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CDC State Preparedness Report Highlights Progress and Challenges

February 20, 2008

OPERATOR:  Good morning and thank you all for holding.  At this time, your lines have been placed on listen only until we open up for questions and answers.  Please be advised, today′s conference is being recorded.  If you have any objections, you may disconnect at this time.

I would now like to turn the conference over to Mr. Von Roebuck.  Please go ahead, sir.

VON ROEBUCK:  Thank you, Laura.  Good morning and thank you for your patience this morning.  I am Von Roebuck in CDC′s main press office.  At 2:00 p.m. Eastern Standard Time today, we are releasing CDC′s first report on state public health preparedness.  The report is called, "Public Health Preparedness; Mobilizing State by State.”  I have with me CDC director, Dr. Julie Gerberding, and CDC′s director of Coordinating Office for Terrorism Preparedness and Emergency Response, Dr. Richard Besser.

Dr. Gerberding and Dr. Besser will make a few brief comments about this report and then, we will take your questions.  Let′s start with Dr. Gerberding.

JULIE GERBERDING, DIRECTOR, CDC:  Good morning and thank you for joining us.  This is really an important for CDC and for our whole public health network.  It represents the first of what we expect will be a series of ongoing preparedness reports.  This report is entitled, "Public Health Preparedness: Mobilizing State by State" and it reflects not the totality of preparedness at the state and local level, but rather the preparedness that was specifically addressed and the investments that CDC has been responsible for through our cooperative agreement program with the state.

I′d like to start by acknowledging and thanking the tremendous leadership and effort of our state, local, territorial and tribal partners.  They have been involved for the past several years in a wholehearted effort to improve their ability to prepare and respond to emerging health threats of an all hazards nature.  And as a first step, we have initiated a set of measures on a state by state basis that are presented in the report that we′re releasing today.

This has been a challenging process.  There is really no gold standard for preparedness and there really is no previously ordained list of measures that we could turn to that say, “These measures indicate success.” So we′ve had to invent the airplane while we are flying it. That′s resulted in a lot of learning and a lot of controversy and a lot of evolution, I believe, in our ability to come to a common set of agreed upon measures and then, recognize how those might evolve over time.

One of our challenges is that the starting point for our states was highly variable across the various capacities that are necessary to build a preparedness effort.  Many of you may recall that there was an Institute of Medicine report in 2002 that indicated that much of our public health system, nationally, was in a state of neglect and that there were decades of neglect in some of these jurisdictions that had to be addressed before we could begin to build a contemporary preparedness network.  So that highly variable starting point, obviously, has lead to some highly variable progress reports at this point in time and we recognize that we′ve had to concentrate our initial measures on looking at capacities because without those capacities, we couldn′t begin to expect to look forward to the ultimate measures of success and results that we intend to accomplish down the road.

So what you can expect from this report is a concise snapshot of current capacities across states.  You′ll see there is some variability, some areas where true achievement has been almost universally accomplished and other areas where we have a long way to go.  But what I think you will be able to see in future reports as we go forward is a much greater emphasis not on capacity, but on results. Actually, the things that we are striving for in our preparedness goals include timeliness of our ability to detect, investigate and mitigate a threat; coverage including all relevant elements of a jurisdiction because, of course, we′re only as strong as our weakest link; and certainly, overall continuous quality improvement in the expertise and innovation that we bring to drive these efforts.

So I, personally, am very excited about this progress.  I am fully candid in acknowledging that it is not the state of measurement that we hope to achieve.  We expect people will immediately recognize that there′s an emphasis on capacity measures here, but this is what we had to do to bring people up to a playing field where we could take it to the next level. With our new round of cooperative agreements, we intend to do just that.  I think our partners across the public health system should be proud of their effort.  I know each and every one of them has accomplished a lot since the data from this report were gathered.  We are well aware that this year there is going to be much greater progress than we′ve seen last year and the year before than what′s included in the report.

So I am very honored to be joined in this press conference with Dr. Richard Besser and his teammates who have really been the driving force behind what I consider to be a giant step forward in CDC′s ability to provide a framework and a common operating picture of the state of state and local preparedness across our country.

So, Dr. Besser, I′ll let you provide some specifics about the content of the report.

RICHARD BESSER, DIRECTOR, CDC:  Thanks very much, Dr. Gerberding.

The work that′s featured in this report falls under one of CDC′s overarching health protection goals and that′s people prepared for emerging health threats - People in all communities will be protected from infectious, occupational, environmental and terrorist threats.  And what you′ll see in reading this report is that there′s been significant progress made towards achieving this goal, progress has been made at the state and local level in terms of preparedness and response.  But the report also identifies preparedness challenges that are still faced by state and local public health and in that light, some of the efforts CDC is undertaking to help address those challenges.

The report is organized into two parts; the first part presents national data from all 50 states, as well as Washington DC.  The second part of the report includes state-by-state data for 50 states and four directly funded localities (Washington, D.C., Chicago, Los Angeles County, and New York City), so there′s information on all of the performance measures for each state, as well as a story from each state that describes a particular response activity or a particular way in which the resources have helped that state to prepare.

There are three critical areas that we focus on, disease detection and investigation, public health laboratories, and response. I want to give you a few examples from each one of those domains.  First, in the area of disease detection and investigation, there have been major improvements in public health workforce and in data collection and reporting systems that have increased the nation′s ability to detect and investigate diseases.  Some examples of this, the number of epidemiologists in public health departments who are working exclusively on emergency response has more than doubled between 2001 and 2006, from 115 to 232.  The number of users of a system called, ‘The Epidemic Information Exchange, a secure CDC based communication system that we use to help track disease outbreaks, has increased from 890 in 2001 to over 4,000 in 2006.

And all state and public health departments now can receive and evaluate reports of urgent health threats 24/7/365.  In 1999, only 12 state health departments could do so.  This puts us on par with other first responder organizations.  An example of how this has been used: in Indiana, in 2007, they used their emergency operation center to help them respond to a nationwide outbreak of botulism from contaminated food products.  They used their operation center to help them track cases and facilitate communication among local and state health departments and CDC and increase their investigative capacity.  It allowed them – they used their emergency surveillance system for almost real time evaluation of chief complaint data in hospitals so that they could identify potential cases of botulism sooner, thereby providing appropriate treatment and potentially saving lives.

The second area I wanted to talk about was public health laboratory capacity.  We are now at a point where 90 percent of the U.S. population lives within 100 miles of a Laboratory Response Network member laboratory.  These laboratories represent state-of-the-art laboratories.  They′re using tests for detecting bacteria and other germs that are the same tests that we′re using here at CDC.  So if a laboratory is a Laboratory Response Network member, if anyone in the country has a positive test, we can take action much sooner.  The number of public health laboratories that are able to test for chemical agents has increased dramatically.  In 2001, none of them could do so.  In 2006, 47 of the laboratories could test for chemical agents.

An example of how the system has been used comes from September 2006.  The Wisconsin State Health Department was investigating an outbreak that they attributed to a bacteria called E. coli O157:H7.  This is a very dangerous bacteria that causes diarrheal disease, but it can also cause kidney failure and death.
They investigated this outbreak, and they did something called DNA fingerprinting tests, or pulsed field gel electrophoresis.  They entered their results into a system called PulseNet, which is a national database coordinated by CDC.  This allowed other laboratory scientists around the country to look at this strain and compare to strains of E. coli that they were seeing in their communities, and the results of this was the identification of a national outbreak of E. coli that was then attributed with investigators and attributed to spinach. We worked with state and locals and other federal partners and implemented an investigation and a recall that quickly got this product off of people′s shelves.

The third area that I wanted to talk about was response.  Response capabilities in public health departments have improved markedly because they′ve been developing response plans, they′ve been increasing their preparedness training, and they′ve been conducting exercises. These sorts of activities were uncommon prior to 2001.  We′re now at a point where all states have developed detailed emergency response plans to address what we call all-hazard scenarios.  So that′s any type of public health emergency, including an influenza pandemic.

All states now have plans to receive, store and distribute material from the strategic national stockpile, which is a repository of antibiotics and other life-saving medications. Seventy-three percent of states have satisfactorily documented their strategic national stockpile planning efforts, and we′re working with the other states to get them to this level of competency.

And lastly, in 2006, 26 states did year-round flu surveillance.  Now all states are doing year-round flu surveillance.  This is critically important in the setting of a potential for pandemic flu.

And let me give you an example of how these response activities have been used.  In 2007 in Barrow, Alaska, there was an outbreak of respiratory syncytial virus, which is a virus that causes severe pneumonia in young children.  Pediatric patients, children, were quickly filling up the available beds in hospitals in the state. The Alaska Division of Health used their emergency response plan and their emergency operation center to coordinate the response to the activity.  They used it to maintain active communication with local public health officials, with hospitals, with the Alaska Native Tribal Health Consortium.  This allowed them to monitor the outbreak and address the immediate medical needs of patients.

The last thing I wanted to mention is that while this report identifies significant accomplishments, there is so much more to be done in the realm of preparedness.  This report focuses on the building of systems, as Dr. Gerberding was saying.  We now need to insure that these systems are working effectively to safeguard health and save lives.

We are working with our states, and they face many challenges.  One of those is conducting their program activities with decreasing resources.  We′re working with the states in terms of prioritization to make sure that resources are being used most effectively to meet the needs of preparedness response.

We′re working with states to meet the critical public health responsibility for countermeasure distribution.  We have to have the ability to get countermeasures into the hands of people during an emergency, and this is true whether we′re dealing with an emergency such as a pandemic of influenza or an anthrax attack.  We′re working with states to increase the use of electronic health data for what we would call real-time health surveillance.  These sorts of systems will allow us to detect and track public health events faster, thereby speeding up the efficiency and effectiveness of our response.

And we′re working with health departments to improve their legal preparedness so that they′re working effectively with other states and with law enforcement to respond to public health emergencies.

This report really represents a milestone for national preparedness activities.  There′s a lot more work to be done, and this report will be issued annually as a way of demonstrating our accountability to the American people and demonstrating our accountability for the preparedness responsibility.

Thank you.

VON ROEBUCK:  Thank you Dr. Besser.  Thank you, Dr. Gerberding.

Laura, we′ll now open it up for questions, please.

OPERATOR:  Thank you.  At this time, if you would like to ask a question, please press star one on your touch tone phone.  You′ll be prompted to record your name for proper registration.  To withdraw your question, you may press star two.  Once again, to as a question, please press star followed by one.

Our first question comes from Todd Zwillech, WebMD.  Please go ahead.

TODD ZWILLECH, WEBMD:  Hi.  Can you guys hear me OK?

BESSER:  Yes.  Very well.

ZWILLECH:  Good.  Dr. Gerberding and Dr. Besser, you both mentioned that there was a lot of work to be done and that some states are further behind in capacity than others.  Could you give some examples of areas, you know, your top areas that need more work on capacity, and also some – maybe a couple of states who have, regardless of whether it′s because resources or whatever, have more work to do than others, the places where they should be concentrating more on building their capacities, they′re a little bit behind.

GERBERDING:  I just want to start by mentioning one thing that both Dr. Besser  and I believe wholeheartedly, and that is the biggest area of effort needs to be in combating complacency because right now we′re operating in an environment where more and more people are concentrating on things that seem far removed from preparedness, and it′s understandable priorities shift. We must remember that we are always in need of preparedness for health threats whether they′re natural or terrorist in nature, and the challenge to overcome complacency is one that I believe every single part of the entire public health network shares.

I don′t want to lose sight of the fact that the most important thing we need to do is to encourage people to continue to focus on these threats and to encourage readers at the community level as well as the state and federal level to continue to demand performance and continue to invest in areas where we can achieve the greatest progress.

BESSER:  Addressing your question as to what are some of the major challenges, you know, the challenge of complacency is an overarching one for all of us.  A specific functional challenge that we all face is the issue of countermeasure distribution, and by that we mean getting the right products, the right drug, into the hands of people in time where it will do some good.

This is a major challenge for federal, state and local public health, and it′s one that we are committed to, and it′s one that we are committed to reporting on in future reports.

If you look at pandemic influenza, we′re looking at a situation where distribution of antiviral medications can be life-saving and can prevent illness.  If we′re talking about a scenario of a large-scale anthrax attack in a city, you have an approximately 48-hour window in which you want to distribute an antibiotic to save lives. This is a major challenge, and we′ve made a lot of progress in this area, but there′s more to be done in terms of demonstrating where we are.

To help accomplish this challenge, it′s essential that we promote innovation.  The Institute of Medicine has a forum on preparedness and response, and in early March they′re hosting a workshop on countermeasure distribution, looking for innovative solutions between the private and the public sectors.  If there′s a better way to do this, we want to know about it and we want to implement that.

So this is one of the overarching challenges that we face.

VON ROEBUCK:  Thank you, Dr. Besser.  We′ll take our next question, please.

OPERATOR:  Thank you.  Our next question comes from John Pope, the “Times-Picayune Newspaper”. Please go ahead.

JOHN POPE, “TIMES-PICAYUNE NEWSPAPER”:  Good morning.  I have two questions.  One is specific, one is general.  Midway through the evaluation period for this study, Louisiana got clobbered by Hurricanes Katrina and Rita.  Did this pose specific problems to the network that you were investigating, and if so, how did the states meet – how did the state meet up, and what deficiencies remain?

BESSER:  Thanks, John.  When you read through this report, you′ll see quite a number of examples of how different states use their response systems to help deal with the challenge posed by Hurricane Katrina.  There are examples of states that used their emergency operations center to help place evacuees from the Gulf Coast and to insure that their needs were met.

You′ll also see in here some exciting examples from Louisiana and Mississippi of what they′ve done in terms of meeting their challenge of preparedness and response.

In 2007, Louisiana conducted a response exercise called Operation Prepare, and this event tested their ability of their public health agencies and partners to reach at-risk populations during an emergency.  It looked at their knowledge and ability to operate their incident management system and their communication plans and equipment. This is absolutely critical because if you want to look at the preparedness of a community, it′s only as good as its ability to take care of those who are most in need.

In Louisiana they were looking here at targeting their educational efforts at non-English speaking populations, the Vietnamese in the New Orleans area.  They were looking at meeting the needs of displaced Hurricane Katrina residents living in Baton Rouge, rural residents in low-lying marsh areas, and elderly residents in areas affected by Hurricane Katrina.

So while Hurricane Katrina and Rita posed major challenges to the area, we′ve seen a lot of progress since those hurricanes, and the public health community has learned across the nation from the experience of Hurricane Katrina.

VON ROEBUCK:  And quickly, John, you had a second question?

POPE:  What surprises did you find when you were – or did you find any surprises when you were compiling this report?

GERBERDING:  We didn′t quite hear that question.  Could you repeat it?

POPE:  Sure.  Did you encounter any surprises when you were preparing this report, disagreeable or otherwise?

BESSER:  Well, you know, this is the first time we′ve taken a broad look at preparedness across the country.  A pleasant surprise for me was the amazing level of accomplishment that we′ve seen across the board.  This is something that we need to build on.

The laboratory system, I provided some of the data there, but the fact that 90 percent of the U.S. population lives within a hundred miles of a Laboratory Response Network laboratory is a fantastic capability for our country.

The activities that states reported on in response to the E. coli outbreak in 2006 were also impressive.  We were aware of those, but to hear those stories from the state and local perspective was extremely important.

VON ROEBUCK:  All right, thank you, Dr. Besser, Dr. Gerberding.  We′ll take our next question, please.

OPERATOR:  Thank you.  Our next question comes from Mimi Hall  USA Today.  Please go ahead.

MIMI HALL, USA TODAY:  Hi.  I cover homeland security, so I′m slightly more interested in those kinds of preparedness questions, and I notice here it says that no state public health lab can rapidly identify priority radioactive materials in clinical samples, and I′m wondering – I guess I have two questions about that, that go to how big a problem that is.

First is, it occurs to me that maybe if there were an accident or attack or something where there was a big exposure that DOE teams or the labs or somebody could probably rapidly send folks in to do that kind of work, so I′m wondering if it′s really necessary that all state public health labs can do that, and if so, how costly would it be for them to get the equipment or know-how or whatever they would need to be able to?

GERBERDING:  There are two different frames for this.  One is if there′s an exposure in the environment, can somebody quickly go in and determine if there′s radiation exposure present, and so most of the threat agents in that domain, we do have the capacity to do that from an environmental perspective.

But the human health monitoring is a completely different situation.  If you can imagine a scenario where you know there′s radiation of some type present, there′s still a lot of effort that is required to assess the exposure of the individuals in that environment.

HALL (ph):  OK.

GERBERDING:  That requires the kind of capability that CDC is developing here in Atlanta, but we have only a marginal ability to expand that human health monitoring part of this out to jurisdictions, and we have very limited search capacity, so although we′ve been able to scale up and improve the technology for doing this quickly, we have a long way to go before that has been extended so that it is within the same 100-mile radius of the majority of our population that we have for the bacterial drugs, and there are circumstances where rapid knowledge about radiation exposure are going to be very important because we′ll need to triage some of the countermeasures for radiologics …

HALL (ph):  Correct.

GERBERDING:  … and that will depend in part on what we can learn about who′s exposed and who isn′t.

We have made astonishing progress.  We′ve even been able to develop some strategies that with a single instrumentation can quickly partition out and determine the broad spectrum of potential sources in an unknown sample, so the science is moving forward, but the translation of that science to the practical level in the local jurisdiction has got to be a higher priority for us as we go forward.

VON ROEBUCK:  And do you have a second question, Mimi , very quickly?

HALL:  No.  I didn′t have another one.

VON ROEBUCK:  OK.  Thank you.  Next question, please.

OPERATOR:  Thank you.  Our next question we′ll hear from Karen Schidler (ph), Wichita Eagle.  Please go ahead.

KAREN SCHIDLER , WICHITA EAGLE:  Hi.  I′m wondering whether – how this report compares or doesn′t compare to the readiness reports that have been issued in recent years by Trust for America′s Health.  It looks like they have looked at many of the same factors.  I′m wondering what differences and similarities there are.

BESSER:  The Trust for America′s Health has really done a tremendous service in pioneering and demonstrating the value of assessing state preparedness on a regular basis, and I think that these two reports are complimentary.  It′s very difficult to directly compare because there are different measures used and different data sources used, but I would view the two products as complimentary.

GERBERDING:  I think it′s fair to say that Trust for America′s Health may be taking a broader look at preparedness generally, and the CDC report, at least this first report, is looking mainly at the impact of our specific investment, so it′s slicing this into the domain of we′ve invested money here, what results are we able to show for and the value of that investment on a state-by-state basis, so we probably have more specificity about a smaller set of measures, and the Trust for America′s Health report traditionally has taken the broader picture, and I think exactly what Dr. Besser said, they′re really complimentary.

We hope over time that we can converge to reports that actually look at results, timeliness, coverage and quality of the preparedness effort, and I think as the systems improve, that will be very feasible.

VON ROEBUCK:  Thank you.  Our next question, please.

OPERATOR:  Thank you.  Our next question comes from Mike Stobbe, the Associated Press.

MIKE STOBBE, ASSOCIATED PRESS:  Hi.  Thanks for taking the question.  Two, actually.

First, understanding that this is a first look at the different health departments and that there is variability in achievement, is there a letter grade, a kind of class average grade that you can give to help simplify how things are?

And the second question had to do with federal support for state preparedness.  Could you provide some detail on what that′s been and what it′s looking to be in the near future?  I understand there′s a downward trend.

BESSER:  No, I think that, you know, it′s not possible to give a state-by-state score for a number of reasons.  One is, this is not a complete picture of preparedness.  This is looking at various aspects and slices of that, and you will see as you read through the various state reports that states vary in terms of the areas where they have demonstrated the most success and have faced the most challenges.

I think in terms of effort and progress, overall I would give an A.  In terms of the amount of work to be done, I would say it′s absolutely enormous.

So, you know, the takeaway from that is that as you read each state′s report, view it as a state of where they were at a point in time.  Many states have already moved beyond what is captured in this report, and so I would urge you to talk to the state and local public health leaders as you′re thinking about reporting on state-specific information.

VON ROEBUCK:  OK.  Thank you.  Got a second question, Mike, very quickly?

STOBBE:  Yes.  There′s the funding question, federal funding for state preparedness.  What is that currently and what′s that going to be in the near future?

BESSER:  Well, the funding for preparedness is featured in the report in the appendix, and there you′ll find state-by-state figures on funding.

This funding table includes the core funding that′s been received as part of the public health emergency preparedness cooperative agreement as well as the significant supplemental funding that states have received for pandemic flu.

VON ROEBUCK:  OK.  Thank you, Dr. Besser.  We′ll take one more question, please.

OPERATOR:  Thank you.  Our next question comes from David Markiewicz, Atlanta Journal Constitution.

DAVID MARKIWICZ, ATLANTA JOURNAL CONSTITUTION:  Good morning.  Thank you.  I noticed in here specifically Georgia had a particularly low score in terms of its ability to distribute supplies from the SNS, and I was wondering if you might elaborate on the reason or cause of that, as well as speak to the importance particularly of that issue.

BESSER:  You know, countermeasure distribution, as I′ve said, is a critical function, and it′s one that we need to devote our best and our brightest to tackling.

Each locality that is reported in this document faces unique challenges, and so I would talk to Georgia about some of the challenges they face.

I would like to say, though, that Georgia and Atlanta have been extremely innovative in their approach to countermeasure distribution.  They′ve been partnering with a group called Business Executives for National Security to look and see what the private sector can bring to this challenge, and these are recent activities that may not be captured within that one point-in-time score.

Georgia is also going to be exercising with us at CDC in the middle of March when we do our next large scale exercise for pandemic flu preparedness, and this again demonstrates their commitment to moving forward on their preparedness and response mission.

VON ROEBUCK:  OK.  Thank you, Dr. Besser.  Thank you all for joining us today for this brief.  If you have additional questions about the report, please contact CDC′s main press office.  The preparedness report will be posted on CDC′s Web site after 2:00 p.m. Eastern Standard Time today.  A written transcript of this briefing will be posted on the CDC Web site later today.

Thank you and have a good day.

OPERATOR:  Thank you.  And this does conclude today′s conference call.  We thank you for your participation, and you may now disconnect your lines.




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