To date, there is no pandemic/avian flu in the United States, nor is the Nassau County Department of Health collecting or testing birds for the avian flu. For the latest information, news, key facts and other information such as surveillance and national strategy for a pandemic/avian influenza, link to the official U.S. Government web site sponsored by the U.S. Department of Health and Human Services at www.pandemicflu.gov or the CDC Centers for Disease Control and Prevention Influenza Flu Homepage at www.cdc.gov/flu/avian or call 800-CDC-INFO.

Testimony by Dr. David Ackman, MD, MPH
Nassau County Commissioner of Health
Past-President, New York State Association of County Health Officials

The Joint New York State Senate Health and Homeland Security Committees
Hearing on Avian Influenza Preparedness

Friday, March 10, 2006
Mineola, NY

To the Committees 

Thank you for inviting me to speak on this very important topic.  The threat of avian influenza has received much recent attention, as have national and state plans to prepare for a major influenza pandemic.  Just a few weeks ago the State Health Department convened a meeting to review the New York plan, and the role assigned to local health departments. 

I will speak primarily on what we have done locally to plan and prepare for an avian influenza epidemic. In this I will also be speaking for my colleagues at NYSACHO.  Every county, and every county health official, will bear similar responsibilities in the event of a pandemic. Much of what I will describe is a continuation of the general preparedness work we have undertaken since 2001.  I will also discuss where we find the major gaps or pitfalls in flu preparedness, much of which will not be solved at the local level.  Finally, I want to relate my concerns about the increasingly prescriptive way we fund public health preparedness activities.

Context
Fears about an influenza pandemic are based on knowledge of how the influenza virus behaves normally, and how a highly pathogenic strain might behave.  Every year one or more strains of influenza infect millions of people worldwide.  In the United States influenza causes approximately 30,000 deaths a year, primarily among the aged.  Because the virus is so easily spread from person to person, most people have some degree of immunity due to exposure to previous years’ strains.

A pandemic strain (arising either by a mutation from an avian (H5N1) strain or a human strain) would be easily transmissible from person to person, cause infection in a high percentage of the population, with a large proportion of those becoming severely ill either due to lack of immunity or the inherent pathogenicity of the virus.   Our planning is based on a worst-case scenario similar to the 1917-18 pandemic.

Planning
Since 2001, every health department in the country has been developing, testing and refining plans to deal with bioterrorism, natural outbreaks and now pandemic influenza.  Much of this has been done with guidance from NYS, but local officials are ultimately responsible for developing a realistic, workable plan for their county.

In Nassau, the HD has completed annexes to our central county emergency guidance document, including plans to address Isolation and Quarantine, an anthrax outbreak, the reemergence of smallpox or other agents of bioterrorism.  All of these were completed with the help of other county agencies, outside partners and consultants.  All conform to state-approved templates and to the essential, time-tested approach to epidemic control: detection, mitigation and communication.  All plans delineate how to enhance disease surveillance, conduct rapid case investigations, make environmental assessments, get people into care, distribute medications, prevent disease transmission, and all the while keeping other officials, agencies, and the general public calm and informed. 

 Surveillance
Local HDs are not charged with detecting the introduction of avian influenza in wild or domestic wildlife.  If one of the highly pathogenic H5N1 strains were detected, the role of local health departments would be to assist in the detection of human disease due to an avian strain.  We would inform the medical community and enhance surveillance for influenza like illness by tracking school absenteeism, emergency room visits for influenza, and investigation of persons with potential exposure to avian strains. We would also arrange for submission of clinical specimens to the NYSDOH or CDC.

Early Control
If we are able to identify the earliest cases in a community, using isolation and quarantine measures might delay widespread illness.  NC has an I&Q plan, but we have not identified an institution or facility where we could support a large number of people outside the home.  However, isolation and quarantine are unlikely to have more than a temporizing effect on influenza transmission.

Distribution of vaccine and medications
In the case of a pandemic flu emergency, NCDOH will receive guidance from the NYSDOH and the Federal Government to disseminate available vaccine or antiviral medication.  The HD has established Points of Distribution sites (PODs) with various agencies and municipalities and intends to also use large employers to distribute medications to their employees.  NC does not have plans to stockpile vaccine or antivirals.
It is critical to recognize that at the early stages of a pandemic, vaccine will probably not be available.  Even with expedited and expanded production, vaccine will arrive in small qualities, requiring that we prioritize immunization.  Therefore, it is important to decide now how we will prioritize vaccinations.  Two years ago we struggled when faced with a temporary shortage of flu vaccine in a very mild year.  We need to work this out well in advance, and make the public aware that this will be part of our national plan. 
Similarly, we do not anticipate having enough antivirals to distribute to all 1.3 million residents.  Even if we did have enough supply, the utility of antivirals in preventing severe disease or transmission in the community has not been demonstrated.  Therefore, while we will be able to distribute medications and vaccines, their availability and effectiveness are questionable.

Creating Surge Capacity

A major pandemic will test the health care system, especially hospitals, which often operate near capacity. Hospitals and nursing homes are developing plans to free up beds, but this may not provide all the needed capacity.  The health department, in coordination with the North-Shore-LIJ Regional Resource Center is also beginning to locate alternate care facilities.  However, we have already seen (in our planning for a smallpox epidemic) that no hospital or nursing home wants to be identified as the “epidemic” hospital.    We also need to plan for staffing these facilities, protecting workers and their families, and prioritizing levels of care. It still has not been clearly delineated who has the authority to order redistribution of medical resources in an emergency, but local officials would have to be part of any such decision.  Finding or creating surge capacity, who pays for it, and who controls it, are all major uncompleted tasks in pandemic planning.

Public Health Measures and Communication

Even without vaccine or medication, there are ways to potentially slow or prevent the spread of disease.  This includes personal actions, like covering your mouth when you cough, hand washing, wearing a surgical mask or staying home when you are ill.  Other measures include canceling school or large events.  Because we may not have much warning, we need to prepare these messages and strategies in advance, and decide who will make decisions that impact schools or private businesses. 

Partnerships in Emergency Response

One of the greatest benefits of these five years of planning and training in emergency response has been the relationships and partnerships forged with emergency management, police, fire, hospitals and professional organizations.  It has also created a much stronger bond between state and local health departments.   We are now in our fourth year of federal funding for bioterrorism planning, and it continues to be a highly collaborative and cooperative joint venture in New York State.

Funding for Preparedness

The efforts I described were largely supported by federal grants.  Some of these funds were used to buy equipment, conduct drills, hire consultants and for other one-time costs.  The greatest benefit, however, has been to boost basic public health infrastructure by allowing us to hire staff, conduct trainings and acquire new expertise.  NYSACHO has always believed that a robust and ready public health system is essential if we expect a high level response, and this, I believe, was the original intent of the bioterrorism grant. 

Therefore, we are concerned that new federal funding will be overly prescriptive. Local contracting rules, shortages of outside consultants, and other rules will make it increasingly difficult to spend funds for say the costs of conducting a drill.   Also, we cannot predict for how long, and at what level, the CDC will continue this funding.

That is why state and local support for public health preparedness is so important. This year the governor did not propose cutting state support for local health departments.  We are grateful for this and your recognition of the importance of Article 6 and we endorse the proposed changes that will encourage localities to address emerging public health threats while increasing accountability. We are always eager to demonstrate the value and importance of local health departments, because it is almost always a very compelling picture for support, from the public and from public officials. 

Appendix: Details for Nassau County Health Department Planning Efforts

1. Pandemic Influenza Annex to NC Emergency Response Plan
The NC pandemic influenza plan, which we intend to submit to the NYSDOH in July, will:

• Conform to NIMS and can be implemented under the ICS, if necessary; 
• Maintain existing relationships with public and private partner agencies capable of assisting with preparedness activities (planning, training, and exercises);
• Allow for training and equipping staff to activate a pandemic flu response;
• Rely on traditional surveillance for seasonal influenza, including electronic reporting, and implementation of enhanced surveillance once a pandemic is detected.
• Guide rapid epidemiological investigations to identify the source of infection, risk factors, and appropriate interventions;
• Set out methods and locations for distributing vaccine and anti-viral medications, when and if they become available;
• Maintain the ability to activate a telephone hotline and Web site, to respond to local questions from the public and professional groups;
• Ensure that all reasonable measures are taken to limit the spread of an outbreak within and beyond Nassau’s borders through education and other state initiatives;
• Identify key spokespersons and provide public education.

2. Public Health Partnerships in Emergency Preparedness

• NCDOH has well-developed communication systems with our 71 volunteer fire departments, Nassau County and local PDs and FM, universities and emergency departments and Infection Control Practitioners in 12 Nassau County hospitals.  An example of a multi-agency collaboration at the local and state level was in the case of suspected monkey pox. 
• NCDOH participates on several committees including VOAD, Regional Preparedness Council, which provide a venue to further coordinate and share resources.
• NCDOH coordinates with the North Shore-LIJ Regional Resource Center, to support and address issues that are specific to the hospitals.
• NCDOH is successful and continues to actively recruit new members to serve in our local MRC.  At this point, NCDOH MRC has 320 volunteers, which include all types of licensed and certified health professionals who are credentialed and trained to respond under the direction of NCDOH.  Our MRC has already participated in five training programs: Disaster Triage, Medical Triage, Pandemic Flu, POD training and acute traumatic stress management. Our MRC participated in a BDS drill held with the USPS, to prophylax the staff of the postal facility in the event the BDS system detects a letter containing anthrax. During 2004, the NCDOH activated its ICS plan, using the MRC, to address a rabies epidemic over a sustained period of time.  At the flu POD held during November 2004, NCDOH demonstrated it could vaccinate 8,000 senior citizens in 2 eight-hour shifts.
• NCDOH in June will drill its first responder prophylaxis plan. This exercise will include our 71 Volunteer Fire Departments, Police Department and Fire Marshal and 12 Nassau County hospitals.

3. Major Accomplishments in NCDOH Preparedness

• Medical Reserve Corps- original grantee, nationally recognized, developed credentialing system (police dept and county attorney) and deployed successfully in two drills
• Documented capacity to operate POD system (2004 influenza season)
• First responder prophylaxis planning and exercise scheduled June 2006
• POD planning with municipalities and business
• Training on I&Q with County Attorney and Courts
• Strong local academic partnerships (Adelphi, Columbia, NYCOM)
• Participated in BDS drill and currently hold prophylactic antibiotics for postal workers

For up-to-date weekly influenza surveillance reports click here

This message is current as of June 1, 2006.

Influenza and pneumococcal immunization clinics for Nassau County senior residents will be scheduled beginning in mid-October 2006.  The schedule and information for making appointments will be available in late September.

Nassau County Department of Health recommends that everyone should take the following steps to protect themselves, their family and others from respiratory illness:

• Clean your hands. Washing your hands after coughing and sneezing and washing your hands often will help protect you from germs.
• Avoid touching your eyes, nose, or mouth. Germs are often spread when a person touches something that is contaminated with germs and then touches his or her eyes, nose or mouth.
• Cover your cough or sneeze. Covering your mouth and nose with a tissue when coughing or sneezing may prevent those around you from getting sick.
• Avoid close contact with people who are sick. If you are sick, keep your distance from others to protect them from getting sick too.
• Stay home when you are sick, if possible. Staying home from work, school and errands when sick will help prevent others from catching your illness.