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.