Legislature(2005 - 2006)BUTROVICH 205
02/13/2006 01:30 PM Senate HEALTH, EDUCATION & SOCIAL SERVICES
| Audio | Topic |
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| Start | |
| Overview - Department of Health and Social Services Pandemic Influenza Response Plan | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| + | TELECONFERENCED | ||
ALASKA STATE LEGISLATURE
SENATE HEALTH, EDUCATION AND SOCIAL SERVICES STANDING COMMITTEE
February 13, 2006
1:36 p.m.
MEMBERS PRESENT
Senator Fred Dyson, Chair
Senator Gary Wilken, Vice Chair
Senator Kim Elton
Senator Donny Olson
MEMBERS ABSENT
Senator Lyda Green
COMMITTEE CALENDAR
Overview - Department of Health and Social Services Pandemic
Influenza Response Plan
PREVIOUS COMMITTEE ACTION
No previous action to record
WITNESS REGISTER
Richard Mandsager, MD, Director
Division of Public Health
Department of Health and Social Services
PO Box 110601
Juneau, AK 99801-0601
POSITION STATEMENT: Presented Pandemic Influenza Response Plan
Overview and answered questions.
Jay Butler, MD, Chief
Epidemiology Section
Division of Public Health
Department of Health and Social Services
PO Box 110601
Juneau, AK 99801-0601
POSITION STATEMENT: Presented Pandemic Influenza Response Plan
Overview and answered questions.
ACTION NARRATIVE
CHAIR FRED DYSON called the Senate Health, Education and Social
Services Standing Committee meeting to order at 1:36:46 PM.
Present were Senators Gary Wilken, Kim Elton, Donny Olson and
Chair Fred Dyson.
^Overview - Department of Health and Social Services Pandemic
Influenza Response Plan
1:37:04 PM
CHAIR DYSON announced that the committee would hear an overview
on response plans for pandemic influenza.
RICHARD MANDSAGER, MD, Director, Division of Public Health,
Department of Health and Social Services (DHSS), introduced
himself and Dr. Jay Butler, the new state epidemiologist.
JAY BUTLER, MD, Chief, Epidemiology Section, Division of Public
Health, Department of Health and Social Services, told members
that prior to taking his new position he was director of the
Arctic Investigations Program in Anchorage under the Centers for
Disease Control and Prevention (CDC). He has lived in Alaska
since 1998.
1:37:52 PM
DR. MANDSAGER explained that he and Dr. Butler would discuss
avian influenza and preparations for pandemic influenza. He
briefly reviewed the four items in members' packets: a brochure
discussing types of flu; a copy of Administrative Order 228,
signed January 2, 2006, relating to preparedness; a copy of the
State of Alaska Pandemic Influenza Preparedness Concept Plan;
and a copy of the PowerPoint presentation. He explained that
Dr. Butler would present the science of influenza and he would
discuss preparations.
1:41:04 PM
DR. BUTLER presented the following:
Influenza: What Is It?
¾Respiratory tract infection-caused influenza virus.
¾Transmission by respiratory droplet.
¾Illness begins 1-5 days after exposure.
¾Infectious from day before or day of illness onset, lasts
3-5 days.
¾There are three major types of influenza:
¾Influenza A is the focus of the current
discussion - frequent winter epidemics, also
causes pandemics.
¾Influenza B - occasionally causes winter
epidemics.
¾Influenza C - fairly uncommon - episodic
infection.
1:42:49 PM
Influenza A
¾Typing is based on the surface projections from the virus.
¾ There are 16 H types and 9 N types. This is
where the sub-typing names such as H5N1 come
from. They are based on those surface components
of the virus.
¾Exists in nature primarily in aquatic birds.
¾Occasionally, strains will "jump species."
¾Some strains are specific to horses.
¾Many strains infect pigs.
¾Strains have adapted to infect seals and whales.
¾Several avian strains are capable of infecting
domestic poultry, which is of importance
economically.
1:43:58 PM
SENATOR OLSON asked if Dr. Butler was referring to the antigens
when he spoke of H and N types.
DR. BUTLER replied yes; they are projections on the surface of
the virus itself.
SENATOR OLSON asked if they are in the RNA.
DR. BUTLER explained that the RNA is the genetic component
within the virus, while the H and N are surface components. The
H stands for hemoglutinin, which is what binds the respiratory
tract of the infected animal. The N stands for neuraminidase,
the component of the virus that helps it to bust out of infected
cells in large numbers.
1:45:17 PM
DR. BUTLER continued:
Human Influenza
¾Influenza A subtypes can be spread widely among humans.
¾H1N1 is a descendant of the strain that caused
the 1918 influenza pandemic.
¾H3N2 is currently the most common subtype and
descends from the 1968 pandemic
¾H1N2.
1:46:18 PM
Avian Influenza
¾Is an influenza A virus that is found mainly in birds.
¾There are two types.
¾Low-pathogenic is most common, and the disease
may be mild or absent. Manifest as ruffled
feathers and/or reduced egg production.
¾Some strains become highly pathogenic. They are
identified as being capable of killing more than
75% of experimentally infected chickens. In
agricultural situations, mortality can approach
100% in the infected birds.
SENATOR OLSON questioned whether the virus could penetrate the
egg.
DR. BUTLER replied that the concern isn't that it penetrates the
egg. Rather, it's that the virus can be transmitted from the
contaminated shell of the egg.
1:47:58 PM
SENATOR OLSON asked if exposure to the chick is automatic once
the egg is broken.
DR. BUTLER replied that it would occur through exposure to the
other birds in the flock that are infected.
DR. BUTLER continued:
H5N1 Avian Influenza
¾A low-pathogen strain was first isolated from terns in
South Africa in 1961.
¾H5N1 circulates globally in wild birds. It's been isolated
from wild birds in North America in the past but that's
always been the low-pathogen strains.
¾In 1997 a highly pathogenic strain emerged among domestic
poultry in Hong Kong.
¾It was unusual in that it caused severe disease
among humans who were infected. Before 1997 only
H7 strains of avian influenza had infected
humans. Eighteen people were infected and six
died.
¾The virus was contained by controlling the
infected flocks.
¾The virus re-emerged in Southeast Asia in December 2003.
1:49:22 PM
Transmission of H5N1 Avian Influenza to Humans
¾Primarily through direct with infected domestic poultry or
their excretions.
¾Human-to-human spread has been rare to date.
¾Rare health care worker transmission
¾In September 2004 a child became infected. The
infection spread to the mother who had no
exposure to poultry. Further transmission didn't
occur.
1:49:54 PM
Spread of H5N1 in 2005
The slide indicated countries in Eurasia with outbreaks, with
and without human cases. In just the first few weeks of 2006
the slide has become out of date.
Outbreaks in birds were identified in Turkey in October 2005,
followed by a cluster of infections among humans in
January 2006. Twenty-one cases were under investigation, and
four have been fatal. All those infections followed exposure to
infected domestic poultry.
Infected birds have recently been identified in Greece, Italy
and Bulgaria. Of greatest concern is the discovery of H5N1 avian
strains that are infecting domestic poultry in Nigeria.
During the last few weeks, infections have been identified in
Iraq; the first human case has been identified there as well.
That brings to seven the number of countries where human
infections of H5N1 have been identified.
SENATOR ELTON mentioned a report of infected birds on the
Denmark border.
1:51:53 PM
Why Should We Care?
Recipe for an Influenza Pandemic:
¾A new influenza virus to which the population has little
immunity.
¾That's present in the form of H5N1.
¾Ability of the virus to replicate in humans and cause
disease.
¾Two additional fatal cases were identified in
Indonesia over the last weekend; and one more
fatal case was identified in China. Since
December 2003, the total is 169 cases with 91
deaths in Eurasia.
¾The most critical ingredient is efficient and sustained
person-to-person transmission. That hasn't yet occurred
with H5N1.
1:52:43 PM
Potential Clinical Impact of Pandemic Influenza in Alaska
Outcome Approximate Number
Illness 200,000
Clinic visits 100,000
Hospitalizations 2,000-22,000
ICU admissions 300-3,000
Mechanical ventilation 150-1,500
Deaths 400-4,000
DR. BUTLER explained that in pandemics the population is very
susceptible. Over a period of 12 to 18 months, it's anticipated
about one-third of the population becomes ill. In Alaska that
translates to about 200,000 cases, and about half would be ill
enough to seek medical care in clinics. Hospitalization
estimates range from 2,000 to 22,000, depending on the
differences in the ability of various pandemic strains to cause
disease. For perspective, he pointed out that there are just
1,400 licensed hospital beds in Alaska. Lower estimates are
based on virus types that caused pandemics in 1957 and 1968,
while higher estimates are based on the 1918 influenza pandemic.
Of those hospitalized, it's estimated that roughly 10 percent
will require intensive care, and between 150 and 1,500 will
require mechanical ventilation. In a regular influenza season,
50 to 100 people die. It's estimated that during the next
pandemic between 400 and 4,000 people will die in Alaska.
He said, as far as what to do about the projected numbers,
public health has three tools available. The first is vaccines,
which won't be available at the start of the next pandemic. A
vaccine to treat the H5N1 strain is under development, but that
might not be the next pandemic strain. The second tool is use
of antiviral drugs early in treatment, and stockpiling of about
20,000 courses is recommended in Alaska. The third tool is
infection-control measures including personal protective
supplies and education about transmission in health care
facilities and communities.
CHAIR DYSON asked how patients are treated.
DR. BUTLER explained that if treatment is started early,
antiviral drugs are used. Beyond that, treatment is supportive
and includes treatment of secondary infections. A number of the
deaths that occurred during the 1957 and 1968 pandemics were due
to bacterial pneumonia, a complication of influenza. In the 1918
pandemic, many more people died quickly of the primary influenza
infection.
1:54:55 PM
CHAIR DYSON asked whether the respiratory system is permanently
compromised.
DR. BUTLER replied that most people who are able to survive the
infection do very well, but the long-term effects of influenza
is a topic of ongoing debate. For instance, there is a question
about whether some cases of Parkinson's disease seen in the
middle of the 20th century were related to the 1918 pandemic
strain.
SENATOR OLSON asked about the anticipated time for being on a
respirator.
DR. BUTLER stated that it depends on the severity of the illness
and whether other organs fail.
SENATOR OLSON referenced the 91 deaths out of 170 cases since
December 2003 and asked if any had access to intensive care
units (ICUs) with mechanical ventilation capability.
DR. BUTLER replied that there are exceptions, but many cases did
have access to intensive care.
CHAIR DYSON questioned whether certain conditions make someone
more vulnerable to influenza.
DR. BUTLER answered that the very young and the very old are
more at risk, and the older the patient, the greater the risk of
death. Also, people with underlying diseases or compromised
immune systems are at greater risk of dying. For the next
pandemic it's hard to say. The 1957 and 1968 pandemics behaved
like seasonal influenza, but the 1918 pandemic was different.
In that one, people between 25 and 40 years of age had a higher
death rate, perhaps because the virus was able to induce an
immune response that damaged the lungs in particular. When the
H5N1 virus infects people, it seems to cause a similar reaction,
he noted.
CHAIR DYSON asked about transmission of the disease.
DR. BUTLER explained it's transmitted via respiratory droplets;
it's different from an airborne disease such as tuberculosis or
measles. Influenza viruses are fairly stable, so ordinary
hygiene is important.
2:02:52 PM
Common Misperceptions About Pandemic Influenza
¾An influenza pandemic is overdue, and it will be caused by
H5N1 "bird flu."
¾This is a "gambler's fallacy." Because there
hasn't been a pandemic since 1968 doesn't mean
one is more likely this or next year.
¾We don't know which type of influenza will cause
the next pandemic. Strains other than H5N1 can
cause a pandemic.
¾We do have better technology to recognize trends
in viral evolution and infection in animals and
humans than in the past.
2:04:26 PM
CHAIR DYSON asked what symptoms, other than mass die-off,
infected birds might exhibit that the general population could
recognize.
DR. BUTLER explained that a large die-off might occur if a
highly pathogenic strain entered an area, but that is a poor
signal because certain species don't die when infected. Species
such as ducks, swans and geese that serve as the reservoir for
influenza A are capable of carrying the virus asymptomatically
and infecting other birds on the migratory path.
CHAIR DYSON asked if the symptoms for avian flu are different
from those of ordinary flu.
DR. BUTLER explained that it's a case-by-case basis, but the
cardinal ways for detecting are to check for recent travel to an
area that has the particular virus, or to check for exposure to
sick poultry.
CHAIR DYSON questioned whether practitioners in the state have
gotten the message to ask the right questions.
DR. BUTLER replied that the epidemiology bulletin has been used
to alert Alaskan clinicians about H5N1. Furthermore, he
indicated he'd been making rounds and speaking with physicians
to ensure that people are aware of the clinical manifestations
of H5N1, as well as the availability of tests.
CHAIR DYSON asked what the clinical manifestations are.
DR. BUTLER answered that for H5N1 in humans, of which there have
been fewer than 200 cases to date, a classic description
includes a fairly severe respiratory illness that rapidly
progresses to pneumonia, a syndrome known as the adult
respiratory distress syndrome (ARDS), and sometimes multi-organ
failure; fever is common. Patients with H5N1 don't seem to have
as much muscle ache as with regular seasonal influenza, and may
be more likely to have gastrointestinal symptoms, particularly
diarrhea.
SENATOR ELTON asked whether cooking poultry gets rid of the
danger.
DR. BUTLER answered that the virus is deactivated at
temperatures of 155 to 165 degrees, which was addressed in
initial guidelines put out for Alaskan hunters for wild game.
He pointed out that there's no documentation that the infection
is spread through eating infected birds, or evidence that the
H5N1 strain is in Alaska. However, the recommendation is that
any game that is poultry should be cooked to at least 165
degrees Fahrenheit.
SENATOR ELTON said it seems the problem with a pandemic is that
it might not be this particular virus, which precludes being
able to develop the proper vaccine. Thus all that can be done
right now is to observe, and all the medical community can do is
to keep track of reports when the contact may have come from
poultry, and then determine whether it has spread from human to
human.
DR. BUTLER answered that more can be done. The challenge with
vaccines for the next pandemic is twofold. One is what exactly
the next strain will be. The second is "how we do it," which is
where there is an opportunity; he specified that "we" means the
medical community as a whole. Currently, influenza vaccines are
mass-produced, using the same technology used 50 years ago. The
six- to nine-month process involves inoculating a large number
of fertilized eggs, then harvesting the virus and activating it,
creating the vaccine.
He said part of the federal funding focuses on developing new
technologies based on cell culture, with the hope of shortening
that time to just a few months. "If we have a pandemic anytime
in the next couple of years, we will not have a vaccine probably
for about the first six months or so," he concluded.
2:12:25 PM
DR. BUTLER continued, presenting the following:
Common Misperceptions About Pandemic Influenza
¾Like a forest fire, an influenza pandemic can be snuffed
out if caught early.
¾Given the short incubation period, viral shedding very
early after infection, and ease of spread, this is highly
unlikely.
¾There is nothing that we can do and the federal government
is going to take care of this anyway.
¾Preparedness is critical for mitigation but
¾Vaccines will probably not be available at the
beginning of the next pandemic.
¾Antiviral drugs will likely be in short supply.
¾There are things that we can all do.
2:14:15 PM
SENATOR OLSON asked about availability and cost of the antiviral
drugs.
DR. BUTLER answered that two classes of the four antiviral drugs
are specific for influenza. Unfortunately, seasonal influenza
has become increasingly resistant to the older class, which
includes amantadine and rimantadine. The newer class of
antiviral drugs is the neuraminidase inhibitors, which includes
Tamiflu. These drugs can reduce the severity of influenza if
administered in the first 48 hours after infection. They may
play a preventative role if administered prior to exposure. The
cost of these drugs is a challenge, however. In the private
sector, the neuraminidase inhibitor costs about $40 for a five-
day course of medication.
SENATOR OLSON asked how long the protection lasts.
DR. BUTLER replied that it depends on whether it's given before
or after exposure. Supply is the other challenge: in Alaska
about 1,000 doses are available now.
2:17:14 PM
SENATOR WILKEN asked whether so-called mad cow disease is a
pandemic or an epidemic.
DR. BUTLER replied that it's neither; it's food-borne through
ingestion of infected beef. "Pandemic" is used for any epidemic
that occurs worldwide. The term "influenza" is used for new
strains that humans aren't immune to.
2:19:58 PM
DR. MANDSAGER presented the following slides related to what is
reasonable in order to diminish the effects of an influenza
pandemic on communities:
Public Health's Role
¾Surveillance for Human Disease
¾Disease Control Policies and Strategies
¾Plan - Train --- Exercise
¾Encourage and Support Partners:
¾Medical System
¾Community Leaders
¾Business Leaders
¾Schools
2:21:40 PM
We're Better Prepared Than Ever Before...
¾New Public Health Law in Effect
¾Emergency Plans for:
¾Incident Command Operations
¾Epi Investigations
¾Mass Prophylaxis (preventive treatment)
¾Pandemic Flu
¾Training of Public Health Staff
¾Mass Prophylaxis Clinic Exercises
¾Human Disease Surveillance
¾Bird Disease Surveillance
2:23:20 PM
SENATOR OLSON asked what form of vaccine would be used.
DR. MANDSAGER answered that the clinics are being tested using
the annual fall flu vaccine. The last two years, communities
have been contacted to see whether they want to test it and test
their own planning and improve readiness. Probably the biggest
exercise so far was in Fairbanks. He noted that last August,
Anchorage tested the ability to distribute medicine by giving
out candy as a surrogate.
DR. MANDSAGER explained that for the United States, Alaska is
the epicenter of bird disease surveillance for summer 2006.
This has everything to do with migratory birds and protection of
the poultry industry. In Alaska, the concern is about human
protection for hunters who handle game birds. The U.S.
Department of Agriculture (USDA) has money - as does the U.S.
Fish and Wildlife Service and the U.S. Geological Survey (USGS)
- appropriated by Congress for surveillance. The nesting area
for many Eurasian species is Alaska, and they mix with birds
coming up the Pacific, Midwest and California flyways. There's
concern that if H5N1 gets to Alaska, it likely will affect birds
heading to the Lower 48, where protection of the domestic
poultry industry is of critical importance.
DR. MANDSAGER mentioned participating in a teleconference six
weeks ago. He said it became clear that care must be used with
regard to the language used on the public, because the domestic
poultry industry is scared. He also noted that range-grown
turkeys in Palmer will cause concern if the strain comes to
Alaska. He mentioned subsistence harvests, as well, indicating
samples were sent to Fish and Wildlife in Madison, Wisconsin.
He said the new Department of Environmental Conservation (DEC)
lab in Anchorage is capable of screening, and there is capacity
in Fairbanks for human screening.
2:29:37 PM
CHAIR DYSON asked what to look for, other than dead birds.
DR. MANDSAGER replied the screeners would swab and collect
feces. A lot of wild birds carry the virus without getting
sick. He said he believes the majority opinion today is that it
spreads via migratory birds, and there is a need to watch for
whether and when it appears in North America. People will be
looking for die-off, but also swabbing apparently healthy birds.
2:30:29 PM
SENATOR WILKEN mentioned a story in USA Today about Foster Farms
and what has been done to isolate chickens, using a clean-room
environment, hopefully rolling that into its marketing to show
that the birds are virus free.
DR. MANDSAGER related a similar positive-marketing article from
the San Joaquin Valley in California, where people who work on
one farm aren't allowed to go to another farm. It isn't just
this virus, he pointed out, naming Newcastle virus as another
against which protection is sought. He emphasized that the
poultry industry anticipates the public fear that will come if
the virus is reported in North America.
SENATOR WILKEN inquired about airplane traffic into Fairbanks
from Asia with regard to this issue.
DR. MANDSAGER noted that the human surveillance issue is the
other part. How will this H5N1 virus get to Alaska? One means
is by migratory birds, but the other is from a person who
unknowingly carries the disease if human-to-human transmission
occurs. If someone arrives by plane from Viet Nam or China, for
example, and is exhibiting flu symptoms, the epidemiologists
will likely be called and will be screening because awareness of
possible human transport is high in Alaska. In that case, if
someone comes off a cargo plane, for example, there is a chance
to contain it, whereas if someone who is sick comes off a
commercial airliner from Asia, it will be far more difficult.
SENATOR WILKEN asked if he would be stopped if he disembarked
from a plane arriving from Asia and was exhibiting flu or cold
symptoms.
DR. MANDSAGER replied probably not, as long as human-to-human
transmission hasn't been reported. However, as soon as there
are reports of community clusters elsewhere in the world,
anxiety will go way up. He noted that Dr. Butler was part of a
team when SARS severe acute respiratory syndrome (SARS) was of
high concern; CDC was working with a quarantine service then for
flights in and out of Anchorage, and people were interviewed
before being allowed to disembark.
He said those days could be coming back. The federal government
has established a quarantine office in Anchorage, staffed with
one person, and the Anchorage airport is updating its quarantine
plans, working with the Division of Public Health. If the need
arises, screening would probably occur before people disembark.
2:35:01 PM
SENATOR ELTON asked whether it's really possible to control
people's movements.
DR. MANDSAGER said he'd address the question in subsequent
slides, but clearly the question is mitigation rather than
control. Furthermore, how much mitigation can there be without
causing social and economic collapse?
2:37:10 PM
DR. MANDSAGER continued, presenting the following:
The Immediate Work Includes....
¾Engaging Faith Organizations, Communities, Businesses, and
Schools
¾Things to do - checklists are available.
¾Alternate Care Site Exercises
¾Hospitals will be overwhelmed, so where will the
less-sick people be housed? Who will staff those
places and how will staff be protected?
¾Developing Antiviral Strategies
¾Is it the public government's responsibility to
stockpile, and how much is appropriate?
¾Who will receive the drugs?
¾Identification of Essential Services and Workers
¾Business should assume that 10-30 percent of its
staff will be sick over the peak period.
¾In Alaska, airline personnel will be important.
¾Isolation and Social Distancing Strategies
¾Community leaders must consider where crowds
gather and how to spread concentrations out.
2:42:35 PM
State of Alaska Pandemic Influenza Preparedness Concept Plan
¾Planning Assumptions
¾State Emergency Response Plan = Foundation for
Preparedness and Response
¾Shortage of antivirals
¾No vaccine for at least 6 months after start of
pandemic
¾Global problem
¾Widespread illness = personnel shortages
¾Duration of 6 - 12 months
¾Health care facilities overwhelmed
¾Reduced national-level resource support
¾Objectives
1. Alaska Pandemic Influenza Annex
¾Annex to Division of Public
Health's Emergency Operations Plan
¾Based on National Pandemic
Influenza Plan
2. Public Information and Education
3. Outreach to Community and Business Leaders
4. Training and Exercise Support for Communities
2:44:15 PM
Guidance to Business & Community Leaders
Pre-pandemic:
¾Identify "essential functions and workers"
¾Determine potential impact on services and supplies
¾Barges may be the most important here in Alaska
¾Establish emergency communications plan
During Pandemic:
¾Establish sick leave policies to keep ill employees home
¾Use flexible workplace and work hours
Before, During, and After:
¾Share best practices and "lessons learned"
¾Stay informed
2:46:00 PM
Legislative Support for Preparedness
Accomplished in 2005 Session:
¾Updated state public health laws (HB 95)
¾Authorized funding for new virology laboratory (SB 73)
Next Steps:
¾Community leadership
¾Ask local leaders about status of emergency plans
¾Participate in community emergency planning
meetings
¾Governor's funding initiative for public health
preparedness
¾Possible future legislation to improve preparedness
¾If hospitals stretch, are they protected
from liability issues?
¾Address licensing issues for nurses who have let their
licenses expire.
2:48:05 PM
$7.23 Million FY2007 Budget Initiative
Alaskans Safe & Secure from Infectious Disease Threats and
Public Health Emergencies
¾$1.0 M: Epi disease surveillance, investigation, and
control
¾$1.0 M: Public health laboratory disease surveillance
¾$1.5 M: Public health nursing support for community-based:
¾Emergency planning and exercises
¾Monitoring of health status
¾Disease investigation and control
¾$2.5 M:
¾$2.05 M: One-time capital project development
¾$0.45 M: On-going maintenance expense
¾$1.23 M: Alaska-based antiviral stockpiles
¾The national plan assumes states will purchase
and contribute about 25% of the stockpile. If
that happens the federal government will provide
incentive by reimbursing 25% of the purchase
amount.
¾It's not known when the antiviral would be
available to Alaska.
2:51:53 PM
SENATOR ELTON asked if additional money is available for
waterfowl surveys.
DR. MANDSAGER replied that the governor's budget for this year
doesn't allocate money for bird surveillance simply because
federal money is available. If H5N1 reaches Alaska this coming
summer, however, it should be a budgetary consideration for next
year.
2:53:10 PM
DR. MANDSAGER continued his presentation:
In Summary
¾It is likely that a pandemic of influenza will happen in
the future.
¾We are better prepared than ever, but we have much more
work to do.
¾The work we do to improve preparedness for pandemic
influenza makes us better prepared for other threats and
emergencies.
¾The Legislature plays a significant leadership role for
Alaska's citizens.
2:53:48 PM
Additional Information
¾Website pandemicflu.gov
¾Website pandemicflu.Alaska.gov
¾The Great Influenza, John M. Barry, Penguin Books, 2004
¾Wall Street Journal, January 12, 2006
¾Article discusses "just in time" and "just in
case."
¾"Just in time" inventory works well for
most business plans today but it works
poorly when preparing for a pandemic
emergency.
¾The military stockpiles inventory "just
in case" there is a wartime event.
¾The public policy question is how much is a
governmental responsibility to do "just in case."
The public health argument is that stockpiling
antivirals is a legitimate "just in case"
expenditure.
2:55:31 PM
DR. MANDSAGER read from the last page of Mr. Barry's book
relating to misinformation and how it can create terror. He
then concluded his presentation by restating a principle that
was learned as a result of the 1918 pandemic: The public must
be honestly informed, and the government must do the best job
possible to mitigate societal effects that could be profound.
2:57:38 PM
SENATOR OLSON asked how to prepare for a possible pandemic and
at the same time ensure a bureaucracy isn't created that is
difficult to fund in the future.
DR. MANDSAGER replied that it comes down to legislative
vigilance and oversight. Training is an ongoing process, but
with regard to stockpiling the question is very appropriate.
2:59:37 PM
SENATOR OLSON asked about advances in irradiation to stop viral
transmission.
DR. BUTLER explained that irradiation may have a role in
prevention of certain food-borne illnesses and prevention of
tuberculosis, but it hasn't been identified as a useful modality
in cases of influenza.
3:00:31 PM
SENATOR OLSON asked what the involvement will be for Bush
hospitals that are already strapped for trained personnel, and
how they'll cope with some of these issues. He noted that when
somebody gets sick in the Bush, that person is often sent via
medevac to Anchorage or Fairbanks.
DR. MANDSAGER answered that the rural provider issue in Alaska
is profound and important. There are several issues. First,
with regard to available resources, DHSS has received federal
funds from the Health Resources and Services Administration
(HRSA), U.S. Department of Health and Human Services, for bio-
preparedness for the last three years. Until this year, the
priority has been to build into all hospitals the capacity to
deal with chemical poisonings, radiation incidents or terrorist
events, for example. However, there is a significant refocusing
with regard to infectious-disease preparedness.
He noted that, second, the interagency effort to be headed by
Department of Military and Veterans Affairs (DMVA) and DHSS will
involve community and business leaders, both rural and urban,
including those from the hospital industry.
He reported that, third, Nome and Kotzebue have been working on
training and are moving to the "alternate care" side, looking at
how to find volunteers and staff in a rural community.
Ketchikan will be the first community to do an exercise, and
will test for a couple of days to see whether it's possible to
keep 20 staffed beds operational and to find trained volunteers.
The best lessons from each community will be used. Once they
move from hub communities to villages like Hooper Bay, where a
single nurse practitioner may be the only medical staff, keeping
those few medical personnel healthy through use of "antivirals"
will be important because there is no replacement for them.
SENATOR OLSON asked about the potential for an allergic reaction
to the antivirals.
DR. BUTLER told him the potential is low for the newer agents;
oseltamivir, in particular, is well tolerated. The older agents
tended to cause more problems such as dizziness or bad dreams,
although relatively safe. The inhaled drug sometimes causes
coughing, especially for people with underlying lung disease,
who often need it most. Thus it's fortunate there is an oral
form. He said the experience with oseltamivir, for several
years now, has looked very good.
SENATOR ELTON requested a flowchart showing who decides who gets
the vaccine first, for example, and how the state interacts with
the federal government.
DR. MANDSAGER replied that some has been done and some has yet
to be determined. As for who gets antivirals in short supply,
the website contains the DHSS proposal with regard to the
priorities. He suggested a need for the plan to be well vetted,
with opportunity for people to comment. This involves rationing
decisions. Who will decide those is an important question. Dr.
Mandsager said it isn't clear to him right now; he surmised that
political leaders would want to weigh in, especially regarding
prophylaxis. A key function with DMVA and DHSS is to get that
question out there and under discussion, and then for political
leaders to weigh in.
SENATOR ELTON expressed particular concern with the nexus
between state officials, who have familiarity with Alaska, and
federal officials, who may just come in and make pronouncements.
DR. MANDSAGER said Commissioner Campbell, (DMVA), has clarified
the desire to make it clear that the state is in charge, and
that, when it comes to federal resources, they are being
requested rather than forced. He said it already became fuzzy
with this summer's bird surveillance plan, because the only ones
with money are the federal agencies right now.
3:08:03 PM
SENATOR WILKEN asked how this differs from the SARS virus three
years ago, and why it won't just go away like SARS did.
DR. BUTLER replied that one difference between influenza and the
SARS virus relates to containment and control. Most of it
relates to the behavior of the virus in the infected person.
For SARS, the peak of viral shedding doesn't occur until the
second week of illness, usually around day 8-12. With
influenza, infectiousness begins upon onset of the illness or
just before symptoms appear, and can peak in the first day or
two. The window of opportunity with SARS enabled the
recognition of people who were at risk and putting them in
isolation to prevent its spread.
He added that SARS is a different virus. While it's tempting to
say public health intervention completely contained it, that
isn't a certainty. From past experience with influenza, by
contrast, there has never been an ability to contain it
altogether. Pandemics occurred in the past and likely will
occur in the future.
SENATOR WILKEN referred to the $1.23 million for the stockpile
and asked about the shelf life.
DR. MANDSAGER answered that it has a shelf life of five years.
Discussions are beginning right now with some drug wholesale
companies in Alaska. It would be ideal, if there were a
stockpile, that the companies keep it and guarantee they had
enough in Alaska, but also keep "feeding it into the normal
usage pattern" so that the state wouldn't have to worry that it
would become outdated. If the state had to keep it, there'd be
a problem with replacement. He added that the federal Food and
Drug Administration (FDA) is presently looking at whether it has
a longer shelf life.
SENATOR WILKEN asked if the major water utilities should have an
internal plan.
DR. MANDSAGER explained that the question he's trying to get
business and utility leaders to address is how they'd maintain
services if 10 to 30 percent of their personnel were out sick.
He pointed out that the same issue applies to the oil pipeline.
SENATOR WILKEN suggested it's the infrastructure, then.
DR. MANDSAGER concurred.
CHAIR DYSON remarked that he was impressed with the depth of
consideration. He said one question raised was the liability
for health care institutions and staff. He asked whether there
is precedent for that.
DR. MANDSAGER said he didn't know, but it is being discussed. He
pointed out that states have "Good Samaritan" laws, and most
have the ability for the governor to declare an emergency. He
said it's been assumed that would protect people. He
acknowledged that people are concerned enough now to want to
make it more explicit that staff don't stay home because of
concern for their personal liability if those people have skills
that can be used in an emergency.
CHAIR DYSON inquired about measures that the testifiers believe
the legislature should take.
DR. MANDSAGER said they aren't ready yet, and are still talking
to colleagues across the country, looking for a model to ensure
that the authority isn't used inappropriately but is available
as a tool. He expressed confidence that they'd be ready with a
proposal at the beginning of the next legislative session.
3:13:36 PM
SENATOR OLSON referred to malpractice liability. He asked what
the chances are of enacting something nationally with regard to
torts.
DR. MANDSAGER agreed it would make good sense in order to
protect people nationwide, if needed. He concluded by saying
there is still a lot of work to do, though much has been done.
CHAIR DYSON adjourned the Senate Health, Education and Social
Services Standing Committee meeting at 3:14:25 PM.
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