ALASKA STATE LEGISLATURE  HOUSE HEALTH, EDUCATION AND SOCIAL SERVICES STANDING COMMITTEE  January 26, 2006 3:11 p.m. MEMBERS PRESENT Representative Peggy Wilson, Chair Representative Paul Seaton, Vice Chair Representative Vic Kohring Representative Sharon Cissna Representative Berta Gardner MEMBERS ABSENT  Representative Tom Anderson Representative Carl Gatto COMMITTEE CALENDAR CONFIRMATION HEARING(S) State Medical Board Dr. Kevin M. Tomera - Anchorage Nancy Puckett - Anchorage Edward A. Hall - Anchorage - CONFIRMATION(S) ADVANCED Commissioner, Department of Health and Social Services Karleen Jackson - Juneau - CONFIRMATION(S) ADVANCED OVERVIEW(S): DEPARTMENT OF HEALTH AND SOCIAL SERVICES - INFLUENZA PANDEMIC - HEARD PREVIOUS COMMITTEE ACTION No previous action to record WITNESS REGISTER KEVIN M. TOMERA, MD, Appointee to the State Medical Board Anchorage, Alaska POSITION STATEMENT: Testified as appointee to the State Medical Board. NANCY PUCKETT, Appointee to the State Medical Board Anchorage, Alaska POSITION STATEMENT: Testified as appointee to the State Medical Board. EDWARD A. HALL, Physician Assistant (PA), Appointee to the State Medical Board Anchorage, Alaska POSITION STATEMENT: Testified as appointee to the State Medical Board. KARLEEN JACKSON, Commissioner Department of Health and Social Services (DHSS) Juneau, Alaska POSITION STATEMENT: Testified as appointed commissioner of DHSS. RICHARD MANDSAGER, MD, Director Division of Public Health Department of Health and Social Services (DHSS) Juneau, Alaska POSITION STATEMENT: Co-presented the overview regarding the influenza pandemic. JAY BUTLER, MD, Chief Epidemiology Section Division of Public Health Department of Health and Social Services (DHSS) Anchorage, Alaska POSITION STATEMENT: Co-presented the overview regarding the influenza pandemic. ACTION NARRATIVE CHAIR PEGGY WILSON called the House Health, Education and Social Services Standing Committee meeting to order at 3:11:35 PM. Representatives Cissna, Gardner, Kohring, Seaton, and Wilson were present at the call to order. Representative Gatto was excused. 3:11:47 PM ^CONFIRMATION HEARING(S) ^State Medical Board 3:12:28 PM KEVIN M. TOMERA, MD, Appointee to the State Medical Board, provided his personal history as a urologist in the Anchorage area since 1993. He said that he looks forward to serving the community via this appointment, and, in response to a question, said that he is too new to have a specific agenda. REPRESENTATIVE CISSNA asked whether he is familiar with the pro bono medical program established by the United Way to assist the growing number of uninsured, low-income Alaskans. She also asked whether he supports the before mentioned program. DR. TOMERA stated that the Anchorage urology group already participates in [pro bono medical ] program and have historically provided services regardless of the patient's ability to pay. Additionally, he expressed concern for the rising cost of health insurance stating that there is not an easy solution. When asked what he considers to be the major role of the State Medical Board, he responded that the board "should be in the practice of medicine," not "social engineering." REPRESENTATIVE GARDNER moved that the House Health, Education and Social Services Standing Committee, forward the name of Dr. Kevin J. Tomera to the joint session for consideration of appointment to the State Medical Board. There being no objection, the confirmation of Dr. Kevin J. Tomera was advanced. 3:18:14 PM NANCY PUCKETT, Appointee to the State Medical Board, provided her personal history as a 15-year Alaskan resident, and highlighted her recent work with the private nonprofit sector. She stated that she looks forward to this appointment as a vehicle to continue serving the community. In response to a question, she explained that the board is comprised of two public seats, one physician assistant (PA) seat, and the balance of seats are for physicians; she noted that she appointed to fill one of the public seats. Therefore, she opined that she expects to speak for the public and protect the public interest. VICE CHAIR SEATON moved that the House Health, Education and Social Services Standing Committee, forward the name of Nancy Puckett to the joint session for consideration of appointment to the State Medical Board. There being no objection, the confirmation of Nancy Puckett was advanced. 3:22:14 PM EDWARD A. HALL, Physicians Assistant (PA), Appointee to the State Medical Board, stated that he has been in Alaska since 1994, and an active member of the Alaska Academy of Physician Assistants (AKAPA). He explained that he represented AKAPA at medical board meetings for several years, eventually supporting a lobby for an AKAPA seat on the board. He applied for this seat, as a continuum of his board meeting attendance and his interest in serving AKAPA in this capacity. In response to a question, he stated that PAs are integral in serving Alaska's rural districts, and that AKAPA supports the pro bono health program. Further, he named the rural areas that he has had an opportunity to visit. VICE CHAIR SEATON moved that the House Health, Education and Social Services Standing Committee, forward the name of Edward A. Hall to the joint session for consideration of appointment to the State Medical Board. There being no objection, the confirmation of Edward A. Hall was advanced. ^Commissioner, Department of Health and Social Services 3:28:46 PM KARLEEN JACKSON, Commissioner, Department of Health and Social Services (DHSS), provided personal highlights of her 40 years in Alaska, including her higher educational pursuits. She provided that three years ago she was recruited to serve as the deputy commissioner, and that she has enjoyed working with the management/leadership teams of the department since her hire. In response to questions, she explained that DHSS has been considering integrated case management, which will eliminate the concern of casework isolation as the applicable divisions and the associated state departments would be appropriately informed/engaged. Also, she stated, the DHSS management team has been discussing ways and means to upgrade and improve children's services. She opined that although change will not happen quickly, progress will be made. REPRESENTATIVE KOHRING moved that the House Health, Education and Social Services Standing Committee, forward the name of Karleen Jackson to the joint session for consideration for confirmation as Commissioner of the Department of Health and Social Services. There being no objection, the confirmation of Karleen Jackson was advanced. ^Overview (S) ^Department of Health and Social Services - Influenza Pandemic The committee took an at-ease from 3:39:45 PM to 3:44:17 PM 3:48:03 PM JAY BUTLER, MD, Chief, Epidemiology Section, Division of Public Health, Department of Health and Social Services, began the slide presentation explaining that influenza is a respiratory tract infection caused by the influenza virus, and dispelling stomach flu as a true influenza. He described the difficulty in treating a virus, explaining that a virus is often not treated, and how a virus is commonly spread via respiratory droplets. Naming the three known influenzas, he stated that today's topic of focus would be influenza A. He explained how influenzas: receive a letter and a numeric "type" name; originate with waterfowl; will occasionally mutate or "jump species" to affect domestic fowl, equines, swine, seals, and whales; and are limited in the number of types that can cause human influenza. Introducing H5N1, he explained that this is the strain currently circulating as bird influenza, and was originally isolated from terns in South Africa, in 1961. It then emerged as a highly pathogenic strain in domestic poultry in Hong Kong in 1997, where it first infected humans and was commonly termed "bird flu." Although it was thought to be contained within the domestic flocks identified and culled at the time, the highly pathogenic strain emerged again in Southeast Asia in December 2003, proving that in actuality the virus had spread. 3:52:51 PM DR. BUTLER, responding to a question, clarified that the current concern is for the influenza [type] A [strain H5N1] known as "Z Clone," which emerged in December 2003 and has not yet appeared in North or South America. He explained that the transmission of H5N1 to human populations has either been by direct contact with infected domestic poultry and their secretions, or via human-to-human contact, which has thus far been rare. He provided a map to illustrate how the disease has spread; indicating the 14 countries with cases identified in poultry and the six countries with cases identified in humans. He pointed out that the map is changing almost daily. 3:54:59 PM DR. BUTLER explained that a pandemic influenza occurs when: there is a new strain of virus to which the population has no immunity; the virus has an ability to replicate in humans and cause disease; and the virus maintains an efficient and sustained person-to-person transmission. He provided a history of the three influenza pandemics of the 20th century, which occurred in 1918, 1957, and 1968. Extrapolating on the statistics from these three pandemics, he presented an estimate of how a pandemic might effect Alaska's current population. The statistics indicated that Alaska's annual death rate could be expected to double. In response to a question regarding effective treatment alternatives, he stated that the bird flu fatalities reported from Indonesia involved patients who were treated in intensive care units and had received anti-viral drugs. He contrasted the Asian experience with the recent influenza outbreaks appearing in the more developed country of Turkey, where treatment has proven more successful and the death rate lower. REPRESENTATIVE CISSNA inquired about the differences of the first two 20th century pandemics in America, and asked: were the severity levels of the influenzas different; if they were the same, what other factors caused death; and, today, are there particular populations that are more likely to succumb to the influenza virus. DR. BUTLER answered that the primary determinant for the severity of a pandemic is the strain of influenza involved. He explained that the 1918 influenza created an immune response that was primarily detrimental to the vigorous and healthy victims, in the 20-40 age group, versus the young and elderly, who were primarily effected by the pandemics later in the century. As to what populations might be at highest risk, he stated that there are no definite answers. However, he pointed out that during the 1918 pandemic the western Alaskan villages experienced mortality rates greater than 50 percent ranking them among the highest in the world. 4:01:48 PM DR. BUTLER described means to reduce the projected impact numbers for Alaska. He explained that, unlike seasonal influenza with a ready immunization, a pandemic strain vaccine would not be available for perhaps six months following the initial outbreak, and he highlighted the need for infection control measures to be immediately initiated. Also, he stressed the need to have anti-viral drugs available to minimize the impact of the virus, and explained that the national influenza pandemic plan calls for stock piling anti-viral drugs. However, each state is required to bear one third of the responsibility to create and maintain the necessary stockpile of drugs. He pointed out how Alaska's unique dependency on air travel would need to be factored into a pandemic scenario. 4:03:43 PM VICE CHAIR SEATON asked whether the current recommendations, regarding anti-viral medication usage recently issued from the Center for Disease Control (CDC), will affect these projections. DR. BUTLER stated that the CDC recommendations are for seasonal influenza anti-viral drugs, and, in further response, discussed the effectiveness of anti-viral agents. Regarding the role that children play in the proliferation of the virus, he said "as the mosquito is to malaria so children are to influenza," which is one reason that the CDC has been expanding its recommendations for routine influenza immunizations to include young children. DR. BUTLER described the impact a pandemic could have on businesses providing for employee absenteeism, widespread fear, and possible restrictions on transportation and public gatherings. He related common misperceptions about a pandemic influenza, and clarified that pandemic strains always originate in animals, progress to humans, and eventually mutate enough to be able to be transmitted from person to person. In conclusion, he said that there are a number of ways to prepare for a pandemic, beyond waiting for the federal government to respond, which the co-presenter would be highlighting. 4:13:20 PM RICHARD MANDSAGER, MD, Director, Division of Public Health, Department of Health and Social Services (DHSS), provided the nine most effective ways to minimize a pandemic influenza outbreak: practice hand hygiene; cover coughs and sneezes; avoid touching eyes, nose, and mouth; remain at home when ill; rest and exercise; eat a balanced diet; minimize the consumption of alcohol; avoid tobacco smoke; and take an annual influenza vaccination. He noted his agreement, with Chair Wilson that a pocket sanitizer would go a long way in slowing down the spread of disease and stated that a virus can reside on a hand for some time thus making handshake transmission possible even if symptoms are not apparent in the carrier. REPRESENTATIVE CISSNA asked how avoiding tobacco smoke protects against influenza. DR. BUTLER responded that all smoke is a respiratory compromiser, allowing for an increased susceptibility to more severe manifestations of influenza infection. DR. MANDSAGER explained the role of the Division of Public Health in training communities to prepare for rapid disease response. Responding to a question, he said that a pandemic situation is managed in two parts. In the first part, prevention procedures are followed, then, as the pandemic manifests, secondary procedures are implemented to stem the situation. This second phase would require "trade offs" to precautions that were deemed necessary during the first phase. To further illustrate his point, he described the public health response to the polio epidemic of the 1950's. DR. MANDSAGER explained how the health industry is better prepared to handle a pandemic today due to: new public health laws; emergency plans; mass prophylactic clinic exercises; human disease surveillance; and bird disease surveillance. However, there is more work to be done, he said, and listed strategies that need to be implemented, stressing that the development of public trust is an essential aspect of the preparation. 4:23:59 PM DR. MANDSAGER stated that bird disease surveillance is "a hot topic in Alaska" because the state is the central corridor for bird flyways to Asia. He described the avian surveillance plans which will be conducted, beginning this summer, and named the various state, Native, federal, and private agencies who will be participating in the effort. Considering how this pandemic virus has been spreading, he opined that, even if the disease does not become a major human threat, it will continue to be of concern for the poultry industries of North America. In response to questions, he clarified that if the virus arrives in North America via birds, it will arrive in Alaska first, due to the bird flyways; however, if it arrives via human carrier, it could enter the continent at any international airport, including Anchorage. In further response, he stated that the culling of poultry flocks has not stopped the spread of the virus. He explained that the virus has a devastating effect on the poultry industry, because, even though the meat is safe when fully cooked, consumers tend to boycott the meat out of fear. Further, he responded that scientists are working to isolate specific "risky" aspects of handling afflicted fowl. 4:28:46 PM DR. MANDSAGER explained that volunteers will need to be prepared and trained for their role in sustaining communities through a pandemic. He posed questions that each community, along with its community support managers, will need to answer. The imminent exercise/test that Ketchikan is planning will be the first community pandemic emergency response undertaking in Alaska, he reported. DR. MANDSAGER posed specific questions which each community will need to be prepared to answer prior to a pandemic situation; bulleted on the slide as: prioritization of immunizations; rationing of community supplies; how to maintain an operational community infrastructure; and ways to prepare the population that will mitigate widespread surprise and confusion. He stated that a planning assumption, in the state's emergency operation plan, is that "public order will survive," and that holding public forums is one way to ensure this assumption. In response to further questions, he stressed the importance of reaching out to special population groups, and contacting people who live in isolated situations. He posed other questions in regard to scenarios that are unique to Alaska. He also pointed out that a pandemic of this magnitude is both a medical and a socio- economic issue. 4:36:42 PM REPRESENTATIVE SEATON inquired about practical supplies that might be needed by the public during the time between a pandemic outbreak and the development of the vaccine. Given the possibility of an interruption in transportation, he asked if [the state] should be identifying and procuring supplies for immediate stockpiling. DR. MANDSAGER stated that the governor's budget proposes funding for anti-viral medication, and explained that the current plan is to create an anti-viral medication stockpile. The stored medications will be available to treat anyone who becomes ill, but the exact contents/supplies of community stockpiles are in the planning stage, he said. In response to a question he explained that a vaccine must be tailored for the novel virus that eventually surfaces and this is the reason that it takes approximately six months to develop a vaccine. He provided that part of President Bush's initiative is to advance technology and shorten the time factor for vaccine development. Further, he stated that the vaccine carries a five-year expiration date and, when stockpiled, needs to be continually monitored and cycled. He also explained the need to consider mandatory and voluntary social distancing on a community level. 4:43:23 PM DR. MANDSAGER introduced Governor Murkowski's Administrative Order No. 228, issued January 9, 2006, which names the Department of Military & Veterans' Affairs (DMVA), and DHSS as the lead agencies for the state in [pandemic] planning and strategy implementation. He also introduced the State of Alaska Pandemic Influenza Concept Plan, which provides planning assumptions that are in current use. He highlighted the expectation that, if the virus arrives via a human carrier, national resources may be overwhelmed in meeting population needs in the lower 48. However, if the virus arrives via a bird, Alaska would be the first state effected and could expect to receive prioritized federal assistance. He stressed that we must plan to be ready for either scenario. He continued with the Alaska Pandemic Influenza Preparedness Concept Plan objectives which provide for: the development and activities of the Alaska Pandemic Influenza Annex; public information and education dissemination; outreach activities; and training and exercise activities to commence by the end of January 2006. 4:46:23 PM DR. MANDSAGER explained that in providing guidance to business leaders, "pre-pandemic" considerations urge them to: develop a plan, encourage annual influenza vaccinations, and evaluate employee access to health care and mental health services. In response to a question, he stated that the goal this winter is to raise public awareness of the [pandemic] subject. To that end, he announced that on April 13, 2006, Michael Leavitt, United States Secretary of Health and Human Services, will hold a summit in Alaska to increase public awareness. He went on to provide the "during pandemic" guidelines to business leaders, which advises employers to: establish a sick leave plan; use flexible workplace and work hours; restrict business travel to affected areas; encourage employee hand hygiene and respiratory etiquette; and provide infection control supplies to employees. 4:51:44 PM REPRESENTATIVE CISSNA described technology that is available which would allow for meetings and communications while being able to follow some of the restrictions that Dr. Mandsager has outlined. 4:54:12 PM DR. MANDSAGER briefly provided some topics which will need to be considered if the governor declares a state emergency. Further, he outlined the budget initiative and the funding breakout of the $7.23 million requested in fiscal year 2007. DR. MANDSAGER summarized his presentation stating that: a pandemic of influenza will happen in the future; it is important to be prepared; this preparedness will also help the state to be prepared for other threats and emergencies; and the legislature plays a significant leadership role for Alaska's citizens. Finally, he presented three pertinent web sites for further information. 4:57:15 PM   ADJOURNMENT  There being no further business before the committee, the House Health, Education and Social Services Standing Committee meeting was adjourned at 4:57:31 PM.