Preparing For and Responding To Future Public Health Security Threats

Chairs McMorris Rodgers and Guthrie, Ranking Members Pallone and Eshoo, and distinguished members of the Committee, it is an honor to appear before you today to discuss the Pandemic and All-Hazards Preparedness Act reauthorization, and the Centers for Disease Control and Prevention’s (CDC) role in preparedness and response to public health emergencies.

The Department of Health and Human Services (HHS) had to overcome real challenges while responding to the once-in-a-century COVID-19 pandemic and other recent emergencies, including the infant formula shortage, mpox, and Hurricanes Ian and Fiona.  Similar such challenges in the future will be even harder to effectively address without appropriate additional authorities, flexibilities, and funding as requested in the FY 2024 President’s Budget.  Together, the proposals my colleagues and I will discuss today will help bridge key gaps and barriers to enable a robust and timely response to future emergencies—by enhancing early detection; safe, effective, and accessible Medical Countermeasures (MCMs) and other supplies such as personal protective equipment (PPE); response and health system capacity; and recovery and other supports. These proposals complement the discretionary funding and $20 billion mandatory funding requested across HHS public health agencies to prepare for biological threats.

Americans and people around the world rely on CDC to detect and respond to emerging public health threats both foreign and domestic. This requires CDC’s world-leading experts to anticipate, prevent, research, track, and mitigate threats to our nation’s health security.

For decades, CDC has been on the front lines of public health response, providing assistance to states, tribes, local communities, and territories on the most pressing infectious disease outbreaks within the United States and across the globe, including H1N1, Ebola, Zika, seasonal influenza, COVID-19, polio, mpox, and Marburg.

While the COVID-19 pandemic was the most serious public health event in over 100 years, the increased frequency of infectious disease outbreaks should highlight the sobering reality that we should not be asking if we will face another serious public health threat, but when.

The health security of the United States depends on the strength of the public health system, and CDC must be ready to play a leading role in any future public health emergency, whether a global pandemic or a natural disaster.  CDC will innovate and improve on each response, while building on our existing expertise and successes. This means a CDC that supports the following activities:

• A workforce across the public health system – CDC and our state, tribal, local, and territorial (STLT) partners – that is trained and ready to respond to large, sustained, and concurrent public health emergencies and biosecurity threats.
• Strategic partnerships with the private sector to drive innovation and adoption of data, laboratory systems, and technology for multiplexed and pathogen agnostic early warning and real-time monitoring of biological threats.
• Timely and quality data and making data and science quickly available for federal, state, and local decision-makers to translate findings into policy and guidance for communities.
• Integrated early warning systems with global public health partners to expand the perimeter of and advance the technologies for multiplexed and pathogen agnostic detection of potential public health threats in an economy that relies on the movement of people and products across international borders.
• Transparent communication with partners and the American people so that CDC’s mission, methods, and recommendations are clear and well understood by everyone.

These activities and the vision for a well-prepared public health system must be built on a foundation of core capabilities in public health including: state of the art laboratories, a diverse public health workforce that reflects the communities it serves, world-class interoperable data & analytics, rapid response to outbreaks at their source, and strong global capacity & domestic preparedness.

CDC’s unique laboratory expertise lies in its ability to detect and track a broad range of microbes and respond to disease threats from many different pathogens – both well-known infectious diseases and rare or unknown, but equally dangerous threats – and in its ability to work with and support state and local public health partners as they respond to these threats.

For example, the Laboratory Response Network (LRN), a network of thousands of trained labs across the country was founded in 1999 as a partnership between CDC, the Federal Bureau of Investigation, and the Association of Public Health Laboratories to support the U.S.  detection of biological threats and emerging infectious diseases quickly and accurately anywhere in the United States.

Previous investments in domestic preparedness for smallpox through the LRN provided immediate testing capacity across the United States for mpox. In fact, the first case was detected in the Massachusetts Public Health LRN Laboratory using a PCR test developed by CDC and authorized by the Food and Drug Administration (FDA) in 2018. The LRN, in partnership with CDC’s high containment laboratory, played a significant role in slowing the outbreak of mpox in the United States, from a peak of 600 cases a day in August to fewer than 10 cases a week since January 21, 2023.

In addition to these efforts in CDC laboratories, CDC’s Advanced Molecular Detection (AMD) program has been working with state and local health departments over several years to bring genomic sequencing of pathogens into routine use. The AMD program worked with state and local partners to rapidly scale up COVID-19 sequencing in U.S. public health labs, increasing from 23 labs generating around 17,000 COVID-19 sequences during 2020, to 68 labs generating over 690,000 COVID-19 sequences during 2022.

Efforts like these have also provided an opportunity for CDC to accelerate innovation and partnerships in new ways, harnessing the collective efforts of public health and academic expertise to advance the application of genomics in combating outbreaks including through expanding use of methods such as wastewater surveillance. Two promising partnerships involve the Pathogen Genomics Centers of Excellence (PGCoE) network and the Sequencing for Public Health Emergency Response, Epidemiology, and Surveillance (SPHERES) consortium.  Beginning with COVID-19, the SPHERES consortium engaged academic and private sector sequencing laboratories to help us monitor changes in the virus, gain important insights to support contact tracing efforts, provide crucial information to aid in identifying diagnostic and therapeutic targets, and advance public health research in the areas about transmission dynamics, host response, and evolution of the virus.  The Centers of Excellence will extend these partnerships and help CDC leverage state of the art laboratory technology and public health innovation to continue to advance genomic surveillance.

State, tribal, local, and territorial health departments are the foundation of the public health system.  The infrastructure needs in these health departments are substantial: many public health agencies lack resources for foundational capacities such as operations, communications, and emergency preparedness, which are the building blocks of any future response. To be ready for any biothreat, the public health system in the United States requires a robust and nimble public health infrastructure and a skilled public health workforce ready to respond to emergencies. According to a recent report by the DeBeaumont Foundation¹, state and local health departments need to hire a minimum of 80,000 more workers — an increase of nearly 80 percent — to provide minimum public health services.

CDC has made substantial one-time investments to address these longstanding needs, including $2 billion for immediate emergency crisis response and $3 billion in foundational workforce and infrastructure. These funds not only provide critical support for school-based health programs, public health professional development, and acquisition of important technological upgrades, but they allow state and local jurisdictions to build their workforce to best serve their communities. For example:

• The Ohio Department of Health was able to provide surge staffing during the East Palestine train derailment response, including epidemiologists and other key personnel
• The Vermont Department of Health is retaining staff hired during the COVID-19 response
• The Shelby County, Tennessee Department of Health is supporting 13 employees pursuing public health degrees at the University of Memphis

These investments are a good start, but public health needs remain deep and long-term. As requested in the FY 2024 Budget, sustained investment in our nation’s public health departments and infrastructure must remain an ongoing priority.

Internally, CDC is focused on internal transformation so staff can transition from their daily positions to emergency response rapidly and effectively when needed.  In December 2022, CDC launched the new CDC Ready Responder Program with a vision to grow and strengthen a diverse workforce of pre-qualified, trained, and available responders to establish and sustain public health emergency responses regardless of frequency, size, or complexity.

Additionally, public health entities must be able to rapidly share data within and among jurisdictions, and with CDC, to enable local leaders to make the best decisions for their communities and save lives in dynamic situations. We’ve made incredible progress from the pre-COVID-19 era. The Response Ready Enterprise Data Integration platform (RREDI), which is the next generation of HHS Protect, is a secure decision-making and operations platform developed for the whole-of-government response to the COVID-19 pandemic and is now expanding to support emerging outbreaks such as mpox and future public health responses. RREDI uses and integrates data from more than 300 sources across federal, state, and local governments and the healthcare industry; and is accessible to 4,500+ unique users across 30+ federal agencies, 56 states and territories, and the private sector. In addition, CDC’s National Healthcare Safety Network (NHSN) has provided essential data on known and emerging threats from more than 38,000 American healthcare facilities, including the U.S. government’s first comprehensive look at pathogen-agnostic hospital bed occupancy and capacity data from all U.S. hospitals.  CDC continues to leverage systems like NHSN to meet the goals of the National Biodefense Strategy and to build on the lessons learned from the COVID-19 pandemic to maintain and enhance an enduring domestic all-hazards hospital data collection capability.  Even with this progress, we have much more to do when it comes to building data infrastructure for both routine and emergency work. Congressional funding and legislative policy changes as requested in the FY 2024 Budget will be necessary to achieve these goals.

To be effective responders, CDC must implement appropriate, equitable, and immediate early interventions and prevention strategies to prevent an outbreak from becoming an epidemic or a worldwide threat. These interventions must be implemented based on the best available science and informed by the communities where the interventions will take place.  Dedicated CDC preparedness funding over the past two decades built many of the basic capacities and capabilities that accelerated the STLT public health response to the COVID-19 pandemic. CDC-funded infrastructure and CDC guidance enabled jurisdictions to stand up emergency operations functions, provide medical-grade warehousing capability and logistics, coordinate mass vaccination and cold chain management functions, and rapidly distribute millions of laboratory test kits, personal protective equipment (PPE), and other critical supplies needed to respond to the COVID-19 pandemic.  As just one example, 93 percent of recipients of funding through the Public Health Emergency Preparedness (PHEP) program report that PHEP funding and the capabilities developed through the program built a strong foundation that positioned them to ramp up COVID-19 response activities very rapidly. Some successes include Tennessee leveraging a state flu exercise program into a real-world COVID-19 vaccination campaign, and Vermont using PHEP funding to enhance its emergency management software and expand its capacity to manage numerous vaccine administration sites during the COVID-19 pandemic.

In the fight against infectious diseases, no nation can stand alone. When it takes less than 36 hours for an outbreak to spread from a remote village to any major city in the world, protecting U.S. health and national security means making sure other countries have the knowledge and the resources to stop threats before they can spread beyond their borders. Together, we must build these first lines of defense to better prevent, detect, and respond to disease and other biothreats.

CDC must have strong domestic and global capabilities to respond to outbreaks, which are becoming ever more complex and frequent, to protect health, save lives, and protect livelihoods. CDC is strengthening its existing global efforts and working to build capacity among international partners to quickly detect and respond to infectious disease outbreaks. For example, CDC continues to support responses around the world as demonstrated by the recent Ebola (Sudan virus) outbreak in Uganda and the current Marburg outbreaks in Equatorial Guinea and Tanzania.

CDC works 24/7 to protect the health and safety of Americans. CDC is uniquely suited to use our expertise to support partner governments in building health programs, address health threats, enhance and strengthen sustainable and country-owned public health systems, and improve health outcomes for all.

The future CDC must be prepared to lead the country in these core capabilities and to set ourselves up for success, we must first find ways to address long-standing challenges. Beginning in spring 2022, I launched an extensive review of the agency’s organizational structures, systems, and processes to strengthen its ability to deliver on its core mission to equitably protect the health, safety, and security of Americans. In August 2022, based on this review and other substantial internal and external input, I launched the CDC Moving Forward initiative which focuses on the following top improvement areas:

• Share scientific findings and data faster
• Enhance laboratory science and quality
• Translate science into practical, easy to understand policy
• Prioritize public health communications
• Develop a workforce prepared for future emergencies – CDC and nationwide, and
• Promote results-based partnerships

On January 24, 2023, I announced a CDC reorganization, one of several foundational steps to achieve progress in the improvement areas outlined above. This reorganization aims to eliminate bureaucratic reporting layers, break down silos in the agency, promote foundational public health capabilities, and improve accountability at CDC.

Parallel to the reorganization, my leadership team has engaged staff from across the agency on priority actions that will improve how we do our work. This work is ongoing, but I’m proud to say that CDC has already implemented numerous actions, including:

• Improved efficiencies in scientific review by reducing clearance time for CDC publications by 50 percent;
• Initiated the CDC Infectious Disease Test Review Board, an internal group to promote quality assurance prior to national deployment of laboratory tests;
• Established process for institutions to submit applications for access to investigational drugs; reducing the time required for institutions to apply from 14 days to 6 hours – utilized with tecovirimat for mpox; and
• Implemented executive leader performance plan changes that outline expectations for CDC leaders in response participation, data modernization, and scientific quality and timeliness.

As the CDC community tackles challenges internal to the agency, we also need support from Congress consistent with the FY 2024 Budget request, to support revised and new authorities so that CDC can be better prepared and respond to the next emerging disease.

Historically and today, CDC is forced to rely on time-consuming “work-arounds” within our existing authorities and policies to meet operational and programmatic needs when time is of the utmost essence. The COVID-19 pandemic and other outbreaks have only underscored how much these challenges have hampered the agency and continue to do so. If CDC is to play a key role in rapidly detecting pathogens to support all levels of government response to biological threats as envisioned in the new National Biodefense Strategy and Implementation Plan, these gaps must be addressed. In the FY 2024 Budget, we have requested flexibilities and authorities in the context of the PAHPA reauthorization that are critical to the agency’s ability to be more effective and responsive during fast moving, large-scale public health outbreaks. These proposals fall under two broad categories: 1) operational readiness and 2) strengthening workforce capacity. On their own, these proposals are not likely to be sufficient to change how CDC responds to the next emerging threat. However, taken together, they offer a roadmap to provide the tools and resources CDC needs to better prepare for, and respond to, the next emerging public health threat, whether from a local outbreak or a global pandemic. I have highlighted examples of a few authorities below and welcome continued discussion on ways to strengthen CDC to protect our national security through public health.

Data must serve as the foundation for everything we do, particularly in the context of a public health emergency response where critical decisions on where and how to target interventions must be made quickly. Having timely, high-quality data on where disease is spreading, the severity of illness, and the populations most impacted is a critical element of operational readiness. It allows state and local public health and other health care professionals, and policy makers to target resources to mitigate an outbreak and predict future spread. We are grateful that Congress has authorized and funded CDC’s newest center, the Center for Forecasting and Outbreak Analytics, to improve the nation’s ability to prepare for and respond to public health threats using data, modeling, and analytics. But if CDC must continue to rely on a decentralized framework for data reporting, subject to a patchwork of individually negotiated Data Use Agreements, we will not be able to provide the best forecasts and modeling in the world.

Where we can, we are making improvements on sharing data. CDC’s Center for Forecasting and Outbreak Analytics delivered four technical reports on the mpox outbreak. These reports are publicly available, have been shared widely, and provided timely updates on CDC’s response to the outbreak, including our estimates of the trajectory of the outbreak. These reports were developed at the speed of the outbreak, to get the best information we had out to decision makers quickly. We included qualitative risk assessment information in these reports to deliver the bottom-line up front while also making it clear the level of confidence we have in our analyses.

However, the way in which public health data are collected and shared has resulted in delayed, fragmented and inconsistent reporting to CDC, and to state and local public health partners. To address this issue and support better data sharing with states, locals, and providers, CDC will need updated legislation as requested in the FY 2024 Budget.

Unlike the public health infrastructure that exists for children to receive recommended vaccines from their pediatricians, the current infrastructure for adults is not robust. In response to the COVID-19 pandemic, CDC built infrastructure to rapidly deploy safe and effective vaccines to the entire U.S. population. As proposed in the FY 2024 Budget, CDC’s Vaccines for Adults (VFA) program would begin to expand access to Advisory Committee on Immunization Practices (ACIP)-recommended routine and outbreak vaccines at no cost for uninsured individuals. Establishing a robust infrastructure for adult vaccination will support response readiness by reducing vaccination coverage disparities, improving outbreak control of vaccine-preventable diseases, and enhancing and maintaining the infrastructure needed for responding to future pandemics.

In addition to operational improvements, CDC needs a workforce that is nimble and response ready. CDC is enhancing its work to better prepare and coordinate staff across the agency ahead of emergency events. However, as requested in the FY 2024 Budget, CDC needs additional operational authority to implement policies to address issues such as overtime pay caps, danger pay, loan repayments, and other flexibilities that enable CDC to rapidly respond to urgent public health needs. These authorities would greatly improve CDC’s workforce capacity and help build a pipeline for future public health leaders.

In conclusion, CDC is working hard to address challenges identified during the COVID-19 pandemic.  We are building on a strong foundation of core capabilities in public health and leveraging our areas of expertise and successes to build systems that are more resilient that can better respond and adapt to emergencies. Yet, to fully enable CDC to better prepare for, and equitably respond to, the next emerging public health threat, the agency needs the support, flexibilities, and authorities as requested in the FY 2024 Budget. We must look for opportunities to apply lessons learned and advance bipartisan solutions to be better prepared for future public health challenges. Congressional action to support these FY 2024 Budget proposals in the PAHPA reauthorization will improve how CDC responds to future emerging threats and will support the agency’s modern-day mission. I look forward to working together to implement the solutions that will make this agency – the work of which is so critical to America’s health – and our partners at the state, local, tribal, and territorial level, better prepared for what comes next.

Thank you, and I look forward to your questions.