us a 
nuance of this debate that we have to understand as to how this 
could be accomplished. The tentacles of this anthrax menace are 
spreading from the Postal Service and locations in the Federal 
Government, to Indiana, Kansas City, Missouri, a hospital in 
Manhattan, and the British Embassy in Beijing, recently.
    What more devastation might lurk from anthrax or other 
biological agents. Who knows. These are very chilling fears 
that Americans have. We must be prepared and so I think this 
hearing is crucial and timely.
    And I would be anxious to hear from the other witnesses how 
we can get higher compliance and so we can improve the system 
so that it is faster and more automated, and more universal, 
and I thank you, Mr. Chairman.
    Mr. Greenwood. The Chair thanks the gentleman from Florida 
for his opening statement, and recognizes the gentleman from 
Michigan, Mr. Stupak, for his opening statement.
    Mr. Stupak. Thank you, Mr. Chairman, and thank you for 
holding this timely and important hearing on Federal 
bioterrorism. As we sit here today the reality of bioterrorism 
has hit home for many Americans and us here on Capitol Hill.
    And the reality is that we are not prepared. Today's 
hearing focuses on how best to prepare our local communities to 
monitor and integrate a public health surveillance system.
    The logistical elements of coordinating our efforts are 
staggering to say the least, but necessary because local 
monitoring is where the epidemics and major health problems 
first get noticed.
    Effective communications, means establishing links among 
law enforcement, local health departments, clinics, and 
hospitals, so that the critical data in the emergency situation 
can identify, contain, and respond to an emergency efficiently.
    However, we lack the personnel and the resources to do 
this. I remain highly interested in just how we aim to have a 
completely integrated public health system in this country. The 
systems that we will discuss today seem like good ideas, but 
again good ideas are not necessarily a mark of success.
    We need a proactive health surveillance system, and not 
systems where data and information lie untouched. I look 
forward to the testimony of today's witnesses to see how we can 
best accomplish these goals without unnecessarily burdening the 
front lines of our health care system; that is, our providers 
and our doctors.
    Thank you, Mr. Chairman, and I will yield back the balance 
of my time as I look forward to hearing from our witnesses.
    Mr. Greenwood. The Chair thanks the gentleman, and 
recognizes the gentleman from Kentucky, Mr. Whitfield, for 5 
minutes for his opening statement.
    Mr. Whitfield. Mr. Chairman, thank you very much. This 
obviously is a timely hearing, and I am not going to make a 
long statement, except to say that I am looking forward to the 
testimony on the electronic surveillance information system.
    I know that there have been pilot projects in some States 
with a desire to expand that, and I do look forward to that 
testimony, particularly on that issue as well as others.
    Mr. Greenwood. The Chair thanks the gentleman, and 
recognizes the gentlelady from Colorado, Ms. DeGette, for her 
opening statement for 3 minutes.
    Ms. DeGette. Thank you, Mr. Chairman, and I would 
particularly like to welcome Dr. Davidson, who is with us here 
today, and who I only found out was appearing here last night.
    And so I would particularly like to welcome him. I met with 
Dr. Davidson and a number of representatives of the Denver 
Health Departments team that is charged with some kind of early 
response to bioterrorism.
    And I must say, and not to be a local bragger, but we have 
a fantastic program in Denver and Colorado designed to 
coordinate agency responses with physician responses, and I 
know that the committee will love hearing about it today.
    I am very proud of it, but I also know that to have any 
kind of effective network that it has to be a national network, 
and I know that we are looking forward to hearing about that 
today.
    We had a hearing on October 10 in this subcommittee about 
the threat of a biological or chemical attack, and at that time 
Americans feared that post-September 11 that a biological or 
chemical assault was imminent. Well, guess what. Here we are 
today.
    At the time of October 10, bioterrorism experts pointed out 
the difficulties of pulling off such an attack. They said that 
the No. 1 obstacle is disseminating the agent, and pointed to 
the attempts and relative failures made by terrorists across 
the world as an illustration of the difficulty.
    Unfortunately, what most Americans feared back then has now 
come to pass. The attack that we are in the midst of appears to 
be small in scale, but it is clear that we must be better 
prepared in the event of a larger, more widespread assault.
    Issues surrounding biological weaponry, and how various 
agents can be spread, and their effect on the human anatomy, 
for example, need greater understanding and clarity. We had an 
exercise about a year ago.
    Some of you have probably seen Dr. Davidson and Dr. Steve 
Cantrell from the Denver Health Department talking about 
Operation Top Off, where we actually had an exercise involving 
the plague.
    And what was really disturbing in that exercise is how many 
thousands of people were affected by it, and equally disturbing 
is because of the movements in our society today, how almost 
immediately the plague in this exercise was spread throughout 
the United States and even around the world.
    And so early response and coordination is clearly the key, 
and is what we need to work at. There are gaps at the State and 
local level because of a lack of coordination at the Federal 
level.
    For example, the September 2001 General Accounting Office 
report on bioterrorism, Federal research and preparedness 
activities, points out that at the Federal level alone several 
agencies share responsibility for coordinating various 
functions, which limits accountability and hinders unity of 
effort.
    What is even more amazing to me is some of these agencies 
that are dealing with emergency preparedness don't even have e-
mail capability, and so they cannot coordinate with their 
fellow agencies.
    I look forward to hearing from each of the panelists. I 
think that this is an urgent need that we need to address 
before we see widespread bioterrorism or chemical terrorism, 
and not after, and I know that everybody can contribute to this 
effort, and I yield back.
    Mr. Greenwood. The Chair thanks the gentlelady, and with 
unanimous consent, would recognize the gentlelady, Ms. Harman, 
from California, who while not a member of this subcommittee, 
is a member of the full committee, and a very active 
participant as a member of the Intelligence Committee in all of 
these issues, and she is recognized for 3 minutes for an 
opening statement.
    Ms. Harman. Thank you, Mr. Chairman, and I appreciate the 
opportunity to attend this meeting and participate even as an 
outsider in what I think are the most important issues that our 
country faces.
    This hearing, as I understand it, will highlight the most 
important functions of our public health system in confronting 
and combating terrorism. Disease surveillance, and outbreak 
detection, as we are now learning are the greatest challenges 
of our terrorism response. This is the foundation of all other 
health consequence management actions by doctors and government 
officials.
    Much of the language that we use in discussing health 
security is the same as in discussing national security. 
Syndromic surveillance, epidemiological intelligence. This link 
just highlights what more and more people are coming to 
realize--that our public health system is an essential part of 
our homeland defense strategy.
    I am particularly glad that we will hear from infomatics 
experts on how to upgrade our surveillance system. I have long 
advocated the need to eliminate barriers of communication 
between our intelligence and defense agencies, and for 
upgrading our intelligence technologies for the digital era. In 
fact, I often say that we have analog capacity to confront a 
digital threat. Our public health system must have integrated, 
advanced, digital communications systems so it can respond 
quickly and effectively to the bioterrorist threat and disease 
outbreaks.
    Only yesterday, Mr. Chairman, some of us who visited the 
Center for Disease Control last week introduced a bill to 
accelerate $300 million in infrastructure investments in a new 
infectious disease building at the CDC.
    This new facility is critical to our surveillance effort, 
and I would hope that all members of the subcommittee, and in 
fact the full Commerce Committee, will get behind the Lender-
Harman bill.
    I also hope, Mr. Chairman, that as we develop the 
bioterrorism package that you and Chairman Tauzin talked about, 
we might consider this bill as part of the package. It may seem 
strange to think that a building is a critical part of a 
bioterrorism effort. But this building will conduct the 
critical cutting edge research and design the strategies to 
confront the threat, and as we think about moving forward as 
you say in real time to our ability to respond, I think it 
relies on three things.
    One, talented people; two, technology that integrates all 
aspects of the response, starting with understanding what is 
going on out there, and who is coming to our hospitals; and, 
three, having the infrastructure to house the people in that 
technology in a safe and secure fashion.
    So I thank you for letting me participate, and I am very 
eager to hear these witnesses. I yield back.
    Mr. Greenwood. The Chair thanks the gentlelady, and notes 
or appreciates the reference with regard to the CDC 
infrastructure. In fact, if the schedule permits, some of the 
members of this committee will be flying to Atlanta tomorrow to 
visit the CDC.
    Without objection, the opening statements of any other 
members not present will be entered into the record.
    [Additional statement submitted for the record follows:]
   Prepared Statement of Hon. Michael Bilirakis, a Representative in 
                   Congress from the State of Florida
    Thank you, Chairman Greenwood, for holding this important hearing 
today. The Oversight and Investigation Subcommittee's hearings on 
bioterrorism have been instrumental in assessing the needs of our 
nation in the event of a bioterrorist attack. In particular, these 
hearings have informed the bipartisan process that Chairman Tauzin, 
Ranking Member Dingell, Representative Brown and myself have been 
engaged in to develop new comprehensive and appropriate legislative 
authorities that will protect us from a bioterrorist event.
    Since the horrific events of September 11th, the United States has 
been engaged in a war on terrorists who threaten our way of life. Our 
thoughts and prayers are with those whose lives have been forever 
altered by the evilness of terrorism. Unfortunately, the weapons of 
terrorism are not limited to hijacked airplanes and bombs, but also 
biological agents. Through these hearings and our legislation the 
Energy and Commerce Committee is taking the lead to ensure that our 
nation can tackle this very difficult issue.
    I share the concerns of many Americans who are worried about 
possible bioterrorism attacks such as anthrax exposure and outbreaks of 
smallpox. There recently have been several cases of anthrax exposure 
through the postal mail which have not only complicated the mail 
delivery process, but have caused all Americans to fear for the health 
and well-being of their families.
    An outbreak of smallpox is another potential threat. The United 
States currently maintains national smallpox vaccine stocks sufficient 
to immunize 6 to 7 million people. Efforts are being undertaken to 
expand this reserve so that more Americans can be protected from the 
threat of smallpox.
    Cases of anthrax exposure can be treated and infection can be 
prevented through antibiotics. Great quantities of antibiotics for 
anthrax and smallpox vaccines are being stockpiled by the Centers for 
Disease Control and Prevention (CDC) in the event of additional 
biological attacks. We must ensure that the United States has a 
sufficient stockpile of vaccines and antibiotics, and that these 
medications are securely protected. We must also make certain that our 
public health infrastructure can detect disease outbreaks that may 
represent a bioterrorism attack.
    This is a time for all of us to pull together as Americans. I 
personally thank and honor those who are on the front lines fighting 
this war. The United States is a great country, and we are all blessed 
to enjoy our freedoms.
    Again, thank you Chairman for holding this important hearing.

    Mr. Greenwood. And with that, the Chair welcomes the first 
panel of witnesses. And they are Dr. Claire Broome, who is the 
Senior Advisor of Integrated Health Information Systems, Office 
of the Director, Centers for Disease Control and Prevention, in 
Atlanta.
    And Dr. Anita Barry, Director, Communicable Disease 
Control, of the Boston Public Health Service; and Dr. Arthur J. 
Davidson, Director, Public Health Informatics, Denver Public 
Health Department.
    I assume that each of you have been advised that this is an 
investigative hearing and it is the practice of this committee 
to take testimony under oath. And so I should ask if any of you 
have any objections to offering your testimony under oath.
    [No response.]
    Mr. Greenwood. Seeing no such objections, I would advise 
you that under the rules of the House and the rules of the 
committee that you are entitled to be advised by counsel. Do 
any of you care to be advised by counsel today?
    [No response.]
    Mr. Greenwood. In that case, if you would please rise and 
raise your right hand, I will swear you in.
    [Witnesses sworn.]
    Mr. Greenwood. You are now under oath, and we will turn to 
Dr. Broome first, and you are recognized for 5 minutes for your 
testimony. Thank you for being with us.

 TESTIMONY OF CLAIRE BROOME, SENIOR ADVISOR, INTEGRATED HEALTH 
   INFORMATION SYSTEMS, OFFICE OF THE DIRECTOR, CENTERS FOR 
    DISEASE CONTROL AND PREVENTION; ANITA BARRY, DIRECTOR, 
COMMUNICABLE DISEASE CONTROL, BOSTON PUBLIC HEALTH SERVICE; AND 
ARTHUR J. DAVIDSON, DIRECTOR, PUBLIC HEALTH INFORMATICS, DENVER 
                    PUBLIC HEALTH DEPARTMENT

    Ms. Broome. Good morning, Mr. Chairman, and members of the 
subcommittee. Thank you for the invitation to discuss CDC's 
public health surveillance activities. As the events of the 
last month have shown, and as the subcommittee has so 
eloquently described, public health surveillance is a crucial 
monitoring function for CDC, its partners, and the country.
    Ongoing data collection activities help us detect threats 
to the health of the public in time to prevent the further 
spread of disease. Usually the original source of information 
is the health care provider.
    For example, the Florida physician's ability to recognize a 
suspected case of anthrax and his role in rapidly reporting it 
to the local health department, was critical to our original 
recognition of the current bioterrorist events.
    There is no substitute for this heightened awareness for 
diagnosis of conditions of public health importance by doctors. 
They are the front lines, and they need to be aware, and they 
need to know who to notify in the local health department, the 
State health department, and the CDC.
    We work with our public health partners to define 
conditions that should be reported to public health 
departments. Health Departments then work with their local 
partners in the health care system to be sure that they have 
the information needed.
    You have received copies of an October 19, 2001 issue of 
our MMWR, recognition of illness associated with the 
intentional release of a biologic agent. I think this is a 
concrete example of the kind of information that we are 
constantly distributing to our partners to ensure that they 
have the latest information.
    Of course, this information also goes out electronically. 
If a case of illness is particularly unusual or severe, such as 
a case of anthrax or rabies, the provider will call the local 
health department immediately.
    However, routine public health surveillance, the reporting 
is still done largely by paper or fax. This largely paper based 
system is burdensome both to providers and health departments, 
and therefore reports are often incomplete and not timely.
    I have discussed the role that surveillance plays in early 
detection, but surveillance data are also crucial for the 
public health response. Surveillance data helps us to determine 
where cases are occurring, and where they are not occurring, so 
we can target the response appropriately.
    It tells us when cases are occurring. Are they increasing, 
or are they decreasing. It also helps us to take our laboratory 
test results and match them with the case information so that 
we can track down the source and define areas at risk.
    Such information is vital to directing our investigation 
and control efforts, but it requires a well designed system to 
rapidly input and analyze the voluminous data required, such as 
the thousands of swabs tested for anthrax in the current 
investigations.
    We also recognize the need to take advantage of recent 
information technology advances to bring our surveillance 
systems into the 21st century, and I would like to describe a 
little bit about our new system that has been developed based 
on infomatics principles.
    Several years ago we initiated the development of the 
national electronic disease surveillance system, NEDSS, a web-
based surveillance system for use at State and local levels. 
The goal of NEDSS is electronic real time reporting of 
information for public health action.
    NEDSS includes direct electronic linkages with the health 
care system. For example, information about relevant diagnostic 
tests can be shared electronically with public health as soon 
as a clinical laboratory receives a specimen.
    For example, requesting testing for anthrax.
    NEDSS emphasizes national standards, and using national 
standards for data content, security, and information 
technology architecture. As we build NEDSS, we are ensuring 
that the data standards we use are compatible with the leading 
standards for health care systems, so the public health can 
receive data electronically from the health care delivery 
systems with less burden on data providers.
    The reliance on de facto industry standards for information 
technology means that NEDSS can incorporate sophisticated 
commercial products for security, for analysis, for mapping. 
This is particularly critical for guiding the public health 
response to an epidemic.
    Standards also mean that systems can inter-operate between 
States so we can detect problems occurring in multiple 
locations. The CDC has worked with our State and local partners 
on the development of NEDSS. We have provided funding and 
support to all 50 States for activities related to NEDSS 
planning and development.
    A NEDSS based system that incorporates the standards and 
functions mentioned will be deployed in at least 20 States 
during 2002. This project is critical for ensuring our ability 
to capture data efficiently, electronically, and to use it 
effectively for public health response.
    And a public health surveillance system that spans the 
Nation will be essential to detect threats to the public, 
wherever they might occur and whatever they might be. 
Recognizing the need for immediately increased capacity while 
NEDSS is implemented, CDC and its public health partners 
initiated various activities to improve their ability to detect 
events of importance.
    For example, with the first CDC funding for countering 
bioterrorist activities, many State health departments were 
able to purchase the most advanced pattern recognition analytic 
capacity available today, a trained human being.
    We funded States to hire epidemiologists, whose duties 
included coordinating bioterrorism surveillance, informing 
health care providers of what to look for, and who to contact 
if something suspicious turned up.
    CDC also funded eight States for special surveillance 
projects, and projects looked at the utility of possible early 
warning systems, such as emergency medical systems, 911 calls, 
hospital emissions, emergency department visits, absenteeism 
rates, pharmacy data.
    After September 11, these systems were explicitly called on 
to provide heightened surveillance information. CDC is 
undertaking a critical review of these activities to identify 
the most useful and practical approaches that may be 
implemented on a national basis.
    Key questions to address include how rapidly are data 
available for analysis; can the systems identify true outbreaks 
in the noise of ongoing illness; what effort to enter data is 
required from already busy health providers; can the systems be 
used in geographic areas beyond those where they were 
developed.
    In addition, CDC has established networks of clinicians, 
infectious disease specialists, travel medicine specialists, 
emergency department physicians, whose functions are to serve 
as early warning systems for public health by providing 
information about unusual cases encountered in the clinical 
practice of their members.
    In conclusion, our public health surveillance systems 
provide a critical piece of the public health infrastructure 
for recognizing and controlling deliberate bioterrorist 
threats, as well as naturally occurring new or re-emerging 
infectious diseases.
    We have made substantial progress to date in enhancing the 
Nation's capability to detect and respond to problems that 
threaten the public's health. These cross-cutting efforts to 
build the surveillance infrastructure will be useful to detect 
any problem, and not just potential bioterrorist events.
    The ongoing use of this surveillance capacity will assure 
that it is familiar and functional should bioterrorist events 
continue to occur. A strong and flexible public health 
infrastructure is the best defense against any disease 
outbreak. Thank you very much for your attention. I will be 
happy to answer any questions you may have.
    [The prepared statement of Claire Broome follows:]
 Prepared Statement of Claire Broome, Senior Advisor to the Director, 
 Centers for Disease Control and Prevention, Department of Health and 
                             Human Services
    Good morning, Mr. Chairman and Members of the Subcommittee. I am 
Dr. Claire Broome, Senior Advisor to the Director for Integrated Health 
Information Systems at the Centers for Disease Control and Prevention 
(CDC). Thank you for the invitation to update you on CDC's public 
health surveillance activities. I will describe the function of our 
current surveillance systems, update you on recent efforts to build 
surveillance capacity in state and local health departments, and 
discuss the status of the National Electronic Disease Surveillance 
System.
    As the nation's disease prevention and control agency, CDC has the 
responsibility on behalf of the Department of Health and Human Services 
(HHS) to provide national leadership in the public health and medical 
communities to detect, diagnose, respond to, and prevent illnesses, 
including those that occur as a result of a deliberate release of 
biological agents. This task is an integral part of CDC's overall 
mission to monitor and protect the health of the U.S. population.
    Much has been in the news lately about the disease detective 
function of CDC and its epidemiologists, including Epidemic 
Intelligence Service Officers. What has not been often emphasized is 
the need for continued watchfulness to first detect problems that our 
disease detectives then investigate. We refer to this function--this 
constant state of alert--as public health surveillance.
    Public health surveillance is a crucial monitoring function for CDC 
and its partners. It is these ongoing data collection activities that 
help us detect threats to the health of the public. Without our public 
health surveillance systems, we might not identify outbreaks or other 
important problems in time to prevent the further spread of disease. We 
cannot investigate problems, identify their causes, and implement 
control measures if we have not detected them. Recent events have 
underscored this essential role of public health surveillance, as well 
as the integral role of health care providers in the overall public 
health system. For most of our surveillance data, the original source 
of information is the health care provider; the Florida physician's 
ability to recognize a suspected case of anthrax and his awareness of 
his role in reporting it to the local health department was critical to 
our initial recognition of the current bioterrorist events. Indeed, 
identification of subsequent anthrax cases has also relied on 
heightened awareness among health care professionals that the wounds 
and respiratory syndromes they were seeing were actually cutaneous and 
inhalation anthrax, not merely spider bites and pneumonia.
                      current surveillance systems
    The best initial defense against any threats to the health of the 
public, whether naturally occurring or deliberately caused, continues 
to be accurate, timely recognition of a problem. Key elements of our 
current surveillance systems include awareness and diagnosis of a 
condition of public health importance, whether by a clinician or 
laboratory, with subsequent notification of the local health 
department, which in turn reports to the state health department, which 
shares information with CDC. We work with our public health partners to 
define conditions that should be reported to public health departments; 
health departments share these definitions and guidelines with health 
care providers, infection control practitioners, emergency department 
physicians, laboratorians, and other members of the health care system. 
A timely example of such guidelines was included in the October 19, 
2001, issue of the Morbidity and Mortality Weekly Report (MMWR), in the 
report that dealt with ``Recognition of Illness Associated with the 
Intentional Release of a Biologic Agent.'' Copies of the MMWR have been 
provided to the Subcommittee.
    The traditional operation of our surveillance systems generally 
consists of paper or facsimile reporting by providers to health 
departments. If a case of illness is particularly unusual or severe 
(such as a case of anthrax or rabies), the provider will call the local 
health department immediately. As mentioned, health care provider 
recognition of the illness and awareness that certain health events 
require immediate notification of public health authorities, is 
critical to our ability to detect problems and mount a public health 
response. It was another alert clinician in 1993, a pediatric 
gastroenterologist, who provided the early warning about a potential 
diarrheal disease outbreak to the Washington State Department of 
Health. Within one week, the Health Department identified hamburgers 
from Jack-in-the-Box as the cause of the outbreak, and the fast-food 
chain voluntarily recalled all hamburger meat from their restaurants in 
the state. However, for routine public health surveillance, this 
largely paper-based system is burdensome both to providers and health 
departments, and therefore reports are often incomplete and not timely. 
In addition, the volume of paper reports and the need to enter the 
information collected into various information systems leads to errors 
and duplication of efforts.
    These shortfalls influence more than our ability to detect an 
event; surveillance also plays a pivotal role in event management. 
Surveillance data help us to determine where cases are occurring and 
who is affected (e.g., particular age groups or occupations such as 
children or postal workers), when cases are occurring (i.e., are cases 
still occurring; are the numbers increasing or decreasing with time?), 
and matching such information to the laboratory data about the 
particular agent, to trace its origin as well as to identify whether 
cases in different geographic locations might have resulted from the 
same source. Such information is vital to directing our investigation 
and control efforts, but it requires a well-designed system to input 
and analyze the voluminous data required, such as the thousands of 
swabs tested for anthrax.
    Given the crucial function of public health surveillance, we have 
recognized the need to take advantage of recent information technology 
advances to bring our surveillance systems into the 21st century. First 
I will describe the overall direction that we are headed to transform 
our public health surveillance systems, and then I will describe some 
of our short-term efforts to enhance current surveillance systems in 
the aftermath of September 11, as described in the MMWR report 
mentioned previously.
        integrated, electronic surveillance information systems
    CDC and its partners have recognized the need to build more timely, 
comprehensive surveillance information systems that are less burdensome 
to data providers. Several years ago, we initiated the development of 
the National Electronic Disease Surveillance System (NEDSS). The 
ultimate goal of NEDSS is the electronic, real-time reporting of 
information for public health action. NEDSS will include direct 
electronic linkages with the health care system; for example, medical 
information about important diagnostic tests can be shared 
electronically with public health as soon as a clinical laboratory 
receives a specimen, or makes a diagnosis. In the future, NEDSS coupled 
with a computer-based vital statistics system and computerized medical 
records, not only in hospitals but also in ambulatory care offices, 
could facilitate immediate awareness of unusual illnesses such as 
anthrax or smallpox, as well as our ability to detect more subtle 
problems that may be dispersed across the country.
    NEDSS emphasizes a standards-based approach, relying on the use of 
standards for data, information architecture, security, and information 
technology (de facto industry standards). This reliance on standards 
will ensure that data need only be entered once, at the point of care 
for a patient, without a need for re-entry of data by our local and 
state partners. Use of standards is critical to ensure that our public 
health partners can use technology more effectively and 
collaboratively. As we build NEDSS we are ensuring that the data 
standards we use are compatible with those used in health care systems, 
so that we can make sense of health-related data and therefore detect 
potentially related cases across the country. In addition, a standard 
information architecture and appropriate, high level security will 
enable public health partners to share data in a secure fashion, which 
is critical for identifying problems that cross jurisdictional 
boundaries. And finally, the reliance on de facto industry standards 
for information technology ensures the availability of multiple 
commercial products to meet the needs of our public health partners, 
including state-of-the-art analytic tools and geographic information 
system capacity.
    CDC has worked with our state and local partners on the development 
of NEDSS. We have provided funding and support to all 50 states for 
activities related to NEDSS planning and development. NEDSS is an 
ambitious project; defining appropriate standards and ensuring 
appropriate data sharing among the myriad health care systems, over 
2000 local health departments, 50 state health departments, and 
numerous federal public health agencies is a complex process. As a 
start, a NEDSS Base System that incorporates the standards and 
functions mentioned will be deployed in at least 20 states during 2002. 
This project will ensure our ability to capture data efficiently, 
electronically, and to use it effectively for public health response. 
And a public health surveillance system that spans the nation will help 
detect threats to the public, wherever they might occur.
    Indeed, 2 related projects also provide a key part of the effort to 
ensure the development of the public health communications 
infrastructure. Health Alert Network (HAN) is a nationwide program, the 
goals of which include provision of Internet connectivity and rapid 
communications capability among local and state health departments, 
which will also facilitate linkage of local health departments and 
health care providers. This connectivity will be crucial for rapid 
sharing of surveillance data among public health agencies. In addition, 
the Epidemic Information Exchange, or Epi-X, provides secure, high-
speed, Web-based communication about outbreaks and other acute or 
emerging health events among public health officials from CDC, state 
and local health departments and the military. One of the unique 
features of Epi-X is the ability to provide a forum for secure 
communications for state epidemiologists to post information on 
surveillance and response activities for approximately 500 public 
health officials around the country, including the U.S. military. 
Another unique feature of Epi-X is emergency notification by telephone 
and/or pager to defined groups of public health officials.
    Support to date for these important national projects has 
strengthened our public health infrastructure for detection of events 
of concern and subsequent communication to ensure appropriate public 
health response.
                     near term surveillance efforts
    Recognizing the need for near term increased capacity while NEDSS 
is implemented, CDC and its public health partners initiated various 
activities to improve their ability to detect events of importance to 
the health of the public. For example, with the first CDC funding for 
countering bioterrorist activities, in Fiscal Year 1999, many state 
health departments were able to purchase the most advanced pattern 
recognition analytic capacity available today--a trained human being: 
an epidemiologist whose duties included coordinating bioterrorism 
surveillance and rapid response activities. The activities range from 
enhancing communications (between state and local health departments 
and between public health agencies and health-care providers) to 
conducting special surveillance projects. These special projects have 
included active surveillance for changes in the number of emergency 
medical system/911 calls, hospital admissions, emergency department 
visits, and occurrence of specific syndromes. After September 11, these 
systems were explicitly called on to provide heightened surveillance 
information. CDC is undertaking a critical review of these activities 
to identify the most useful and practical approaches that may be 
implemented on a national basis. One key question to address is the 
feasibility of capturing medically relevant data in a timely and 
appropriately representative fashion, since we do not know when or 
where the next event might occur. Furthermore, what effort do proposed 
systems require from health care providers to report, or enter data in 
the systems? Can the systems be used in geographic areas beyond those 
where they were developed? In addition, given the substantial burden of 
investigating potentially concerning events, we are evaluating 
mechanisms for minimizing the proportion of alerts generated by the 
system that are false alarms.
    Other related activities useful for early detection of emerging 
infections or other critical biological agents include CDC's Emerging 
Infections Programs (EIP). CDC funds EIP cooperative agreements with 
state and local health departments to conduct population-based 
surveillance and research that goes beyond the routine functions of 
health departments, and often involve partnerships among public health 
agencies and academic medical centers. In addition, CDC has established 
other networks of clinicians--whether infectious disease or travel 
medicine specialists, or emergency department physicians--whose 
functions are to serve as ``early warning systems'' for public health 
by providing information about unusual cases encountered in the 
clinical practices of its members. The guidance provided in the October 
19 MMWR is intended to heighten awareness among these clinical partners 
about what to watch for, and what to report to public health. It is 
important to note that these relationships, particularly between health 
care providers and local health departments, are the foundation on 
which our surveillance systems operate. The local health department is 
the front-line of defense for the public health system. Many other 
projects and proposals for rapid surveillance omit the vital connection 
to public health, especially the local public health agency, which is 
responsible for the initial public health response.
                               conclusion
    In conclusion, CDC is committed to working with other federal 
agencies and partners as well as state and local public health 
departments to ensure the health and medical care of our citizens. The 
best public health strategy to protect the health of civilians against 
illness, regardless of cause, is the development, organization, and 
enhancement of public health prevention systems and tools.
    Our public health surveillance systems provide a critical piece of 
the public health infrastructure for recognizing and controlling 
deliberate bioterrorist threats as well as naturally occurring new or 
re-emerging infectious diseases. We have made substantial progress to 
date in enhancing the nation's capability to detect and respond to 
problems that threaten the public's health. Recognizing that there is 
no simple solution for our surveillance needs, we have supported 
augmenting the staff in state and local health departments, as well as 
special projects to explore the usefulness of various clinical data 
sources. We are undertaking a critical review of current efforts to 
determine what would be feasible and useful to implement more broadly 
in coming weeks. We are implementing the National Electronic Disease 
Surveillance System, which will provide direct linkages with the health 
care system in 2002, improving the timeliness, efficiency, and 
usefulness of our surveillance efforts. These cross-cutting efforts to 
build the surveillance infrastructure will be useful to detect any 
problem, not just potential bioterrorist events; the ongoing use of 
this surveillance infrastructure will assure that it is familiar and 
functional should bioterrorist events continue to occur. A strong and 
flexible public health infrastructure is the best defense against any 
disease outbreak.
    Thank you very much for your attention. I will be happy to answer 
any questions you may have.

    Mr. Greenwood. Thank you, Dr. Broome. I appreciate your 
testimony.
    Dr. Barry, you are recognized for 5 minutes for your 
testimony.

                    TESTIMONY OF ANITA BARRY

    Ms. Barry. Chairman Greenwood and honorable committee 
members, thank you for inviting me here to speak with you today 
about public health surveillance. My name is Dr. Anita Barry, 
and I am the Director of Communicable Disease Control for the 
Boston Public Health Commission, which is the local health 
authority for the city of Boston under the leadership of our 
mayor, Tom Menino.
    In 1999, the Boston Public Health Commission participated 
in a city-wide disaster tabletop exercise that simulated an 
outbreak of pneumonic plague. Through this exercise, we 
realized that in a medical or public health crisis, health care 
providers must have timely and accurate information, including 
clinical guidelines.
    Boston's disease monitoring system at that time relied 
primarily upon local hospitals, health care providers, or 
laboratories, to call when they diagnosed a reportable disease 
or identified a cluster of unusual illness.
    Unfortunately, this method often provides late and 
incomplete information, especially in an emergency. It became 
clear that we needed an active system to let us know about 
problems early on.
    Thanks to the Federal Centers for Disease Control and 
Prevention, Boston received a grant for $1 million over 5 years 
to develop and implement an early warning system to detect 
bioterrorism or any other infectious disease mass casualty 
event.
    For the last 2 years, we designed and set up this system, 
which has now been operational for 6 months. Additional 
components of the system, including daily information from the 
Poison Control Center located in Boston, Boston Emergency 
Medical Services, and death certificates, will be on-line in 
the next few months to supplement the already incoming health 
care site data.
    One of the first things we did to create our surveillance 
system was to convene a task force of key stakeholders to 
develop a workable system. We invited representatives from 
emergency departments, acute care sites, infectious disease 
departments, the State Health Department, and our local zoo, 
among others, to help us develop this system.
    As a group, we designed the Boston system to minimize the 
effort on the part of emergency department personnel and other 
hospital based personnel. We heard very clearly from the 
emergency department directors that drop in surveillance 
systems, in which a separate additional sheet of information 
for each patient is required to be filled out by their 
personnel, is completely unworkable.
    The Boston system works as follows. Each night the medical 
information system at each facility automatically sends our 
secure web-based server the number of persons seen in that 
emergency department or other acute care site.
    This figure is automatically compared to the expected 
number of visits for that site, adjusted for season of the year 
and day of the week. If it is higher than expected, a one page 
follow-up form is automatically sent to a pre-identified 
contact at that hospital.
    This form asks more detailed questions about the nature of 
cases seen in the acute care site to determine if anything 
unusual is going on. This follow-up information determines 
whether or not further investigation is required.
    Hospital staff appreciate the fact that they are asked to 
take time to provide detailed information only when the system 
indicates that something may be going on. While this volume 
based system will not identify an isolated case like the 
anthrax cases in other cities, the constant reminders that we 
send to health care providers through this system increases the 
chances of timely reporting.
    Our experience in the past 6 weeks has also highlighted how 
this system provides important public health data, whether or 
not there is a mass incident. Although we have had no 
bioterrorist events in Boston, during the first week of reports 
of anthrax cases, we observed a surge in patient volume at 
several hospital sites.
    Follow-up investigation revealed that this was not due to 
any unusual clusters of symptoms, but rather to an influx of 
frightened people requesting nasal swabs and cipro 
prescriptions, despite the absence of any confirmed or 
suspected anthrax exposures in Massachusetts.
    At the local health department, we used this information as 
an indicator of the need for increased public education and 
increased public timely information release. One of the most 
important purposes of the system is to create a flow of 
information between that local health department and local 
health care providers.
    The Boston Public Health Commission, with our surveillance 
task force, also developed a provider education initiative on 
bioterrorism. This program, which began about 1\1/2\ years ago, 
uses a train-the-trainer model to teach physicians and nurses 
to educate their peers.
    This training has been much in demand of late. 
Additionally, we use this electronic surveillance system to 
post and send regular clinical advisories and updates out to 
the surveillance task force members and others, including the 
city's 25 community health centers, the college health centers, 
Boston Emergency Medical Services, and others.
    These guidelines have served as the foundation for 
protocols developed by local hospitals regarding the medical 
management of people being seen with possible anthrax exposure.
    I believe that the Boston system is replicable with 
modifications in other cities and regions, as well as on state-
wide levels. Our experience has also implications regarding 
what is needed for local health departments to maintain an 
effective early warning system, as well as the ability to 
respond to public health events detected by these systems.
    First, key stakeholders must be at the table to design the 
system. Second, the system should serve as a communication 
network, as well as a surveillance system. Third, the system 
should be simple and as automated as possible so it is doable 
by busy health care systems.
    And finally at the same time, it should account for the 
human factor, which is essential both to maintain the system, 
and to obtain the data if the electronic system is delayed or 
temporarily not functioning.
    I also would like to share some thoughts about the broader 
implications of Boston's experience. Last week, Boston Mayor 
Menino and City Public Health and Safety Officials joined 
mayors from across the country at the U.S. Conference of 
Mayors' Emergency, Safety, and Security Summit.
    The following suggestions combined public health action 
steps recommended by the Boston Public Health Commission, and 
the U.S. Conference of Mayors. First, the technical 
capabilities in communication infrastructure of local health 
departments must be improved.
    Our ability to create this surveillance system was the 
result of a CDC grant. Without Federal funding, we could never 
have designed this system. Second, all local health departments 
should have direct access to communications systems like CEC's 
Epi-X to receive ongoing timely updates.
    Such a system is key to having accurate and timely 
information from local public health officials, and so we 
strongly support full funding and expansion of the health alert 
network.
    Third, we need to think regionally about surveillance and 
communications systems, and we need Federal support to 
implement such regional systems. Boston is currently in 
discussion with surrounding communities about sharing and 
expanding our surveillance system, because the impact of an 
infectious disease or bioterrorist events will not end at the 
Boston city borders.
    Fourth, Federal Agencies should direct more funding 
directly to local communities. National public health 
organizations recommend that at least $835 million of the 
Emergency Bioterrorism Funding Request go directly to local and 
State health departments.
    Local communities must receive a significant portion of 
that funding. Too often local health departments are left out 
of the equation, and we bear the major burden of the day to day 
response.
    For example, in Boston alone, the health department 
anticipates spending $700,000 by the end of this fiscal year on 
bioterrorism-related emergency medical service response, and a 
surveillance, epidemiology, communication, and coordination of 
activities within the communicable disease control program.
    Federal funding should be flexible. We need to track and 
respond to a range of public health concerns, including not 
only bioterrorist agents, but also influenza and other emerging 
problems.
    And finally local public health departments should be 
represented at the table in national emergency planning. A 
permanent commission, including mayors, local public health 
officials, and local public safety officials, should 
immediately be established by the Director of Homeland 
Security.
    Local officials are on the front lines of homeland 
security, and it is essential to forge direct lines of 
communication among the Office of Homeland Security, Federal 
Agencies, and local governments.
    In closing, I thank Chairman Greenwood and the committee 
for inviting me to speak today on behalf of local health 
departments, and I would be pleased to provide any further 
information you would like.
    [The prepared statement of Anita Barry follows:]
   Prepared Statement of Anita Barry, Director, Communicable Disease 
              Control, The Boston Public Health Commission
    Chairman Greenwood, Honorable Committee Members, thank you for 
inviting me here to speak to you today about public health 
surveillance. My name is Dr. Anita Barry. I am the Director of 
Communicable Disease Control for the Boston Public Health Commission, 
the health department for the City of Boston, under the leadership of 
Mayor Thomas Menino.
    In 1999, the Boston Public Health Commission participated in a 
citywide disaster tabletop exercise that simulated an outbreak of 
pneumonic plague. Among the participants were representatives from all 
the major Boston hospitals. Through this exercise, we realized that in 
a medical or public health crisis, health care providers must have 
timely and accurate information, including clinical guidelines. At that 
time, Boston had only what most local health departments have: a 
passive surveillance system. We waited for local hospitals, health care 
providers, or laboratories to call us when they diagnosed a reportable 
disease or identified an unusual cluster of illness. Unfortunately, 
this method can provide late and incomplete information, especially in 
an emergency. For example, influenza--one of the diseases we are most 
interested in identifying early--is not required to be reported in 
Massachusetts. Influenza outbreaks tended to be reported late--or not 
at all, making it impossible to introduce timely measures to contain 
the spread of disease. It became clear that we needed a system to let 
us know about problems early on.
    Thanks to the federal Centers for Disease Control and Prevention, 
Boston received a $1 million five-year grant to develop and implement 
an early warning system to detect a bioterrorist or other infectious 
disease mass casualty event. We were one of about seven localities in 
the country to be awarded such a grant, and the only city to monitor 
volume in emergency room and acute care facilities through an 
automated, electronic, real time system.
    For the last two years, we designed and set up the system, which 
has now been operational for about six months. Additional system 
components, including daily information from the Poison Control Center 
in Boston, Boston Emergency Medical Service, and death certificates 
will be on line in the next few months to supplement the health care 
site data. I will give you a brief overview of how the hospital-based 
system works and then share what we have learned that is relevant to 
other localities, as well as federal bioterrorism preparedness planning 
and funding.
    One of the first things we did to create our surveillance system 
was to convene a task force of key stakeholders to help develop a 
workable system. We invited representatives from emergency departments, 
acute care sites, hospital infectious disease specialists, state health 
department infectious disease specialists, representatives from Zoo New 
England, Emergency Medical Services, the Poison Control Center, the 
Chief Medical Examiner, and others.
    As a group, we designed the Boston system to minimize the effort on 
the part of emergency department and other hospital-based personnel. We 
heard very clearly from emergency department directors that drop-in 
surveillance systems in which a separate additional sheet of 
information on each patient is required to be filled out by ED 
personnel are unworkable. The system works as follows. Each night the 
Medical Information Systems at each facility send to our secure web-
based server by FTP the number of persons seen in their Emergency 
Department or other acute care site. This figure is automatically 
compared to the expected number of visits for that site, adjusted for 
season of the year and day of the week. If it is higher than expected, 
a one page follow-up form is automatically sent to a pre-identified 
contact at the hospital.
    This form asks more detailed questions about the nature of the 
cases seen in the acute care site to determine if anything unusual is 
going on. We usually receive these completed forms back from hospitals 
within 1-2 hours. If a form is not returned from a site, the system 
automatically pages a contact at that site to obtain further 
information. This follow-up information determines whether or not 
further investigation is required. Hospital staff appreciate the fact 
that they are asked to take the time to provide detailed information 
only when the system indicates that something may be going on.
    In order to determine the normal volume thresholds as well as what 
is a statistically significant increase in volume for each site, we 
obtained retrospective data from all of the sites and analyzed it. To 
validate the system's ability to detect clusters of illness, we 
retrospectively compared volume spikes above threshold at sites with 
the first confirmed presence of influenza in Boston in 1999. Changes in 
volume detected using the system correlated well with the first 
laboratory confirmed case of influenza. We believe the system will give 
us early warning of other public health concerns, including a range of 
infectious diseases.
    While this volume-based system will not identify an isolated case, 
like the anthrax cases in other cities, the constant reminders that the 
system allows us to send health care providers increases the chances of 
timely reporting.
    Our experience in the last 6 weeks has also highlighted how this 
system provides important public health data. Although we have had no 
bioterrorist events in Boston, during the first week of reports of 
anthrax cases, we observed a surge in patient volume at several 
hospital sites. Follow-up investigation revealed that this was not due 
to any unusual clusters of symptoms, but rather to an influx of 
frightened people requesting nasal swabs and Cipro prescriptions, 
despite the absence of any confirmed or suspected anthrax exposure in 
Massachusetts. At the local health department, we used this information 
as an indicator of the need for increased public education and 
increased public information efforts.
    Because one of the most important purposes of the system is to 
create a flow of information between the health department and local 
health care providers, the Boston Public Health Commission, with the 
Surveillance Task Force, also developed a curriculum on bioterrorism 
for physicians and nurses. This educational initiative which began 
about a year and a half ago, uses a ``train the trainer'' model. The 
health department provides a CD containing slides as well as handouts 
to these trainers, who are physicians and nurses, to educate their 
peers. This training has been much in demand of late.
    Additionally, we use our electronic surveillance system to post and 
send regular clinical advisories and updates out to surveillance task 
force members and others, such as community health centers, college 
health centers, and Boston Emergency Medical Services. These guidelines 
have served as the foundation for protocols developed by local 
hospitals regarding medical management of patients with possible 
anthrax exposure.
    I believe Boston's system is replicable, with modifications, in 
other cities and regions, as well as on a statewide level. Our 
experience also has implications regarding what is needed for local 
health departments to maintain effective early warning systems as well 
as the ability to respond to public health events detected by 
surveillance systems.

1. Key stakeholders must be at the table to design the system.
2. The system should serve as a communication network as well as a 
        surveillance system.
3. The system should be simple, and as automatic as possible, so it is 
        ``doable'' for busy health care systems.
4. At the same time, it should account for the ``human factor,'' which 
        is essential both to maintain the system and to obtain the data 
        if the electronic system is delayed or temporarily not 
        functioning.
    I'd also like to share some thoughts about the broader implications 
of Boston's experience. Last week, Boston Mayor Menino and City public 
health and safety officials joined mayors from across the country at 
the U.S. Conference of Mayors Emergency, Safety, and Security Summit. 
The following suggestions combine public health recommendations from 
the Boston Public Health Commission and the U.S. Conference of Mayors 
National Action Plan for Safety and Security in America's Cities:

<bullet> The technical capabilities and communication infrastructure of 
        local health departments need to be improved. Our ability to 
        create this surveillance system was the result of a CDC grant. 
        Without federal funding, we could not have designed this 
        system.
<bullet> All local health departments should have access to 
        communications systems like Epi-X to receive ongoing timely 
        updates. Such a system is key to having accurate and timely 
        information from local public health officials, so we strongly 
        support full funding and expansion of the Health Alert Network.
<bullet> We need to think regionally about surveillance and 
        communication systems, and we need federal support to implement 
        such regional systems. Boston is currently in discussion with 
        surrounding communities about sharing and expanding our 
        surveillance system because the impact of an infectious disease 
        or bioterrorist incident will not end at city borders.
<bullet> Federal agencies should direct more funding to local 
        communities. National public health organizations recommend 
        that at least $835 million of the emergency bioterrorism 
        funding request go directly to local and state health 
        departments. Local communities must receive a significant 
        portion of that funding. Too often, local health departments 
        are left out of the equation, and we bear the major burden of 
        day-to-day response. For example, in Boston alone, the health 
        department anticipates spending $700,000 by the end of this 
        fiscal year on bioterrorism-related emergency medical service 
        response and the surveillance, epidemiology, communication, and 
        coordination activities of the communicable disease program.
<bullet> Federal funding should be flexible--we need to track and 
        respond to a range of public health concerns, including 
        bioterrorist agents as well as influenza and other emerging 
        problems.
<bullet> And local public health departments should be represented at 
        the table in national emergency planning. A permanent 
        commission including mayors, local public health officials, and 
        local public safety officials should be immediately established 
        by the Director of Homeland Security. Local official are on the 
        frontlines of homeland security, and it is essential to forge 
        direct lines of communication among the Office of Homeland 
        Security, federal agencies, and local governments.
    In closing, I again thank Chairman Greenwood and the Committee for 
inviting me to speak on behalf of local health departments, and I would 
be pleased to provide any further information in the future.

    Mr. Greenwood. Thank you, Dr. Barry. I appreciate your 
testimony as well, and coming here, and Dr. Davidson, you are 
recognized for 5 minutes for your testimony. Thank you for 
being with us as well.

                TESTIMONY OF ARTHUR J. DAVIDSON

    Mr. Davidson. Thank you. Mr. Chairman, and members of the 
committee, I am Arthur J. Davidson, a family physician, 
epidemiologist, and the Director of the Denver Public Health 
Informatics at Denver Health.
    I consider it a privilege to testify before the committee, 
providing a local perspective about our public health 
surveillance system. I guide Denver's public health 
surveillance activities, and am the principal investigator of 
the Denver Center for Public Health Preparedness, where I have 
been involved in the preparation and training from weapons of 
mass destruction over the past 2 years, including the planning 
and execution of Operation Top-Off.
    What I would like to do today is describe Denver Health as 
an example of how an integrated safety net system may play a 
role in public health surveillance, and then discuss linkages 
and potential barriers with other critical health care 
entities, including State and Federal systems.
    Denver Health is a highly integrated safety net 
institution, serving a quarter of Denver's half-million 
residents. Some of its components include Denver's emergency 
response system, an acute care hospital, neighborhood and 
school based health clinics, the public health department, and 
a regional poisonous center.
    Each of these entry points has capacity to contribute to 
surveillance activities. Linked by a unique patient identifier, 
an integrated electronic medical record includes patient 
demographics, image medical records, laboratory, radiology, 
pharmacy, and ancillary systems.
    Denver Health information technology investments have 
exceeded $100 million in the past 5 years. From an infomatics 
perspective, data achieves value through conversion to 
information that guides action.
    Examples of such action within Denver Health include 
electronic reporting of laboratory data to nurse 
epidemiologists for communicable disease surveillance and 
control; or patient-specific pharmacy adherence measures for 
tailored HIV outreach worker interventions.
    While these customized applications have value, our vision 
is to achieve even greater yield through building around 
industry standards. Denver Health, in collaboration with the 
Agency for Health Care Research and Quality, our information 
systems vendor, Siemens, and the CDC, are developing a real 
time method to identify patients at risk for tuberculosis, and 
then alert providers of screening guidelines using a 
standardized rules language.
    These partnerships seek to use our information 
infrastructure to enhance our return on investment by industry 
standard messaging. The ultimate goal is appropriate and timely 
surveillance data with less expended effort.
    Physician identification of disease remains a critical 
component of surveillance. Physicians must be informed to fill 
this role. CDC's health alert network, HAN, has been a wise 
investment, rapidly bringing the latest anthrax information to 
3,000 local health departments and beyond.
    In Denver, I personally disseminate these alerts to all 
health care providers, enabling heightened awareness. While 
disease surveillance is a time honored public health skill, the 
concept of syndromic surveillance is new.
    In Denver, we are testing this concept using an existing 
emergency department electronic data base, and with asthma as a 
disease model, we found symptoms surveillance to be less 
sensitive than diagnosis surveillance, but then more timely.
    While we found spikes and seasonal patterns, thresholds 
still need to be established to assist in interpretation. I 
believe the jury is still out on this one. Although an 
integrated health care delivery system with advanced 
information technology has much potential, these data must be 
integrated with other local, State, and Federal health care 
institutions for a truly robust surveillance system.
    Through preliminary discussions with local health 
maintenance organizations regarding electronic sharing of 
symptom and diagnosis data, issues of patient confidentiality 
have arisen to detect disease and guide local response to 
intentional biologic releases.
    We need laws that protect individual confidentiality, but 
do not inhibit information flow to protect the larger 
population. Your committee may wish to review HIPAA legislation 
toward modifying laws that excessively regulate information 
sharing for public health surveillance activities.
    Regarding Federal and State data linkages, CDC's national 
electronic disease surveillance system, NEDSS, provides a 
coordinated surveillance framework, developing standards and 
conceptual models that maximize information technology.
    Accepting health information industry standards will 
enhance electronic information transfer and capacity for 
automated electronic surveillance. In Colorado, NEDSS, HAN, and 
our center's preparedness funds, are coordinated to help build 
an integrated data repository, support direct laboratory 
transfer of data to the Colorado Electronic Disease Reporting 
System, or CEDRS, develop hand-held devices as surveillance 
tools, establish secure wireless CEDRS access, add geographic 
information functionality, and assure an informed Colorado 
public health work force.
    These are new and exciting challenges for a public health 
infrastructure that has been significantly under-funded in 
information technology for so long. While an effective early 
warning surveillance system is desirable, a major preparedness 
concern persists, insufficient surge capacity within the entire 
public health core system.
    Today, in the absence of a bioterrorist event, most Denver 
hospitals are at capacity, and often cannot receive ambulances. 
Denver Health typifies safety net health care systems with 
extremely tight financial status and no additional support to 
build capacity to respond after a terrorist attack.
    Given these comments, I want to thank Congress and the 
leadership of this committee for the efforts already 
accomplished. Exercises such as Operation Top-Off have proven 
invaluable to stimulate interest and planning for the 
unthinkable.
    CDC's efforts to build and utilize HAN, develop and 
disseminate NEDSS, and focus on work force development, are 
bright spots with real potential to improve operational 
readiness and surveillance capacity.
    However, as shown in numerous other industries information 
can drive feedback, quality control, and triggers for 
intervention. Such an integrated health data environment, with 
proper protection of individual confidentiality, should 
accelerate outbreak investigation, enhancing our public health 
response.
    Your committee has the opportunity to promote and encourage 
this data integration. You should build on these initial 
positive steps and expand capacity to achieve early warning 
systems in every community.
    In closing, I want to thank you, Mr. Chairman, and the 
committee, for this opportunity to discuss some issues of 
concern regarding early decisions detection and response to 
terrorist events at the local level.
    Mr. Chairman, this concludes my testimony, and I am pleased 
to answer any questions that you or the committee might have.
    [The prepared statement of Arthur J. Davidson follows:]
   Prepared Statement of Arthur J. Davidson, Director, Public Health 
              Informatics, Denver Public Health Department
    Mr. Chairman and members of the Committee, I am Arthur J. Davidson, 
a family physician, epidemiologist and Director of Public Health 
Informatics at Denver Health. I consider it a privilege to testify 
today before the Committee to provide a local perspective and concern 
about our public health system surveillance system and its role in our 
preparedness for bioterrorism. One of my roles is to guide Denver's 
public health surveillance activities and I am the principal 
investigator for one of three CDC-funded local health department 
projects, the Denver Center for Public Health Preparedness. For the 
last two years, I have been involved in the local preparation and 
training for weapons of mass destruction and was a participant in the 
planning and execution of Operation TopOff.
    What I would like to do is describe Denver Health's system as an 
example of how an integrated safety net system may play a role in 
public health surveillance, discuss linkages with other critical health 
care entities, the state and federal systems, and the barriers existing 
at each of these levels.
    Denver Health is a highly integrated safety net institution serving 
Denver, the state of Colorado and the Rocky Mountain Region. Some of 
its components (see attachment 1), which are relevant to today's 
discussion, include the 911 medical response system for the City and 
County, an acute care hospital with a regional trauma center, 10 
neighborhood health clinics, 13 school based clinics, the public health 
department and a regional poison center. This system has multiple entry 
points, each with capacity to contribute to surveillance initiatives. 
In addition, the system served more than one in four people in Denver 
last year and thus provides an ability to sample a large segment of the 
population at any given time. Care is provided by one group of employed 
academic physicians, enabling standardized approaches to monitoring, 
reporting and care. The system is linked by a single patient identifier 
and an electronic integrated medical record. The electronic record 
includes patient demographics, imaged medical records, laboratory data, 
radiology, pharmacy and ancillary systems. A picture of the information 
system is include with my remarks (see attachment 2). Denver Health's 
information technology investments have exceeded $100 million dollars 
in the last 5 years.
    We have begun to use and assess the ability of this system to serve 
as a public health and disease surveillance system and to improve 
health care delivery. From an informatics perspective, the true value 
of data can only be achieved through conversion to information that 
guides action. A few examples of such action within Denver Health 
include electronic reporting of laboratory data to Denver Public Health 
nurse epidemiologists for use in communicable disease surveillance and 
control. Patient-specific pharmacy adherence measures for prophylaxis 
and treatment regimens, are provided to HIV outreach workers to target 
interventions. Feedback to providers, using an immunization registry 
and administrative data, enhance efforts to keep children up to date 
with immunizations. While these customized applications have value, our 
vision is to achieve even greater yield through building around 
industry standards.
    In that regard, Denver Health has a task order from the Agency for 
Health Research and Quality to work with our information systems 
vendor, Siemens and the CDC to develop a methodology to identify 
patients at risk for tuberculosis and alert the providers of the need 
for tuberculosis screening. Preliminary data suggest that we may have 
as many as 12,000 at risk patients in our system. We are 
collaboratively developing a real-time system to alert care providers 
of needed action for tuberculosis screening using a standardized rules 
language. Appropriately applied rules can be powerful tools to change 
provider behavior or improve surveillance efforts. This rules-based 
surveillance approach has the potential to dramatically reduce the 
incidence of this important infectious disease. Our goal, and that of 
Siemens and CDC, is to seek ways to take advantage of our information 
infrastructure capabilities and enhance our return on investment. These 
partnerships can improve electronic communication and provide models 
for using industry standard Health Level 7 messaging and extensible 
markup language. The ultimate goal is appropriate and timely 
surveillance data with less expended effort.
    Currently and into the foreseeable future, physician identification 
of disease remains a critical component of surveillance. The two most 
recent nationally recognized emerging infections, West Nile Fever and 
anthrax were identified by astute clinicians. But physicians must be 
informed to fulfill this role. The Health Alert Network (HAN) 
exemplifies how we can wisely invest in infrastructure to quickly bring 
the latest information to the front lines. Now in it's third and final 
year, CDC continues to use the HAN daily, to inform and advise nearly 
3000 local health departments of the latest and rapidly changing 
developments since identifying anthrax released through the mail. In 
Denver, I personally disseminate these alerts to all health care 
providers enabling heightened awareness.
    While disease surveillance is a time-honored public health skill, 
the concept of syndromic surveillance is new and one worth a few 
specific comments. As part of our CDC-funded Center for Public Health 
Preparedness, we are still early in testing this concept. The goal 
would be to identify patterns of patient symptoms to alert public 
health care providers of potential illness. Using the chief complaint, 
recorded in an existing emergency department electronic database, we 
tested asthma as a model disease for our syndromic surveillance. We 
found symptom surveillance to be less sensitive than diagnosis 
surveillance but more timely. While we found spikes and seasonal 
patterns in asthma diagnosis, we need to establish thresholds to 
appropriately interpret the output from any symptom-based surveillance 
systems. Symptom data were easily collected as part of routine patient 
care in our integrated information systems, but a more structured 
format (rather than free text fields) would improve their surveillance 
utility. To date, we are just entering the evaluation stage. The jury 
is still out on this one.
    Although this integrated health care delivery system and its linked 
information technology has much potential, data from such a system must 
be integrated with that of other local, state and federal health care 
institutions for a truly robust surveillance system. A local public 
health system needs to share information across all local health care 
institutions for early recognition and ongoing monitoring of an 
epidemic. We have had preliminary discussions with some local health 
maintenance organizations regarding electronic sharing of symptom and 
diagnosis data. There no doubt will be hurdles regarding 
confidentiality before this is achieved. To detect disease, assess 
threat and guide local response to intentional biologic releases, we 
need laws that protect individual confidentiality but do not inhibit 
information flow to protect the larger population. Since September 
11th, with our national emergency, Congress and the President have 
modified laws that determine how information is shared between 
financial institutions and law enforcement and even diminished some 
civil liberties for the purpose of surveillance and national security. 
Given our recent tragedies, this seems reasonable and prudent. 
Similarly, your committee may wish to review HIPAA legislation toward 
modifying laws that excessively regulate information sharing for public 
health surveillance activities.
    Regarding federal and state data linkages, CDC is in the early 
phases of building the National Electronic Disease Surveillance System 
(NEDSS) to provide a coordinated surveillance framework. Bringing 
local, state and national health departments to the table, NEDSS has 
worked to acknowledge and accommodate our unique data needs while 
developing standards and conceptual models that maximize information 
technology. Defining common information system architectures improves 
our return on investment with decreased maintenance costs. Accepting 
standards, like those within the health information industry, enhances 
our capacity for electronic information transfer, whether that be 
laboratory data or other health-related data such as symptoms or 
diagnoses. If public health surveillance ascribes to these industry 
standards, health care information systems may be better interfaced for 
automated, electronic surveillance seeking syndrome patterns and/or 
diagnostic trends for earlier alerts of potential biologic or chemical 
releases.
    NEDSS within Colorado has permitted us to define a statewide, 
integrated data repository that becomes the hub for information 
organization. Our goal of direct laboratory transfer of data to the 
Colorado Electronic Disease Reporting Systems (CEDRS) is anticipated 
during this NEDSS funding cycle ending June 30, 2002. Direct laboratory 
reporting would improve surveillance completeness as busy clinicians 
are less likely to contact their local or state health department for a 
reportable disease. This should enhance early warning systems given 
improved reporting accuracy. However, laboratory reporting does not 
solve all surveillance needs as some demographic information (e.g., 
address of patient) would not be provided. With combined NEDSS/HAN 
funds, we are developing CEDRS geographic information system capacity 
to report visually based on space and time. Before achieving visual 
presentations of laboratory data, linkage with administrative databases 
for patient address would be necessary. This is a non-trivial task 
given issues of patient confidentiality.
    To improve the timeliness of reporting, we are working to develop 
and test alternative data entry mechanisms. Using Health Alert Network 
and Denver Center for Public Health Preparedness funds, efforts are 
under way to build applications on hand-held devices as surveillance 
data collection tools. Training and testing public health employee 
skills in adapting to these devices is in progress. We have plans to 
develop secure wireless access for rapid data entry into CEDRS from 
multiple surveillance sites (e.g., hospitals). The pilot projects, 
using readily available technology already incorporated in other 
industries are new and exciting challenges for a public health 
infrastructure that has been significantly under funded in information 
technology for so long.
    Making sure that the personal and public health care workforces are 
adequately informed and trained in these new technologies is essential. 
In many rural and smaller urban communities in my state, public health 
workers need training on how to best use the surveillance measures that 
they collect or receive. Even if we had perfect information systems, 
the poorly skilled public health worker may lack the knowledge to put 
that information to good use. Similarly, medical and public health 
sectors that address medical aspects of a biological or chemical 
terrorist attack, sorely lack knowledge and planning to deal with such 
an incident. Enhancement of CDC- and HRSA-funded programs to create a 
knowledgeable and prepared public health system workforce is now of 
central importance to our national security. Coordinated public health 
systems will require additional funding to support planning, readiness 
training and an equipped infrastructure to deal with medical 
consequences of weapons of mass destruction.
    While an effective early warning surveillance system is desirable, 
there remains a major preparedness concern regarding adequate resources 
or ``surge capacity'' within the entire public health core system. From 
Operation TopOff, our local hospital system quickly overloaded with 
patients infected with pneumonic plague. In Denver, over the last 
decade, cost-reduction and a competitive health care market have 
resulted in the loss of over 1000 hospital beds. Thus, at baseline even 
without a bioterrorist event, most Denver hospitals are at capacity and 
cannot receive ambulances on a normal day. Given recent events, we work 
to enhance our local readiness but Denver Health typifies safety-net 
health care systems with extremely tight financial status. Without 
additional support, public safety net hospitals, needed in a terrorist 
attack, will not have the necessary capacity to respond.
    Given these comments, I want to thank Congress and the leadership 
of this committee for the efforts already accomplished. The federal 
government's investment in local training and planning for a potential 
WMD event have in my opinion made significant strides in our awareness 
and preparedness. Exercises such as Operation TopOff have proven 
invaluable to stimulate interest and planning for the unthinkable. 
Efforts to build and utilize the Health Alert Network and disseminate 
National Electronic Disease Surveillance System plans from the CDC as 
well as workforce development by CDC and HRSA are bright spots with 
real potential to improve our operational readiness and surveillance 
capacity. Public health surveillance however can benefit even more from 
information technology. As has been shown in numerous other industries, 
information can drive feedback, quality control and triggers for 
intervention. That same technology, in an integrated health data 
environment, with proper protection of individual confidentiality, 
should accelerate outbreak identification enhancing our public health 
response. Your committee has the opportunity to promote and encourage 
that data integration. We should build on these initial positive steps 
and expand capacity to achieve early warning surveillance systems in 
every community.
    In closing, I would like to thank you, Mr. Chairman, and the 
Committee, for this opportunity to discuss some issues of concern to 
medical and public health communities in our preparedness for early 
detection and response to terrorist events at the local level. Mr. 
Chairman, this concludes my testimony. I am pleased to address any 
questions that you or the Committee might have.
[GRAPHIC] [TIFF OMITTED] 76304.001

    Mr. Greenwood. Thank you for your testimony, Doctor 
Davidson, and the Chair recognizes himself for 5 minutes for 
inquiry. Dr. Davidson, in your testimony, you said that while 
disease surveillance is a time honored public health skill, the 
concept of syndromic surveillance is new.
    The hypothesis that I think this hearing is meant to test 
is this one. It is that by it is possible to create, using 
state-of-the-art information systems, a nationwide early 
surveillance system that would by means of identifying spikes 
in early symptomatology for diseases that would result from a 
bioterrorist event, to get a head start and to move more 
quickly to deploy into that geographical location, or those 
geographical locations, and thereby diminish the infectious--
the rate of infection and save lives.
    And so that is the question that we are asking here, Dr. 
Davidson, and you also talked about a truly robust surveillance 
system, and I think that is what we are thinking about.
    So the question that I would like to pose to each of you is 
do you believe that that hypothesis is a valid one, and 
therefore would you in fact recommend to the Congress that what 
we do is as quickly as is practicable, without throwing money 
at the wall, but to do it as quickly as it is possible, build 
such an early surveillance system nationwide that would 
obviously have great value for health care in general, and for 
such diseases in general, but would be of particularly acute 
value in protecting our country from a bioterrorist event, and 
I will start with Dr. Broome.
    Mr. Davidson. Thank you, Mr. Chairman. I think your 
question is an excellent one, but I think the answer is not 
either/or. I do not think there is a single magic bullet which 
will address all surveillance issues.
    I think the critical issue is to be prepared to detect and 
respond to whatever may come along. If it is isolated single 
cases, as I have indicated, physician awareness, health care 
provider awareness, and contact with a strengthened local 
health department, and a public health infrastructure, is 
critical.
    If it is routine--for example, a low level contamination 
across a commercial food product--and let's go away from 
bioterrorism for a minute and just consider something that does 
happen, the kind of systematic information about specific 
cases--you are looking for the proverbial needle in a haystack, 
and the best way to do that is to be able to define the needle.
    It may not cause a big bump in disease. It may just cause a 
bump in a particular organism, and then finally you have the--
and that is the kind of effort that NEDSS is designed to 
address, among others.
    Then finally you have the potential that some of these 
supplementary surveillance systems might provide early warning 
information that would be more timely. But I agree with the 
other panelists that we need to look critically at what kinds 
of supplementary information would actually improve our ability 
to detect certain kinds of scenarios.
    Mr. Greenwood. Let me see if I understand what you said. I 
gather from what you are saying that it may--would I be 
paraphrasing you correctly if you said that it is necessary, 
but not a sufficient response?
    In other words, that it is worth doing this as long as we 
don't consider it to be sufficient, but rather a part of a 
broader approach to surveillance?
    Mr. Davidson. I think the critical elements of a 
surveillance system we know, and those are the first two points 
that I made; that we need to have educated capacity and 
information communication.
    And then second, we need to have a systematic collection of 
what you might call traditional surveillance information, but 
in a far more timely, less burdensome, and more precise, way.
    Then the final or third leg of the stool if you will is are 
there additional tools out there where we can benefit from 
syndrome surveillance technology and innovative approaches, and 
we are very interested in looking at those. But we think they 
need critical evaluation.
    Mr. Greenwood. Okay. Dr. Broome, would you respond to the 
same question, please?
    Ms. Broome. Yes. I think the timely identification of 
clusters of infectious disease is critical, and I think it is 
possible. The way our system works, all our 11 sites close 
their books at midnight essentially, and their MIS system beams 
one number to ours at the health department.
    We know by 1 a.m. if a site is over-threshold, and frankly, 
we can automatically page out to our onsite contact, but they 
would stop working with us if we made their beepers go off at 1 
a.m. all the time.
    So, typically at about 8 a.m., if a site has exceeded, they 
get a one page telling us so they can report to us if they have 
seen any type of syndromes. So I think it is helpful for us to 
identify changes in uses of health care very, very quickly in 
the city of Boston.
    And as I mentioned, we did pick that up with the influx of 
people looking for cipro and nasal swabs. One thing that you 
should be aware of is that once we believe there is a cluster, 
the story doesn't stop there.
    So we send out a one pager and Mass General, or whomever, 
reports back to us that we are seeing a cluster of febrile 
respiratory illness. That is one of our boxes that they could 
check on the one pager. I then need to have a public health 
nurse from the local health department then do more 
investigation.
    We think that something is going on now, and she or he 
needs to get a line listing on those cases, and find out what 
was common about those cases so we can start to take 
appropriate control measures and move along with diagnostics.
    I agree that the individual provider reporting is key in 
surveillance. You can't ever lose that. You have to have those 
providers. But I think that the cluster based systems, at least 
in my experience, can also do that.
    We are constantly on the incoming side hearing about 
excedences and threshold, and we also are feeding back to 
people: here are the symptoms of cutaneous anthrax, folks--post 
it in your emergency department, and here is who you call if 
you think that is what you have.
    So I think that we need to merge many of these components. 
Our system has been validated to date and we clearly need to 
more work in this area. But we have looked at patterns of 
influenza illness in the city of Boston using retrospective 
data from our surveillance system.
    And it turns out that what our system detected very well 
correlated with the first isolytes of influenza in the city of 
Boston in 1999. I think that there needs to be much more 
emphasis on data mining.
    You know, health care providers aren't going to fill out 
that extra sheet in the ED. We need to figure out how to suck 
out pieces from the medical record and have that make sense.
    And some of the folks in Boston have tried to do that or we 
are currently doing it. Once instance is that one of the 
fellows at a major hospital tried to electronically pull out 
RESP, standing for respiratory illness, electronically from 
records to see if that would help give us more information.
    And I think a lot more work in that area will provide us 
very useful information. We are also looking in some of our 
sites at the use of laboratory data, because hospital labs can 
tell you in a matter of hours how many of certain lab tests are 
being requested.
    So we are analyzing data from a few sites to say, well, 
they have ordered a lot more complete blood counts, and what is 
that telling us. So we think that he base for one of these 
systems, I feel pretty comfortable with what we have built, and 
if our funding doesn't drop out after these few years, I think 
we can use it to mine a lot more information.
    Mr. Greenwood. Thank you. Dr. Davidson.
    Mr. Davidson. Yes. I think I agree with the other panelists 
that our current systems for disease surveillance, where we are 
dependent on physicians, have been serving us fairly well 
throughout the--at least in the last years, the incident of 
anthrax was identified by an astute physician.
    And Westnow fever as well by astute physicians, and who 
have provided that front line for us.
    I have reservations still about the value of a syndromic 
surveillance system only because we have not tested it enough. 
We know that the systems that have been available for a long 
time are a way that our society has dealt with diseases for 
centuries.
    But for us to say that mining the data at this point has 
Dr. Barry mentions will definitely yield a benefit? I am 
uncertain. I think we still need to study this. I think that 
living in Denver, and working in a busy public care health 
system, physicians are overburdened with paperwork and 
activities just to get through their day.
    And to put another computer that will be collecting 
additional information in an emergency room is just untenable 
to my colleagues; to Dr. Cantrell, who Ms. DeGette mentioned 
earlier.
    I think that in terms of syndromic surveillance that we 
need to work to identify what are thresholds. Can we even 
establish a threshold. As we enter the influenza season, how 
does that threshold change if we are trying to look for 
symptoms consistent with inhalational anthrax.
    How will we respond. At present, Dr. Barry mentions using 
her system to inform and have the nurse epidemiologist conduct 
some surveillance activity. I wonder how that may change as we 
get further into the influenza epidemic.
    What will happen. How will the worried well be appearing 
and how will that impact on our need to act on syndromic 
surveillance monitoring.
    Mr. Greenwood. Thank you, Dr. Davidson. Dr. Broome, if you 
can be very brief, we have a vote on, and so we are going to 
try and work the time out here.
    Ms. Broome. Just very briefly. I was trying to also reframe 
it not as syndromic surveillance versus routine. You have to 
define what you are trying to find. We have a very interesting 
system which has automatically detected outbreaks, but it is 
based on detailed information about salmonella, a food borne 
disease.
    We picked up an outbreak in 13 States that nobody was aware 
of, but we needed to have not syndromic information, but 
detailed information about the pattern of isolation of that 
kind of salmonella. So it is complicated.
    Mr. Greenwood. Thank you. The Chair recognizes the 
gentleman from Florida, Mr. Deutsch, for 5 minutes for 
questions.
    Mr. Deutsch. Thank you. Dr. Broome, just to follow up, but 
I guess in a different capacity, what would you need to 
implement the national electronic disease surveillance system 
across all 50 States today?
    Ms. Broome. The implementation of this across all 50 States 
is partly a matter of the resources. That includes trained 
personnel and it includes being sure that information security 
is at a level that can handle this sensitive information.
    So there is certainly a monetary figure, but there is also 
a huge active role for our State and local partners in either 
working with the NEDSS bay system that I described, which is an 
option that the States can choose, or some States have 
developed their own solutions using the standards.
    Mr. Deutsch. So at this point, you are really just saying 
that it is a resource decision for us to make really. The 
bottom line is that based upon the positive effect you have 
seen in your test sites, it would appear as if there is almost 
no reason not to fully implement this system?
    Ms. Broome. We feel that this is a critical part of the 
public health infrastructure that it will support our local and 
State partners in detecting and responding to disease.
    Mr. Deutsch. Let me jump to some of the issues that I 
mentioned in my introduction, and really ask very specifically 
if there were cases of smallpox in American today, I that all 
of us understand at this point that if someone had a full case 
of smallpox that they would look very obvious, assuming they 
didn't wear makeup of some sort.
    Would it be possible to pick up a precursory of that a week 
before, 10 days before, 5 days before, because of a respiratory 
increase in hospitals in a certain location in America?
    Ms. Broome. As you are indicating, we have to be prepared 
for whatever might appear, and smallpox is very high on the 
list of syndromes. In the information that I mentioned, we do 
include information about early diagnosis of smallpox to our 
partners and to help care providers.
    The most--really, the only way to identify that smallpox is 
occurring is to pick up the very earliest stages of the rash.
    Mr. Deutsch. So the actual rash, as opposed to any other 
symptoms, would be the indicator?
    Ms. Broome. Essentially, yes.
    Mr. Deutsch. All right. So, Dr. Barry, you are shaking your 
head, and so basically the system doesn't really help with 
smallpox because we are back to a clinician basically picking 
up a phone and saying that I have got a patient with smallpox?
    Ms. Barry. Well, I think I have a patient with smallpox. I 
guess the point that I was trying to make earlier is that there 
are a lot of different scenarios for different diseases, and it 
is not going to be a one size fits all.
    Mr. Deutsch. And actually, Dr. Barry, do you want to 
respond to that, specifically the smallpox?
    Ms. Barry. Sure. I think it depends on how the smallpox 
exposure occurred. I think if someone did widespread 
dissemination of smallpox, you are going to have a whole 
cluster of people coming in to hospitals, and it is going to 
set off our threshold.
    But more importantly, I think because of the system, 
because of the surveillance system feeding back and forth to 
these health care providers, they are going to know who to call 
and say I have all these adults with what looks like chicken 
pox, but you know what, and that is how we are going to pick 
that up. So it could be an isolated case, but it could be quite 
a number of cases.
    Mr. Deutsch. Right. But I guess that the value of the 
system, in terms of basically bioterrorism, and it is not an 
unlimited number of agents that we are talking about, but for 
those particular agents I am trying to get a sense of--and as 
we are sort of in a funding mode, and let's just talk about 
bioterrorism.
    And not to say that the work that we are doing in all these 
other areas are not very significant; such as with influenza, 
and in terms of food poisoning, et cetera, but I am trying to 
get a sense of the value added in any of these other types of--
well, the plague.
    If there was an instance of plague in America, would we 
pick that up through this system. And related to that, I guess 
it is sort of a contrast between just a traditional clinical 
approach.
    I mean, one of the questions that I have, which is sort of 
a related question, is how much are we doing that on the public 
health side, and there are no physicians in America, I assume, 
who have seen the plague, because it has not existed, although 
we know that it exists in a sort of--in a bioterrorist world, 
but not in terms of the clinical world.
    Now, I assume that there is probably still some clinicians 
out there who have seen smallpox, but the percentage has to be 
extraordinarily low at this point in time. So I am trying to 
get a sense from the system that we have in place how does it 
help us from a bioterrorism perspective?
    Ms. Broome. But I think even though not all physicians have 
seen it personally, the whole point of some of the training 
materials is to make available, for example, descriptions of 
the rash form smallpox, and descriptions of typical x-rays for 
anthrax, and making physicians aware to look for hemostasis 
with plague.
    There are both pictorial and teaching aids which help us 
get from line physicians up to speed in both considering the 
diagnosis and then in being comfortable in making it. So that 
is a very explicit part of the material that has been developed 
with the support for bioterrorism preparedness.
    Mr. Deutsch. Dr. Davidson or Dr. Barry, did either one of 
you want to add to that? I know that my time is up as well, and 
this will be my last question.
    Mr. Davidson. In Denver, we are trying to inform our 
physicians, and we are working based on the CDC advice that we 
receive almost daily on the health alert network to build an 
algorithm that is useful within our own environment.
    Something that tells people exactly what to do, and who to 
call, and how do you evaluate if someone had a known exposure 
to anthrax spores, versus someone who is not. One of the 
clinical signs and symptoms that we would expect on how to 
evaluate a patient who comes in with concern, and whether they 
are symptomatic or not, and whether they need to get 
prophylactics or not.
    I think all of this information, even though I have not 
seen a case of anthrax, and I doubt that my colleagues have 
seen a case of anthrax, we now know how to deal with this. We 
are distributing that information. That sort of information 
provided to the front line is key.
    And that comes from a disease surveillance system that says 
we found cases, and now we need to act and give the information 
to our front lines.
    Ms. Barry. One thing that I wanted to add is that with our 
current surveillance system that we have a secure website, and 
so if Hospital A thinks they have seen a case of bubonic 
plague, I post an alert that says Hospital A has a 45 year old 
man who they suspect has plague, and do any of the other nine 
acute care hospitals in the city of Boston seen anything like 
this, and that goes up right away on our website.
    Mr. Greenwood. Thank you. The gentleman, Mr. Whitfield, is 
recognized for 5 minutes of inquiry.
    Mr. Whitfield. Mr. Chairman, I know that we have a vote 
pending, and so I won't take too long, but it is my 
understanding, of course, that smallpox is quite contagious, 
and would spread rapidly. And I suppose that the bubonic plague 
would be the same.
    And on the anthrax, it is my understanding that there is an 
abundant supply of drugs to deal with anthrax, but it is my 
understanding that there is a significant shortage to deal with 
smallpox; is that correct, if there was a mass outbreak of 
smallpox?
    Ms. Broome. For smallpox, the issue is the availability of 
vaccine.
    Mr. Whitfield. Right.
    Ms. Broome. And it is very complex assessing what the 
likely scenario is and using the available vaccine effectively, 
and being sure that we have sufficient quantities being 
produced.
    Mr. Whitfield. And we are making efforts to do that at this 
time?
    Ms. Broome. Yes.
    Mr. Whitfield. Okay. How would you compare our reporting 
system with, say, the reporting system in Europe?
    Ms. Broome. Well, maybe I am--well, anyway, I think the 
U.S. actually has invested in a reporting system which in many 
ways is a leader in terms of approaches from the public health 
side.
    I do think--and this