[Senate Hearing 108-120]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 108-120

     SARS: BEST PRACTICES FOR IDENTIFYING AND CARING FOR NEW CASES

=======================================================================


                                HEARING

                               before the

                PERMANENT SUBCOMMITTEE ON INVESTIGATIONS

                                 of the

                              COMMITTEE ON
                          GOVERNMENTAL AFFAIRS
                          UNITED STATES SENATE


                      ONE HUNDRED EIGHTH CONGRESS

                             FIRST SESSION

                               __________

                             JULY 30, 2003

                               __________


      Printed for the use of the Committee on Governmental Affairs



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                   COMMITTEE ON GOVERNMENTAL AFFAIRS

                   SUSAN M. COLLINS, Maine, Chairman
TED STEVENS, Alaska                  JOSEPH I. LIEBERMAN, Connecticut
GEORGE V. VOINOVICH, Ohio            CARL LEVIN, Michigan
NORM COLEMAN, Minnesota              DANIEL K. AKAKA, Hawaii
ARLEN SPECTER, Pennsylvania          RICHARD J. DURBIN, Illinois
ROBERT F. BENNETT, Utah              THOMAS R. CARPER, Delaware
PETER G. FITZGERALD, Illinois        MARK DAYTON, Minnesota
JOHN E. SUNUNU, New Hampshire        FRANK LAUTENBERG, New Jersey
RICHARD C. SHELBY, Alabama           MARK PRYOR, Arkansas

           Michael D. Bopp, Staff Director and Chief Counsel
     Joyce Rechtschaffen, Minority Staff Director and Chief Counsel
                      Amy B. Newhouse, Chief Clerk

                                 ------                                

                 PERMANENT COMMITTEE ON INVESTIGATIONS

                   NORM COLEMAN, Minnesota, Chairman
TED STEVENS, Alaska                  CARL LEVIN, Michigan
GEORGE V. VOINOVICH, Ohio            DANIEL K. AKAKA, Hawaii
ARLEN SPECTER, Pennsylvania          RICHARD J. DURBIN, Illinois
ROBERT F. BENNETT, Utah              THOMAS R. CARPER, Delaware
PETER G. FITZGERALD, Illinois        MARK DAYTON, Minnesota
JOHN E. SUNUNU, New Hampshire        FRANK LAUTENBERG, New Jersey
RICHARD C. SHELBY, Alabama           MARK PRYOR, Arkansas

                Raymond V. Shepherd, III, Staff Director
                    Joseph V. Kennedy, Chief Counsel
        Elise J. Bean, Minority Staff Director and Chief Counsel
                     Mary D. Robertson, Chief Clerk


                            C O N T E N T S

                                 ------                                

                                                                   Page

Opening statements:
    Senator Coleman..............................................     1
    Senator Levin................................................     4
    Senator Collins..............................................     5
    Senator Pryor................................................    17
Prepared statement:
    Senator Lautenberg...........................................    29

                               WITNESSES
                        Wednesday, July 30, 2003

Marjorie E. Kanof, M.D., Director, Health Care-Clinical and 
  Military Health Care Issues, U.S. General Accounting Office....     7
James M. Hughes, M.D., Director, National Center for Infectious 
  Diseases, Centers for Disease Control and Prevention, U.S. 
  Department of Health and Human Services, Atlanta, Georgia......    20

                     Alphabetical List of Witnesses

Hughes, James M., M.D.:
    Testimony....................................................    20
    Prepared statement...........................................    61
Kanof, Marjorie E. Kanof, M.D.:
    Testimony....................................................     7
    Prepared statement...........................................    30

                              Exhibit List

1. Charts prepared by Centers for Disease Control:
     a. GSARS Priority Areas.....................................    74
     b. GCDC SARS Preparedness Planning..........................    75
2. Protecting the Nation's Health in an Era of Globalization: 
  CDC's Global Infectious Disease Strategy, Centers for Disease 
  Cotnrol and Prevention, Department of Health and Human Services    76
3. Microbial Threats of Health: Emergence, Detection, and 
  Response, Institute of Medicine, March 2003....................   149
4. Supplemental questions and answers for the record submitted by 
  Senator Frank Lautenberg for Dr. Majorie E. Kanof, General 
  Accounting Office..............................................   157
5. Supplemental questions and answers for the record submitted by 
  Senator Frank Lautenberg for Dr. James M. Hughes, National 
  Center for Infectious Disease, Centers for Disease Control and 
  Prevention, Department of Health and Human Srvices.............   162
6. Correspondence from Dr. Marjorie Kanof, GAO, regarding 
  questions posed at July 30th SARS hearing by Senator Carl Levin 
  asking for comparison of research dollars devoted to SARS and 
  other respiratory infectious diseases..........................   165

 
     SARS: BEST PRACTICES FOR IDENTIFYING AND CARING FOR NEW CASES

                              ----------                              


                        WEDNESDAY, JULY 30, 2003

                                       U.S. Senate,
                Permanent Subcommittee on Investigations,  
                  of the Committee on Governmental Affairs,
                                                    Washington, DC.
    The Subcommittee met, pursuant to notice, at 9:03 a.m., in 
room SD-342, Dirksen Senate Office Building, Hon. Norm Coleman, 
Chairman of the Subcommittee, presiding.
    Present: Senators Coleman, Collins, Levin, and Pryor.
    Staff Present: Raymond V. Shepherd, III, Staff Director; 
Joseph V. Kennedy, Chief Counsel; Mary D. Robertson, Chief 
Clerk; Kristin Meyer, Staff Assistant; Caroline Lebedoff, 
Intern; Brittany Stevenson, Intern; Elise J. Bean, Minority 
Staff Director and Chief Counsel; Christopher Kramer, Minority 
Professional Staff Member; Priscilla Hanley (Senator Collins); 
John Meyer (Senator Specter); Anne Schmidt (Senator Coleman); 
David Berrick (Senator Lieberman); Rebecca Mandell (Senator 
Lautenberg); Reanne Brown (Senator Durbin); and Tate Heuer 
(Senator Pryor).

              OPENING STATEMENT OF SENATOR COLEMAN

    Senator Coleman. Good morning. We are going to call this 
hearing to order. It is a pleasure to be here with our 
distinguished Chairman, Senator Collins--thank you for being 
here--and distinguished Ranking Member, Senator Levin. This is 
the second in a series of hearings by this Subcommittee aimed 
at helping the Nation respond to the threat of SARS. At the 
first hearing on May 21, the Subcommittee heard testimony from 
a number of witnesses at the national, State, and local levels. 
The first panel consisted of three internationally known 
experts in epidemiology: Dr. Julie Gerberding, currently head 
of the CDC; Dr. Anthony Fauci, currently head of the National 
Institute of Allergy and Infectious Diseases; and Dr. Michael 
Osterholm, Director of the Center for Infectious Disease 
Research and Policy at the University of Minnesota.
    Each of these experts testified that it was their opinion 
that the Nation would face additional outbreaks of SARS during 
the regular flu season this fall and winter. For example, Dr. 
Osterholm testified that: ``. . . I am convinced that with the 
advent of early winter in the Northern Hemisphere in just 6 
short months, we will see a resurgence of SARS that could far 
exceed our experience to date. If this projection is correct, 
we have every reason to believe that this disease may show up 
in multiple U.S. cities as we continue to travel around the 
world in unprecedented numbers and speed.''
    ``Imagine now the possibility of simultaneous SARS 
outbreaks in multiple U.S. cities. You may ask how likely is 
this to occur. Honestly, no one knows. But, as a student of the 
natural history of infectious diseases, I am convinced that 
like the early days of the HIV epidemic, the worst of SARS is 
yet to come.''
    If Dr. Osterholm and the other experts are correct in their 
assumptions that the worst of SARS is yet to come--and I 
believe they may very well be--then it is incumbent upon us to 
take immediate and urgent measures to protect our Nation from 
this potential crisis.
    Soon after that hearing, I requested that the General 
Accounting Office undertake a survey of best practices for 
identifying and treating SARS. Because of the short time frame 
for preparing for new cases, I asked that the study be 
completed by the end of July. At today's hearing, GAO will 
release the results of the study. We will also hear from the 
Centers for Disease Control and Prevention about the work they 
are doing to properly inform and work with local agencies.
    I am especially concerned with the adequacy of response at 
the local level. There is a consensus that the quality of the 
first response is crucial to preventing any single case from 
leading to a more generalized outbreak. Local agencies must 
maintain a proper state of vigilance so they can quickly 
identify new cases. They must also know what to do when a new 
series of cases arise in order to prevent further transmission. 
At the same time, local communities need to be properly 
educated so they can protect themselves in a rational manner.
    A case of SARS implies that a large number of coworkers, 
schoolmates, and social friends and their families might 
potentially be infected. As soon as they learn that the parent 
of a schoolmate has SARS, parents will want to know whether 
they should keep their children home, send them to class 
wearing masks, or take other precautions. The lack of education 
can make it difficult for people to properly protect themselves 
from transmission. But it can also lead to a sense of panic and 
overreaction, stalling the economic activity on which all 
employment depends.
    I have a further statement, and what I am going to do is I 
enter the full statement into the record.
    The bottom line is this: We have got to make sure that 
local health officials are properly informed. They need to know 
what to do. They need to remain vigilant. We need to make sure 
that the average citizen can intelligently respond to SARS when 
it appears in his or her community. It was Franklin Roosevelt 
who said that the greatest thing we have to fear is fear 
itself, and I believe with SARS it is the sense of the unknown. 
We still do not know, as I understand it, all the causes of 
SARS and all the treatments for SARS and all the things we are 
doing, are they the right things to do. So there is a lot of 
unknown out there, and that generates greater fear.
    Then, finally--and clearly it is why we are here today--we 
need to have national and regional plans for dealing with SARS, 
particularly if there is a large-scale outbreak. And as I 
looked at the GAO report, though there are many good things 
that are going on and much preparation that has happened, there 
is still a concern about the adequacy of the health care system 
to meet a widespread outbreak. And so there are challenges 
before us. I want to commend those agencies and folks who have 
been dealing with SARS.
    CDC has done a tremendous job. I have talked to folks at 
the local level. They are very thankful. The GAO responded very 
quickly, and for that we are very appreciative.
    This is a challenge. We are moving quickly. We are trying 
to do the right thing, but challenges lie before us, and this 
is an important hearing.
    [The prepared statement of Senator Coleman follows:]

             PREPARED OPENING STATEMENT OF SENATOR COLEMAN

    Good morning and thank you for attending the second in a series of 
hearings by this Subcommittee aimed at helping the Nation respond to 
the threat of SARS. At the first hearing on May 21, the Subcommittee 
heard testimony from a number of witnesses at the national, State, and 
local levels. The first panel consisted of three internationally known 
experts in epidemiology: Dr. Julie Gerberding, currently head of the 
CDC; Dr. Anthony Fauchi, currently head of the National Institute of 
Allergy and Infectious Diseases; and Dr. Michael Osterholm, Director of 
the Center for Infectious Disease Research and Policy at the University 
of Minnesota.
    Each of these experts testified that it was their opinion that the 
Nation would face additional outbreaks of SARS during the regular flu 
season this fall and winter. For example, Dr. Osterholm testified that:

        ``. . . I am convinced that with the advent of early winter in 
        the Northern Hemisphere in just 6 short months, we will see a 
        resurgence of SARS that could far exceed our experience to 
        date. If this projection is correct, we have every reason to 
        believe that this disease may show up in multiple U.S. cities 
        as we continue to travel around the world in unprecedented 
        numbers and speed.

        ``Imagine now the possibility of simultaneous SARS outbreaks in 
        multiple U.S. cities. You may ask how likely is this to occur. 
        Honestly, no one knows. But, as a student of the natural 
        history of infectious diseases, I am convinced that like the 
        early days of the HIV epidemic, the worst of SARS is yet to 
        come.''

    If these experts are correct in their assumptions that the worst of 
SARS is yet to come, and I believe they may very well be, then it is 
incumbent upon us to take immediate and urgent measures to protect our 
Nation from this potential crisis.
    Soon after that hearing, I requested that the General Accounting 
Office undertake a survey of best practices for identifying and 
treating SARS. Because of the short time frame for preparing for new 
cases, I asked that the study be completed by the end of July. At 
today's hearing, GAO will release the results of the study. We will 
also hear from the Centers for Disease Control and Prevention about the 
work they are doing to properly inform local agencies.
    I am especially concerned with the adequacy of response at the 
local level. There is a consensus that the quality of the first 
response is crucial to preventing any single case from leading to a 
more generalized outbreak. Local agencies must maintain a proper state 
of vigilance so they can quickly identify new cases. They must also 
know what to do when a new case arises in order to prevent further 
transmission. At the same time, local communities need to be properly 
educated so they can protect themselves in a rational manner.
    A case of SARS implies that a large number of coworkers, 
schoolmates, and social friends and their families might potentially be 
infected. As soon as they learn that the parent of a schoolmate has 
SARS, parents will want to know whether they should keep their children 
home, send them to class wearing masks, or take other precautions. The 
lack of education can make it difficult for people to properly protect 
themselves from transmission. But it can also lead to a sense of panic 
and overreaction, stalling the economic activity on which all 
employment depends.
    Intelligent education requires several steps. First, local doctors 
need to know how to recognize that new cases of SARS are appearing and 
need to know whom to turn to for information and support. At the 
national and international level, agencies must continue to develop 
information about the characteristics of SARS in order to treat 
patients and prevent its spread. The World Health Organization, the 
National Institutes of Health, and the Centers for Disease Control and 
Prevention perform this role well. Last, the information these agencies 
develop must be transmitted back to mayors, hospital administrators, 
and airport officials so that doctors, airline attendants, researchers, 
and average citizens know how and what to do in order to protect 
themselves. Today's hearing is focused on this last step.
    I believe we face three primary tasks. The first is to make sure 
that local health officials are properly informed about the need to 
remain vigilant against possible SARS cases. Although no new cases have 
been reported recently, most experts believe that SARS has established 
itself in the population and reemerge. Unfortunately, its symptoms 
resemble those of other respiratory flues and tuberculosis. Unless 
local doctors remain mindful of the possibility of SARS, the first 
cases may not be isolated in time to prevent further transmission.
    Second, we need to make sure that the average citizen can 
intelligently respond to SARS when it appears in his or her community. 
Individuals need to know what precautions to take at various stages of 
an outbreak. They also need to know what the true status of risk is, so 
that they do not over respond. In Asia the indirect economic costs of 
SARS far exceeded the direct costs of combating the disease.
    Finally, we need regional and national plans for dealing with a 
large-scale outbreak of SARS. We saw in Toronto that SARS can quickly 
overwhelm even a modern health care system if the first cases are not 
quickly contained. When this happens, regional and national resources 
must be available to fill in the gap. Dr. Kanof will testify about some 
of the hurdles we face in developing such a plan. I am pleased that CDC 
is currently working hard to overcome these.
    I want to take this opportunity to commend both of the 
organizations before us for their previous role in dealing with SARS. I 
have repeatedly heard of the great assistance that the CDC has provided 
to local agencies searching for information on SARS. With respect to 
this disease, it is hard to think of how the agency could have 
responded better. Doctors Gerberding and Hughes deserve our great 
appreciation for the great work that they and their staff have 
performed under tremendous pressure. In the report being released today 
and in previous reports and testimony, GAO has played a valuable role 
in keeping Congress informed of this fast-breaking development. Today's 
report was completed in a very short time frame and I appreciate Dr. 
Kanof's support in making it happen.

    Senator Coleman. With that, I would turn to the 
distinguished Ranking Member, Senator Levin.

               OPENING STATEMENT OF SENATOR LEVIN

    Senator Levin. Thank you, Mr. Chairman.
    First, let me commend you for holding this hearing to push 
for the development of best practices for responding to SARS 
cases before there is an immediate or imminent problem. For the 
reasons you gave, this is a problem which has not gone away and 
will not go away readily. It needs to be addressed in many 
ways, and advanced planning now can save lives and prevent 
future confusion and unnecessary costs.
    SARS is a disease which we cannot afford to ignore. Its 
global impact has already been significant. Cases have been 
reported in approximately 30 countries. Almost 1,000 
individuals have died while hundreds more have suffered and 
recovered. Hospitals' quarantine facilities and health 
resources have been strained. Global travel has been disrupted 
and just recently restored. That is going to increase the 
potential threat of SARS.
    Economists are struggling to evaluate SARS' economic impact 
on China and on Canada. Experts are warning of a possible SARS 
epidemic in developing regions of the world where health care 
systems are not equipped to deal with rapid large-scale 
infection.
    Here in the United States, we have so far avoided having to 
deal with high levels of infection. But as I put it at the last 
hearing, while we can try to isolate SARS patients, we cannot 
isolate our Nation from this disease. SARS has already made its 
way across our borders in several instances, and it is crucial 
that we establish best practices for identifying, treating, and 
halting this illness. While we can hope for the best, we must 
prepare for the worst if we are going to avoid it.
    Despite positive steps to deal with the virus, important 
problems and questions remain unanswered. Health officials 
responding to reported SARS cases need better guidance on how 
best to protect their communities and our country, without 
implementing measures that may be costly or excessive. For 
example, they must determine an appropriate degree of screening 
for hospital patients and staff, determine how best to handle 
patients suspected of carrying the disease, and establish plans 
in the event of a SARS outbreak involving multiple patients. 
They need to know how to communicate what is happening in their 
local communities to the Nation's SARS specialists. In 
addition, health officials must decide how best to inform the 
public about the disease without causing undue concern or 
panic.
    We also need to deepen our understanding of the disease 
itself. We need to develop a rapid, accurate testing procedure 
for SARS, determine how the disease is transmitted, and 
identify high-risk populations. Individuals need to know 
whether they have or are likely to contract the disease. 
Doctors need to be able to quickly diagnose and treat their 
patients. And health officials need to know whether their 
communities are at risk for high rates of infection.
    I look forward to the testimony of the General Accounting 
Office today and to the testimony of the Centers for Disease 
Control. The American public will hopefully be better prepared 
to stop future SARS cases from occurring because of the work of 
the witnesses and others that you mentioned, Mr. Chairman, and 
I believe also because of the work of the Subcommittee itself.
    Thank you.
    Senator Coleman. Thank you very much, Senator Levin.
    It is now my pleasure to turn to the distinguished Chairman 
of the Committee on Governmental Affairs, Senator Collins.

             OPENING STATEMENT OF CHAIRMAN COLLINS

    Chairman Collins. Thank you very much, Mr. Chairman, and 
thank you for calling this hearing. You have been a real leader 
in the Senate in our efforts to deal with the SARS epidemic, 
and this hearing is the second that you have held on this 
issue. It is important that we make sure that our local 
communities are properly prepared to respond to an outbreak of 
SARS because, after all, it is the health care workers and 
others who are on the front lines who will first encounter the 
disease.
    SARS has proven itself to be a formidable global threat. 
There is no cure for this deadly, highly contagious virus that 
has spread throughout Asia and into parts of Europe, Canada, 
and the United States. To date, there have been more than 8,400 
probable cases of SARS reported in 29 countries, and more than 
800 people have died.
    In an age of international travel, diseases know no 
boundaries. Quick action on the part of the Centers for Disease 
Control and Prevention as well as by our State and local health 
officials has resulted in a relatively low number of SARS cases 
in the United States so far, with, fortunately, no deaths. 
Moreover, no new outbreaks of the disease have been reported in 
recent weeks, and travel alerts have been lifted from many 
cities in Asia and in Canada.
    I was, however, in Beijing at the height of the SARS 
epidemic. I saw firsthand what happens when the local, 
provincial, and Federal response is slow, inadequate, and 
uncoordinated.
    There is much good news lately to report about SARS, but we 
should not rest easy. I believe that we are dealing with a 
sleeping giant, and I was very disturbed by the testimony that 
the Subcommittee heard at its first hearing on SARS in May. The 
Director of the Center for Infectious Disease Research at the 
University of Minnesota told the Subcommittee that the disease 
has now seeded itself in a significant number of humans as to 
make its elimination impossible. He then went on to tell us 
that he was convinced that, like the early days of the HIV 
epidemic, the worst of SARS is yet to come--the point made by 
the Subcommittee's Chairman.
    Virtually all of the public health experts who testified 
agreed with his prediction that there will be a resurgence of 
SARS with the onset of the flu season next winter that could 
far exceed our experience with the disease to date. We must be 
prepared.
    While there is absolutely no evidence that SARS is part of 
any planned biological or terrorist attack, our institutional 
capability to deal with such an epidemic is the same whether it 
is the consequence of a terrorist attack or a naturally 
occurring event. In fact, a major side benefit of all of our 
efforts to strengthen our homeland defense capabilities should 
be an improved ability to respond to all kinds of epidemics.
    Since physicians, nurses, and other health care workers on 
the front lines are likely to be the first individuals to 
encounter cases of an emerging infectious disease like SARS, it 
is critical that they have the support and information that 
they need from Federal agencies such as the CDC to identify and 
effectively contain such an outbreak. I therefore want to 
commend the Chairman for his efforts to try to identify ways 
that we can help those on the front lines in our local 
communities to protect our citizens.
    Once again, thank you for convening this hearing.
    Senator Coleman. Thank you very much, Senator Collins.
    I would now like to welcome our first witness at today's 
important hearing, Dr. Marjorie E. Kanof, Director of Clinical 
and Military Health Care Issues for the U.S. General Accounting 
Office. As I mentioned in my opening statement this morning, 
she is here to release the results of the GAO study that I 
requested of national best practices for identifying and 
treating SARS cases. While officials from global health 
agencies have indicated that for the moment SARS appears to be 
stabilized, there is a concern that this is simply the lull 
before the storm and, to reflect upon Chairman Collins' words, 
that what we have here is what could be phrased as ``a sleeping 
giant'' that we have to be prepared for.
    With that in mind, I look forward to hearing the results of 
the GAO study as I believe it is essential for the health care 
community to be prepared. I am hopeful that this study will be 
widely used by the health care community.
    Before we begin, pursuant to Rule 6, all witnesses who 
testify before this Subcommittee are required to be sworn. Dr. 
Kanof, at this time, I would ask you to please stand and raise 
your right hand. Do you swear that the testimony you give 
before this Subcommittee will be the truth, the whole truth, 
and nothing but the truth, so help you God?
    Dr. Kanof. I do.
    Senator Coleman. Thank you, Dr. Kanof, and with that you 
may proceed.

TESTIMONY OF MARJORIE E. KANOF, M.D.,\1\ DIRECTOR, HEALTH CARE-
    CLINICAL AND MILITARY HEALTH CARE ISSUES, U.S. GENERAL 
                       ACCOUNTING OFFICE

    Dr. Kanof. Good morning, Mr. Chairman and Members of the 
Subcommittee. I am pleased to be here today as you consider 
infectious disease control measures to help contain the spread 
of SARS should future outbreaks occur. Although the current 
outbreak is believed contained, the fact that SARS is a type of 
coronavirus, the source of many common colds, leads many to 
suggest that SARS could be seasonal and, as such, could recur 
in the fall and winter months.
---------------------------------------------------------------------------
    \1\ The prepared statement of Dr. Kanof appears in the Appendix on 
page 30.
---------------------------------------------------------------------------
    SARS transmission is most likely spread through person-to-
person contact. Experts agree that infected individuals are 
contagious when symptomatic, a time when they are most likely 
to seek medical attention and come into contact with health 
care workers. In fact, one unique characteristic of the SARS 
outbreak was the high rate of infection among health care 
workers who, before the institution of specific protective 
measures, may have become infected while treating patients with 
SARS. The SARS outbreak in Asia demonstrated that the disease 
can also spread rapidly in the community.
    Currently, there is no definitive test to identify SARS 
during the early phase of the illness, which complicates 
diagnosing the disease. As a result, early diagnosis of SARS 
relies more on interpreting individuals' symptoms and 
identification of travel to locations with SARS transmission. 
The symptoms of SARS are similar to other respiratory 
illnesses, such as the flu and pneumonia. Although SARS did not 
infect large numbers of individuals in the United States, the 
possibility that SARS may re-emerge raises concerns about the 
ability of public health officials and health care workers to 
prevent the spread of SARS in the United States.
    My remarks this morning will focus on the infectious 
disease control measures that were practiced within health care 
and community settings for the containment of SARS and the 
initiatives and challenges in preparing for a possible SARS 
resurgence.
    Infection disease control experts all emphasize that well-
established infectious disease control measures, case 
identification and contact tracing, transmission control, and 
exposure management played a pivotal role in containing the 
spread of SARS in both the health care and community settings. 
No new measures were introduced. Instead, experts said strict 
compliance with and added vigilance to enforce use of the 
current measures was sufficient.
    For SARS, case identification within health care settings 
includes screening individuals for fever, cough, and travel to 
a country with active cases of SARS. In California and New 
York, States with high numbers of potential SARS cases, 
emergency room staff used questionnaires to screen incoming 
patients, and an individual identified as a potential SARS case 
was given a surgical mask and moved into a separate area for 
further medical evaluation.
    Toronto, which experienced a much greater prevalence of 
SARS than the United States, used somewhat different practices. 
At the height of their outbreak, everyone entering a hospital 
was asked screening questions and had their temperature checked 
before they were allowed to enter. As a further measure, 
Toronto health officials established SARS assessment clinics, 
also known as ``fever clinics,'' that they used as screening 
centers instead of hospital emergency rooms or other outpatient 
clinics.
    Contact tracing was important for the identification of 
individuals at risk for SARS and for implementation of 
appropriate measures to reduce their possible spread of the 
disease to others.
    In New York City, teams interviewed each possible SARS case 
in order to identify contacts, and then they called each 
contact to advise them of the symptoms, provide information 
about the risks of SARS, and to ensure that the contacts were 
following infection control measures. Each contact received 
three to five routine calls during a 10-day period.
    Transmission control measures, or the spread of the 
disease, was similar for both health care settings and in the 
community. According to several experts, the simple things your 
mother taught you, such as washing your hands and covering your 
mouth and nose with a tissue when sneezing or coughing, are 
effective in reducing the spread of SARS.
    Hospital transmission control guidelines included routine 
standard precautions, including hand washing, contact 
precautions such as gown and gloves, and airborne precautions 
such as an isolation room and the use of an N-95 disposable 
respirator for individuals entering the room.
    Hospitals in the United States generally saw few SARS 
patients, one or two patients at a time, so they were able to 
manage the SARS patients in available isolation rooms with 
available staff. Because of the greater prevalence of SARS in 
Toronto, however, all 22 acute-care hospitals were directed to 
have SARS units in which they had staff who only cared for 
SARS. Health department officials in Toronto later designated 
four hospitals in the city to be SARS hospitals.
    The use of face masks or N-95 respirators was recommended 
as an effective means of transmission control. In Canada, 
however, health care workers used an additional level of 
protective equipment, almost a total body protective system, 
when conducting high-risk procedures such as respiratory 
intubation.
    Transmission control guidelines for community settings 
incorporated many of the same measures for containing the 
spread of SARS in the hospital. In addition, SARS patients were 
advised to continue infectious disease measures for 10 days 
after their symptoms had abated and to remain in their homes 
during this time period.
    Exposure management practices, isolation and quarantine, 
occurred in both health care and home settings. In Toronto, 
isolation was typically used in the hospital, even in cases 
where individuals were not ill enough to require 
hospitalization. In the United States, home isolation was used, 
unless an individual required hospitalization for medical 
treatment. Similarly, quarantine guidance was based on the 
prevalence of SARS in the community. CDC advised individuals 
who were exposed but not symptomatic to monitor themselves for 
symptoms. Individuals were not instructed to remain in their 
homes. In contrast, Toronto, which experienced a very high 
level of person-to-person transmission, required individuals 
who did not have symptoms but had been in close contact with 
SARS-infected individuals to stay in their homes and avoid 
public gatherings for 10 days.
    Toronto health workers were restricted to a work 
quarantine. They were allowed to travel to and from work alone 
in their own vehicles, but they were not allowed to visit 
public places.
    Effective communication among health care professionals and 
the general public reinforced the need to adhere to all of 
these infectious disease control measures. According to health 
officials, rapid and frequent communication of crucial 
information about SARS were vital components of their efforts 
to contain the spread of disease.
    But how do we prepare for a resurgence of SARS? While no 
one knows whether there will be a resurgence, Federal, State, 
and local health care officials agree that this is necessary to 
prepare for the possibility of a large-scale resurgence. As 
part of these preparations, CDC, along with State and local 
health associations, are involved in developing SARS-specific 
infectious disease control guidelines. These preparations will 
also improve the health care system's capacity to respond to 
other infectious disease controls. Implementing these plans, 
however, may prove difficult due to limitations in both 
hospital and workforce capacity.
    We recently reported that most hospitals lack the capacity 
to respond to large-scale infectious disease outbreaks. Most 
emergency departments have experienced some degree of 
overcrowding, and therefore, may not be able to handle a large 
influx of patients during a potential outbreak of SARS, 
especially if SARS recurs during the peak season for flu.
    Few hospitals have adequate staff, medical resources, and 
equipment needed to care for the potentially large number of 
patients that may seek treatment. In addition, the monitoring 
of individuals placed under isolation and quarantine may strain 
resources if widespread isolation and quarantine are needed. 
Follow-up with isolation and quarantine individuals requires 
additional health care and community resources. In Canada, it 
was the police and the Red Cross that were helping purchase and 
deliver food to those under isolation or quarantine.
    In conclusion, the global spread of SARS was contained 
through an unprecedented level of international scientific 
collaboration and the use of well-established infection control 
measures that had been used effectively in the past to control 
diseases such as tuberculosis and smallpox. Worldwide disease 
surveillance will facilitate prompt identification of a 
resurgence of SARS which would allow rapid implementation of 
infectious disease control measures, which would in turn reduce 
both the spread of SARS and the risk of a large outbreak.
    Preparations are underway, and they do encompass in large 
part approaches similar to those for pandemic influenza plans, 
and they are also a component of more general bioterrorism 
preparedness plans. However, should a large-scale outbreak 
occur in the near term, limitations in the capacity of our 
Nation's health system to undertake effective and rapid 
implementation of the infectious disease control measures could 
prove problematic.
    A major SARS outbreak would necessitate rapid escalation of 
infectious disease control resources, including health care 
workers, emergency room and hospital capacity, and the 
requisite control and support equipment.
    Mr. Chairman, this completes my statement. I would be happy 
to respond to any questions you have.
    Senator Coleman. Thank you very, much, Dr. Kanof, and let 
me say that it is very gratifying to have empirical data that 
says doing what mother taught us is a good thing. I feel very 
uplifted. I am sure my mom will give me a call after this to 
say, ``See, I told you so.''
    Let me make a couple of observations. I get a sense that 
the things in this post-September 11 world, the stuff that we 
did--concerns about anthrax, concerns about bioterrorism--
really have in many ways kind of formed the basis for having a 
system in place that gives us at least a high state of 
readiness. Is that a fair assumption?
    Dr. Kanof. Absolutely.
    Senator Coleman. But in the end, your conclusion is that 
should a large-scale outbreak occur in the near term, there are 
limitations that could prove problematic--staffing, worker 
limitations, health care capacity limitations, or equipment 
limitations.
    What is necessary? Is there a minimum standard that we 
should have at the national level to say here is what we need 
to do to deal with this? How do we address that limitation 
issue better?
    Dr. Kanof. In the previous work that we have done in which 
we looked at seven cities and we looked at the preparedness of 
each of these cities, one key observation was that, in fact, 
the more frequently a city or a community had, unfortunately, 
encountered previous natural disasters, be it a hurricane or 
even an infectious disease, they were, in fact, better prepared 
to respond to ongoing challenges. So I think that is an 
important observation to make.
    The other observation we made in the previous study was 
that, in fact, not every city and community had gone through 
preparedness drills, which is something that a few cities have 
done. There have been some more done recently during the 
summer, but it was really key to have overcome the barrier of 
not wanting to do a preparedness drill, because an important 
factor in being prepared is not just at the hospital but also 
have you established all the right connections to both the 
public health department, the police, the firemen, other 
communities, and in certain borders, other States. And so it is 
important to think about initiating more of these initiatives.
    In terms of resources, what we have found in our previous 
study was that hospitals lacked equipment, that most hospitals 
had only one ventilator for 100 staff beds, that they only had 
one protective suit, that they only had one isolation bed. Half 
the hospitals had six ventilators for 100 beds, three or less 
protective suits, and four isolation beds.
    So there is a significant need within communities to have 
the proper equipment.
    Senator Coleman. One of the concerns that I saw as a mayor 
in looking at the resource issue and talking to my colleagues 
was all of us looking for the same thing at the same time. 
Would it be your recommendation that States set up some kind of 
regional perspective so that we have pooling of equipment? I 
think it would be probably impossible for every community to 
have all the resources that they needed. There are no specific 
recommendations to that effect in this report, just kind of 
observations of the state of readiness. Would that be a 
recommendation to proceed in that manner?
    Dr. Kanof. Well, in fact, what we have included in the 
report--is a SARS preparedness checklist that, in fact, has 
been developed between the State and the communities and CDC, 
that, in fact, highlights many of those issues that you have 
just discussed.
    Senator Coleman. And I was going to compliment you on that 
checklist. I would hope that folks would then use that 
checklist. That was a very clear and focused and thorough kind 
of formula for determining are we prepared and what do we need. 
So I would hope that folks take a look at that checklist. I 
think it is extremely well done.
    What has been the impact of SARS on hospitals? And, in 
particular, is there a higher level of fear among health care 
workers because of the high incidence of SARS among health care 
workers?
    Dr. Kanof. The health care workers that we spoke to in 
Toronto clearly had a higher level of concern than similar 
health care workers we have spoken to in the United States. 
But, clearly, there is a big difference between walking into a 
hospital where you know you have very ill patients. But I think 
among health care workers that we have spoken to, it is a 
heightened level of concern in your differential diagnosis of 
when you are seeing a patient, but, more importantly, in your 
own appropriate use of protective measures such as masks, 
gloves, and hand washing.
    You referred back to HIV and AIDS. There was a time that we 
drew blood as health care workers without wearing gloves, 
something that I think most people would not do today under 
normal circumstances. And so I think among health care workers 
there is just a heightened realization that protective measures 
are important.
    Senator Coleman. In the last outbreak--the first incidence, 
really, of SARS, we knew where it came from--China and those 
areas that had larger contact with China--New York, California, 
and Toronto, centers of focus. If, in fact, going back to Dr. 
Osterholm's comment from our last hearing, saying that SARS has 
now embedded itself in the population, does the dynamic change 
in terms of state of readiness? In other words, I represent 
Minnesota--now if SARS is embedded in Toronto, it is no longer 
looking at a Beijing-to-Minneapolis connection, now it is Maine 
to Canada, now it is Minnesota to Canada. Would that be a 
correct assumption? Does that mean that health care workers 
across the board in any community have to have this higher 
level of readiness as we enter the cold and flu season?
    Dr. Kanof. I think that gets to the unknown and that we do 
not know exactly what will happen, but I think that clearly 
recommendations that have come from the CDC and other public 
health departments would stress that, as we enter the flu 
season, as you see individuals and you establish triage centers 
in almost every emergency room, clinic, physician's office, 
that you need to ask certain questions.
    You are right, we might not be able to ask have you 
recently traveled to a SARS transmission country, since we 
might not have known that. But it needs to be quickly in 
individuals' differentials, and when they have a suspect case--
I think the difficulty with SARS is we do not have a test that 
says you have it--they need to immediately begin protective 
control measures and alert the public health surveillance 
system, because what we are really going to need to do is be on 
alert to understand where there is a trigger event.
    Senator Coleman. And it is interesting that the three 
Senators here, Senator Levin, Senator Collins, and I, we all 
represent border States. I have been on that bridge between 
Michigan and Canada. It is a very thin line. So I think for all 
of us there it is a heightened level of concern.
    Let me then ask a final question at this point in time. It 
is a resource question. Do we have enough resources? What 
recommendations would you make for this body, for this Congress 
today as we look to the future, knowing what we know and 
knowing what we do not know when it comes to the issue of 
resources?
    Dr. Kanof. Well, I think we have in numerous reports 
actually looked even closer on the health care delivery, to 
determine if the public health systems are prepared. We have 
noted many times that there are significant limitations in our 
resources in the public health department and the health care 
delivery system, be it electronic disease surveillance, be it 
electronic databases in which to capture the information. We 
have highlighted that there is a deficiency in the number of 
health care workers, and we have highlighted numerous times the 
shortages at hospitals of basic equipment. And so all of those 
put together, we have highlighted the need to both ensure that 
there are sufficient resources and that there have been Federal 
dollars that have been given specifically for bioterrorism and 
specifically for hospital preparedness. The question, though, 
is: Is that enough, and how much more is available to give?
    I think what's critical, though, is ensuring that 
communities know how to share their resources.
    Senator Coleman. Thank you, Dr. Kanof. And I again want to 
thank the GAO for the expeditious manner in which they pulled 
together all this information and the work that they did, and 
particularly the checklist that you mentioned. I think that 
could be very helpful. Thank you.
    With that, I will turn to Senator Levin.
    Senator Levin. Thank you, Mr. Chairman.
    I would like to ask about that checklist. I am afraid I 
have not seen it. Could you describe how that checklist relates 
to policy positions of CDC? For instance, does CDC recommend a 
particular policy on screening and then the checklist relates 
to a specific recommended policy? Is there a recommended policy 
by CDC on isolation and then the checklist relates to that 
policy? How does that work?
    Dr. Kanof. Dr. Hughes can also answer that question, but 
the CDC, through their website and through their health alert 
system, basically have published guidelines. They have revised 
those guidelines as we have learned more about SARS 
specifically for situations in terms of when do you do 
isolation, when do you quarantine, and when do you use gowns 
and gloves.
    This checklist includes all that type of information at a 
high level, but a large part of this checklist, because it was 
also done with ASTHO, the Association of State and Territorial 
Health Officials, and the National Association of County and 
City Health Officials, goes through some really broader issues, 
such as the legal and policy issues. For example, agreements 
have been obtained with State health insurers, Medicare 
programs and health care product and service providers, for 
cooperation during an epidemic. It talks about authority. Do 
you have the authority that you need for isolation and 
quarantine? It talks about surge capacity and talks about do 
you have established relationships with communities adjacent to 
you and public health officials.
    Senator Levin. I have the checklist now in front of me, but 
does it say that you should do those things, you should have in 
place X policy or you should have a relationship with--the one 
you just read----
    Dr. Kanof. It recommends.
    Senator Levin. It does make the recommendation and then 
asks whether or not that recommendation has been carried out.
    Dr. Kanof. Yes.
    Senator Levin. It is connected to the recommendations. Have 
these checklists been compiled by that association or by 
anybody else?
    Dr. Kanof. I am sorry. Have they been?
    Senator Levin. Been compiled, have we gotten the return of 
these so we can say 38 percent of the public health entities in 
our States have this, 28 percent do this? Do we have any ideas 
statistically?
    Dr. Kanof. No. What has been done in the past is that for 
bioterrorism preparedness, those preparedness plans were, in 
fact, sent to HHS and, in fact, they came before money was 
released, and so people have evaluated those. But I am not 
aware of anybody looking to see if we have checked each State, 
each community for their infectious disease plan.
    Senator Levin. So, for instance, CDC has made a 
recommendation, or there has been a recommendation that has 
been worked out between our national people and the State and 
local people on isolation. If that is on the website, we do not 
have any idea as to what percentage of public health entities 
in the States have adopted that recommendation.
    Dr. Kanof. I am not aware of that at all.
    Senator Levin. Would that be helpful if we could learn that 
to see how well prepared we are, if we could perhaps ask the 
CDC, for instance, to make some kind of spot check assessment 
as to what percentage of recommendations have been adopted?
    Dr. Kanof. I think it would be--it is always helpful, 
whether it is done on a Federal or the State level, but people 
should be checking to make sure that there is a level of 
preparedness. It is similar almost to the report that we did 
just about a year ago. We looked to see were people prepared.
    Senator Levin. The Chairman asked you about research 
dollars, and I want to ask that question in a slightly 
different way. Could you compare the research dollars that we 
are devoting to SARS to research dollars on other kinds of 
diseases? Is there any way of telling us how many dollars are 
being devoted to SARS, or that it is 10 percent as much as we 
are doing on some other infectious disease?
    Dr. Kanof. We could get back to you with the answer,\1\ but 
I do not know that off the top of my head.
---------------------------------------------------------------------------
    \1\ See Exhibit No. 6 which appears in the Appendix on page 165.
---------------------------------------------------------------------------
    Senator Levin. That would be helpful to us, I believe.
    On the border question, which the Chairman also raised, 
have we made an assessment as to the adequacy and the 
appropriateness of checking at our borders? Is it spotty? Is it 
consistent? Are there clear guidelines for trying to identify 
people somehow or other, asking questions perhaps of people 
coming in from areas that have seen a large number of 
infections? Is there any kind of a coherent national policy at 
our borders?
    Dr. Kanof. That is an excellent question and one that we 
did not look at in great detail. I can tell you that CDC 
clearly, again, did have individuals at key locations. They 
were at the airports. They did provide information at all key 
sites. But we did not look, so I cannot tell you the status.
    Senator Levin. Thank you very much, and thank you, Mr. 
Chairman.
    Senator Coleman. With that, I will turn the questioning and 
the gavel over to Senator Collins, and I will be back literally 
in 5 minutes. I have one other hearing where I have to take 
care of some business. Senator Collins.
    Chairman Collins [presiding]. Thank you, Mr. Chairman.
    Doctor, quick action on the part of the CDC and our State 
and local health officials has so far resulted in a relatively 
low number of SARS cases in the United States. I believe that 
to date we have had about 40 probable cases and not a single 
victim in the United States has died.
    Why do you believe that the American experience has been so 
different from that in Canada?
    Dr. Kanof. Well, I think part of it, to quote many 
scientists and physicians asked that question that we 
interviewed was somewhat luck and somewhat timing in that if we 
understand the epidemiological spread of this disease, there 
was a physician who treated SARS patients who was in a hotel 
room in Hong Kong, and several individuals acquired the disease 
from that individual, and one of them, or perhaps two, landed 
in Toronto as opposed to directly in the United States. And so 
Toronto was experiencing illness that we now recognize as SARS 
before it was really known that there was SARS and before we 
really knew that you needed to have all the health care 
precautions that you did.
    We were very fortunate in that we did not get that first 
wave per se and that we were actually on alert in a time period 
after Toronto.
    Chairman Collins. Similarly, why has the infection rate 
among health care workers been so much higher in Canada? Does 
it all go back to that one physician and where he happened to 
be?
    Dr. Kanof. Unfortunately, in large part, yes. It goes back 
to unfortunate lessons we have learned from Canada. We 
understand now the significance of the respiratory spread, and 
so while in Canada, individuals might have been using masks and 
gloves as individuals got sicker and required more intensive 
care and health care workers were having potentially either 
more intense exposure to some of the virus or during procedures 
such as intubation not being protected, more individuals got 
exposed.
    Also, in Canada, not knowing initially about the disease, 
they did not have a system in place to contact everyone who had 
been taking care of a patient, which is why they began to 
create SARS units and SARS-dedicated staff so you knew who was, 
therefore, at a potential risk and could then track them to 
make sure they were not getting ill.
    Chairman Collins. During the SARS outbreak in Toronto, more 
than 10,000 people were quarantined in their homes. In 
addition, many health care workers were work-quarantined; in 
other words, they were allowed to travel to and from work in 
their vehicles, but they were not allowed to visit public 
places.
    How difficult would it be for Federal, State, and local 
public health authorities to impose the same kind of quarantine 
restrictions here in the United States should we be faced with 
a massive outbreak of SARS? Do you think that would be accepted 
in the United States? Do you think we have the knowledge and 
the resources to implement a significant quarantine?
    Dr. Kanof. The lessons learned from Toronto are really very 
interesting. I think you can break your question into two 
parts. One is: Do you have the authority? Then, how do you 
monitor? And then, even more importantly, but how do you 
provide resources? It is one thing to tell someone they need to 
stay in their home, but how do you get them all that they need?
    I think one of the things in the checklist that is very 
important is that States are supposed to be checking to make 
sure that they do have the authority. Information to date 
appears that States do have the authority from a health 
protection point of view to do isolation and quarantine as 
appropriate, and States are, I know, actively looking to make 
sure that extends to SARS.
    The bigger issue, though, is how do we mobilize the 
resources so that for Toronto, as you talked about the work 
quarantine, we learned that they went so far to have 
supermarkets within the hospital so that as you are asking the 
health care workers to come and not go anywhere else, they 
could at least obtain the basic supplies that they need. And I 
think that you are asking an important question that extends 
beyond just the health care delivery system, but the community 
needs to begin working now to ensure that resources are 
available to supply individuals when you ask them to stay at 
home.
    Chairman Collins. What do you think the response of the 
American public would be to a quarantine order similar to what 
was imposed in Toronto?
    Dr. Kanof. I probably would hope, just as you would hope, 
that as necessary, people would understand the need to do that. 
And I think that an important message learned from Toronto was 
the communication, was the actual explaining to individuals the 
need for why this was appropriately done.
    Chairman Collins. I mentioned in my opening statement that 
there is no evidence that SARS was part of a planned 
bioterrorism attack but that it, indeed, arose from natural 
sources. But the capability of State and local health officials 
to deal with such an epidemic should be the same whether or not 
it is due to a bioterrorist attack or whether it is a naturally 
occurring phenomenon.
    In fact, I think there are a lot of lessons that can be 
learned from the SARS outbreak, including how quickly and 
rapidly it spread to 29 countries, that would help us better 
respond to a planned attack.
    Could you comment on whether or not you see capabilities 
that we have developed for homeland security assisting us in 
dealing with a naturally caused epidemic like SARS?
    Dr. Kanof. I think we believe they are all intertwined, 
and, in fact, not focusing too much on this checklist, but many 
are really sub-components of a general bioterrorism plan, and 
that resources that have gone out already to both local 
communities and hospitals in response to bioterrorism 
preparedness will definitely assist them to prepare for any 
infectious disease, be it a bioterrorism threat or a real 
infectious disease threat.
    Chairman Collins. The CDC has been widely credited with an 
effective response to the SARS epidemic. When I was in Beijing 
and travelling through Asia, CDC experts were in all of the 
cities that our congressional delegation visited. They were at 
all of the public health meetings, providing their expertise 
and assistance, which was particularly critical in China, where 
a slow reaction on the part of officials allowed the epidemic 
to be more serious than it otherwise would have been.
    This contrasts to the anthrax attacks back in 2001 when the 
CDC was widely criticized for putting out conflicting and 
inconsistent guidance, and even contradictory information.
    Do you think that the CDC has learned and incorporated 
lessons from its experience with anthrax that it applied to the 
SARS epidemic? Why do you think the performance was so 
different?
    Dr. Kanof. I think CDC has significantly learned from the 
anthrax. I think they are continuing to learn and improve on a 
regular basis. But I think key observations that you can make 
the contrast to, but for SARS, they now have an emergency 
response team and an emergency response room. Eight hundred 
people, I think, were involved in the United States or around 
the world from the CDC for helping contain SARS.
    But I think more importantly what they learned is the 
importance of rapid communication, and I think Dr. Gerberding 
is quoted as saying she knows that needs to be out there and to 
tell the facts as you know them and to keep increasing your 
knowledge and sharing those facts on a regular basis, not just 
to physicians but to hospitals and to the public. And I think 
that is what you have seen here with SARS, not just in the 
United States but throughout the world.
    So there were significant lessons learned that we saw with 
SARS.
    Chairman Collins. Thank you, Doctor. Senator Pryor.

               OPENING STATEMENT OF SENATOR PRYOR

    Senator Pryor. Thank you, Senator Collins. Thank you for 
your leadership, and also to Senator Coleman and Senator Levin, 
I appreciate them bringing this very important issue to our 
attention and keeping us focused on it.
    Let me ask, if I may, a few questions about the spread of 
SARS and our preparedness for it. First I would like to focus 
on rural issues, rural versus urban. Do you think that it is 
likely, more likely, that SARS will start in urban areas and 
spread out into rural areas, or vice versa?
    Dr. Kanof. Again, I think we will learn about SARS as we 
get more experience with SARS. But I think the key is that 
close-to-close--person-to-person contact plays an important 
role in transmission of SARS. And so the density of the 
population clearly is an important factor in the transmission 
of SARS. And so, again, if one were to follow that logic, and 
the density of a city in which there is more close-to-close 
contact would put that city at potentially higher risk. That is 
one side of the equation.
    What you need to ensure, though, is that the health care 
delivery system, both in the city and the rural, though, have 
equal awareness, equal training, equal connections with the 
public health system so that if they suspect an individual has 
SARS, they can tap in equally quick to the appropriate 
resources.
    Senator Pryor. Given that you have just gone through this 
study to try to help the government get a handle on this issue, 
do you feel that you can disseminate the information that you 
have and disseminate it effectively to the health care 
community around the country?
    Dr. Kanof. That we can disseminate the information?
    Senator Pryor. Right.
    Dr. Kanof. I think that we are helping inform Congress, and 
that in turn will help disseminate that information. I think 
key for the dissemination of the information is really that is 
the critical role of the CDC and the State and local 
communities. And what we have seen is that there is active work 
on all those agencies' part, all those Federal, State, and 
local agencies, in order to obtain information.
    Senator Pryor. Has CDC seen your report here? And do they 
agree with it? Are they going to use the guidelines therein?
    Dr. Kanof. Well, in fact, we do not have any new guidelines 
in our report.
    Senator Pryor. OK. So you are taking information from the 
CDC.
    Dr. Kanof. Absolutely.
    Senator Pryor. Perfect. OK.
    Now, one thing I have noticed in just the last few months 
is a number of stories about medical conditions that are 
spreading around the country and around the world. Just a few, 
of course, are SARS and another one is monkeypox and another 
one is West Nile virus. In fact, when I was home in my State of 
Arkansas this last weekend, there were stories in the paper 
about the State possibly confirming the first West Nile virus 
case in a human in Arkansas, and actually, as I sit here today, 
I am not sure whether that was confirmed or not.
    But in your work and in your research into this issue, are 
there other diseases and potential threats out there that we, 
as policymakers, need to know about, things that really have 
not hit the headlines yet like SARS has? Are there other 
diseases on the horizon that we need to be focused on and be 
getting ourselves prepared for?
    Dr. Kanof. I think the answer to that is yes, but if you 
ask me what they are, my answer to you will be I do not think 
we know.
    Senator Pryor. Ask the CDC? [Laughter.]
    Dr. Kanof. It would be an interesting question to ask them. 
I just think, though, that we are a global economy, and travel 
and the world at large is introducing new diseases on a regular 
basis. And I think that is the significance of disease 
surveillance, and it is not disease surveillance limited to the 
United States, but it is disease surveillance for the world.
    Senator Pryor. One last line of questions in terms of your 
research and what you have been doing on this issue, and that 
is the impact on hospitals and the preparations that hospitals 
need to have in place in order to be prepared to address SARS 
if it does re-emerge and the expense involved in that. Is it 
your sense that American hospitals generally are prepared for 
this and that they have the protocols in place and the training 
and the equipment that they need to handle a re-emergence of 
SARS?
    Dr. Kanof. We did not look at hospital preparedness for 
SARS. We have, though, in previous work looked at hospital 
preparedness for other infectious disease. And there is 
evidence that they are prepared in terms of having plans, and 
there is evidence that they have trained their staff in terms 
of infectious disease. But there is definite concern that they 
do not have enough of the resources, both equipment, protective 
equipment, and staff, to handle a large-scale outbreak of any 
infectious disease that would require hospitalization.
    Senator Pryor. OK.
    Dr. Kanof. And the point is that I think it extends beyond 
the hospital. It goes throughout the health care delivery 
system.
    Senator Pryor. I tend to agree with that as well. Senator 
Coleman, that is all I have.
    Senator Coleman [presiding]. Thank you very much, Senator 
Pryor.
    One last question, Dr. Kanof, and I apologize if it was 
addressed in my absence, but it is following up on preparedness 
of rural areas. I look at Toronto, and, first, two questions. 
One, in the Toronto situation, was everything focused in the 
metropolitan area there, or were there experiences that rural 
hospitals had in trying to deal with SARS? Are you aware of 
that?
    Dr. Kanof. I am not aware of that.
    Senator Coleman. And it would kind of then tie into the 
second part of that question. Within this country, any sense of 
the level of preparedness in smaller towns and rural 
communities?
    Dr. Kanof. I think, to go back to a previous answer, I 
think we will have more of a risk of, let's say, SARS in a 
large city as opposed to rural areas just because of the 
transmission of close-to-close contact.
    What we do know, though, from Toronto is that they did 
share information in terms of signs and symptoms with 
surrounding areas, with the United States, and I think that is 
really what is most critical for rural areas in the United 
States, that they, too, are trained to recognize signs and 
symptoms, that they do have limited resources but we ensure 
that they have basic resources in case they do see an 
individual with SARS, but that most importantly they are 
connected to their local and State and Federal public health 
departments so that they are getting all the information that 
they need.
    In Tennessee, they are trying to figure out how do I get 
information out to all physicians in rural areas where they do 
not have E-mail, and they are working to see if people have fax 
machines and maybe they can get information to them through 
their fax machines.
    So I think that is what we really need.
    Senator Coleman. Thank you very much, Dr. Kanof.
    Senator Pryor, any follow-up?
    Senator Pryor. No, thank you.
    Senator Coleman. Thank you very much.
    I would now like to call our second witness. I welcome Dr. 
James M. Hughes, the Director of the National Center for 
Infectious Disease at the Centers for Disease Control and 
Prevention in Atlanta, Georgia. Thank you, Dr. Hughes. I 
appreciate your attendance at today's hearing. I look forward 
to your testimony on what the CDC is doing to help communities 
apply the lessons learned from this Spring.
    I am also eager to hear about your plans for developing 
contingency plans to handle a large-scale outbreak this fall.
    Pursuant to Rule 6, all witnesses who testify before this 
Subcommittee are required to be sworn. At this time I would ask 
you to rise and please raise your right hand.
    [Witness sworn.]
    Senator Coleman. Thank you very much, Dr. Hughes.
    Dr Hughes, before you proceed with your testimony, I want 
to make a public note of the work that the CDC has done. I talk 
to folks at the local level. There has been a lot of outreach, 
a lot of communication, and within the health care community a 
deep sense of appreciation for the way in which the CDC has 
dealt with SARS to date. So I want to express my thanks for 
your efforts.

   STATEMENT OF JAMES M. HUGHES, M.D.,\1\ DIRECTOR, NATIONAL 
CENTER FOR INFECTIOUS DISEASES, CENTERS FOR DISEASE CONTROL AND 
   PREVENTION, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, 
                        ATLANTA, GEORGIA

    Dr. Hughes. Thank you very much, Mr. Chairman. Good 
morning. Senator Pryor, good morning.
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    \1\ The prepared statement of Dr. Hughes appears in the Appendix on 
page 61.
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    Thank you for convening this important hearing on critical 
issues regarding Severe Acute Respiratory Syndrome, or SARS. I 
very much appreciate the opportunity to appear before you today 
on behalf of CDC. I would like to briefly update you on the 
status of the outbreak, the worldwide response to this emerging 
global microbial threat, and CDC's involvement in collaborative 
efforts to prepare for the potential recurrence of SARS.
    As we have seen recently, infectious diseases continue to 
threaten our Nation's health. The emergence of SARS, the first 
reported outbreak of monkeypox in the Western Hemisphere, and 
this year's first cases of West Nile encephalitis are strong 
reminders that infectious diseases respect no boundaries and 
that national and global health are inextricably linked. They 
also clearly indicate the need for continued vigilance in our 
efforts to address emerging infections.
    In early 2003, the first cases of what would later be 
called SARS began to be reported to the World Health 
Organization (WHO) from several countries in Asia. SARS spread 
globally in a matter of weeks, primarily infecting health care 
workers and family members of index patients, but also 
resulting in community transmission in several areas. As of its 
latest update on July 11, WHO had received reports of more than 
8,400 cases and more than 800 deaths among individuals from 
nearly 30 countries.
    As of July 29, 159 suspect and 33 probable cases of SARS 
had been reported in the United States. These current numbers 
are based on a recent change in the U.S. surveillance case 
definition for SARS as recommended by the Council of State and 
Territorial Epidemiologists. The revised case definition allows 
for exclusion of cases whose convalescent serum specimens 
tested negative for evidence of SARS-associated coronavirus 
infection. With this change, the number of reported cases 
decreased by more than 50 percent--from greater than 400 to a 
little less than 200.
    Although the global response to SARS has highlighted many 
priorities for the future, it also represents extraordinary 
collaboration among the clinical, scientific, and public health 
communities worldwide. WHO's coordination of the global 
response provided an opportunity for international assistance 
and rapid sharing of critical information that helped to 
minimize the spread of SARS and to rapidly identify the 
causative agent. At CDC, more than 800 individuals were 
mobilized to help respond to the outbreak.
    The U.S. response involved intense collaborations among 
public health officials at the local, State, and national 
levels, the clinical and academic communities, members of 
professional organizations, and industry representatives. 
Existing collaborations have been strengthened, and new ones 
have been formed both nationally and globally.
    Despite these successes, much remains to be done. Although 
we do not know if SARS will reappear, we must avoid complacency 
and use this time to address future priorities. Toward this 
end, the World Health Organization held a global conference on 
SARS in June in Kuala Lumpur, Malaysia. More than 1,000 
individuals highly involved in the SARS response attended the 
conference to share data and experiences, review lessons 
learned, and develop recommendations to address critical 
issues.
    At CDC we are developing an after-action plan to identify 
gaps and assess priority action areas. We are also developing a 
research agenda to help build the scientific base to ensure 
that the global clinical and public health communities have the 
necessary knowledge and tools to meet the challenges of SARS. 
Priority research areas include early detection and prompt 
reporting of cases, improved testing and treatment, increased 
understanding of the disease, efforts to prevent transmission, 
and effective communications.\1\
---------------------------------------------------------------------------
    \1\ See Exhibit No. 1a which appears in the Appendix on page 74.
---------------------------------------------------------------------------
    We have established a SARS preparedness task force 
comprising the following teams:\2\ Surveillance, clinical, 
laboratory, special studies, information technology, 
communication and education, and preparedness and response for 
communities and for the public health and health care systems. 
These teams are collaborating with many other national and 
international partners to develop effective response mechanisms 
that can rapidly and efficiently detect the introduction of 
SARS into the United States and that can be easily adapted to 
meet a range of local needs.
---------------------------------------------------------------------------
    \2\ See Exhibit No. 1b which appears in the Appendix on page 75.
---------------------------------------------------------------------------
    In mid-March, within 1 week of WHO's first global advisory 
on SARS, the Institute of Medicine of the National Academy of 
Sciences published a comprehensive report describing the 
spectrum of microbial threats to national and global health, 
factors affecting their emergence or resurgence, and measures 
needed to address them effectively. This report, ``Microbial 
Threats to Health: Emergence, Detection and Response,'' \3\ 
emphasizes the need for increased capacity at the local, State, 
and national levels to detect and respond to national and 
global microbial threats, both naturally occurring and 
intentionally inflicted. As indicated in the report and clearly 
reinforced by the emergence of SARS, strong global public 
health systems, robust health service infrastructures, and 
adequate surge capacity and expertise that can be rapidly 
mobilized and deployed remain our best defenses against any 
disease outbreak.
---------------------------------------------------------------------------
    \3\ See Exhibit No. 3 which appears in the Appendix on page 149.
---------------------------------------------------------------------------
    Thank you very much for your attention. I will be happy to 
answer any questions you may have.
    Senator Coleman. Thank you very much, Dr. Hughes. Dr. 
Hughes, first a question about the redefinition of SARS. 
Actually what I am focused on is mortality. You mentioned there 
were 8,400 cases, 800 deaths. Those 8,400 cases, were they 
under the old definition?
    Dr. Hughes. Yes, they were. And those 8,400 cases included 
only the U.S. probable cases. So the U.S. probable cases made 
up only about 74 of those 8,400.
    Senator Coleman. I guess my question is, do we have a good 
estimate of what the level of mortality is for SARS, 
percentage?
    Dr. Hughes. The level of mortality is directly related to 
age. The older people are, the higher the mortality rate. 
Evidence from Toronto and heavily impacted areas in Asia 
suggests that for people over 60 the mortality rate can be 50 
percent or more.
    Senator Coleman. How does that compare to pandemic flu and 
some other diseases?
    Dr. Hughes. A mortality rate of 50 percent or more would be 
substantially higher than the mortality rate that follows 
influenza epidemics that occur each year. But as you know, 
there are about 36,000 people in an average year in this 
country that die of influenza.
    Senator Coleman. Getting back to influenza, one of the 
things--I know we dealt with severe outbreaks of severe 
pandemic flu. I would guess it is kind of the same level of 
preparedness. If you are prepared for one, would it be fair to 
say you would be prepared for dealing with SARS?
    Dr. Hughes. I think there are many lessons from the SARS 
experience that are directly relevant to the thinking along 
preparedness for the next influenza worldwide epidemic or 
pandemic which we absolutely know will occur. We simply do not 
know when. Back in February when we first heard about these 
unexplained cases of pneumonia in South China, shortly 
thereafter we heard about some cases of influenza in Hong Kong 
caused by the H5N1 influenza virus similar to the one that 
caused the bird flu outbreak back in 1997. We were actually 
initially concerned that the outbreak in South China might be 
influenza, but laboratory studies rapidly ruled that out.
    This experience with SARS though shows how critical it is 
that surveillance systems be strengthened around the world so 
that these new problems can be rapidly detected. It certainly 
applies to influenza because we know that the more lead time we 
have when the next pandemic begins, the better, because it will 
give us time, hopefully, to develop a new influenza vaccine 
directed against the pandemic strain.
    Senator Coleman. I am just wondering though if you can tie 
in the preparation for re-emergence of SARS into the pandemic 
flu planning? As I look at that I recall last year, I believe 
there was a report by an Association of State Health Officials 
that only 12 States have completed a pandemic flu response 
plan. I am wondering whether it goes to the question that the 
Ranking Member Senator Levin talked about, regarding the 
checklist. Have we compiled or do we know who is actually 
prepared and who is not? Can you help me get an understanding 
of--do we have a sense of how many States truly have a good 
planning process for SARS? Is the lack of preparation for 
pandemic flu, is that something that gives us cause for 
concern?
    Dr. Hughes. I think that the Association of State and 
Territorial Health Officials and the National Association of 
County and City Health Officials have done a terrific job in 
developing this checklist for preparedness as it relates to 
SARS. I think in doing that, we have worked with them and they 
have drawn from some of the bioterrorism preparedness thinking 
as well as some of the influenza pandemic thinking and planning 
that has been going on a number of years.
    Actually there are 53 elements on this checklist. I doubt 
that there is a jurisdiction in the country anywhere that could 
put a yes in all 53 boxes. This checklist includes things that 
ought to be in place, and if they are in place for SARS, we are 
going to be much better off in dealing with pandemic flu or a 
bioterrorism attack. Progress has been made, but as we have 
heard, there is much that remains to be done.
    Senator Coleman. What is the plan for the distribution of 
that checklist?
    Dr. Hughes. We will be working with, and talking frequently 
with ASTHO and NACCHO officials in terms of not only sharing 
this with their membership, but then as suggested in some of 
the previous conversation I think the need to assess where we 
currently are and then monitor progress is important.
    Senator Coleman. Talk to me a little bit about early 
detection. My sense is that early detection is not an easy 
thing to do. That we are still not really sure what it is that 
we need to see in order to be positive that it is SARS. With 
that lack of certainty, the difference between SARS and a cold 
or the flu, tell me what you mean by early detection and how 
effective you think it is.
    Dr. Hughes. That question is right on the mark. SARS, when 
it presented, you may remember the initial reports out of South 
China were that this was a community-acquired atypical 
pneumonia. We see atypical pneumonias in the United States all 
the time, particularly in the wintertime, and there is a broad 
range of causes. But even in research studies that are done 
looking at people who have atypical pneumonia, only about 50 
percent will actually have a specific cause identified using 
the broad range of techniques currently available. So that 
right there is, in and of itself, a research priority even 
before SARS came along.
    The problem now, if SARS returns in the winter, the problem 
is going to be sorting out patients with acute respiratory 
disease who either contact their health care provider or are 
present for medical care. So it is important that we look, and 
we are with others, very closely at the clinical manifestation 
of SARS. Hopefully we will be able to come up with a clinical 
description that is more precise, or an algorithm maybe that 
helps clinicians make a better judgment in terms of whether 
they might be dealing with a case of SARS or not.
    Clearly, this is where we go back to the global 
surveillance. We do not have any evidence that the virus is 
circulating in this country at this time. It could be but we do 
not have any evidence that it is. We do not know the source of 
it in South China. The evidence suggests that the virus 
probably originated in an animal species there. It has been 
found in a couple of exotic animals in South China. But the 
original source in nature has not been identified.
    The more warning we have, the better, of course, if it does 
resurge. So we are working with Chinese public health officials 
and others in Asia, along with WHO, to try to support them in 
strengthening surveillance efforts there, at the same time that 
we are trying to strengthen surveillance efforts here. We and 
others are working to develop better, more sensitive, more 
specific rapid early diagnostic tests, not only for SARS, but 
if we had rapid tests for the other agents that cause atypical 
pneumonia we could at least know a subset of the people that we 
do not have to worry about because they have another specific 
cause, and be able to focus in on those cases of unknown 
etiology.
    So a long-winded response but a big research agenda with 
absolutely direct, concrete public health relevance and 
urgency.
    Senator Coleman. How close are we to that research giving 
us the capacity to measure what it is we have, whether it is 
SARS or something else?
    Dr. Hughes. There is some very promising, innovative 
research going on. We currently have antibody tests, and we 
have RT-PCR, these rapid molecular amplification techniques 
that need further evaluation and refinement. We have deployed 
those in State public health laboratories but they are not yet 
at a stage where they can get out into the clinical laboratory 
settings for use which is where we really need them. So this is 
urgent but I cannot sit here and tell you that we will have 
these this week or next month or in time for the next flu 
season.
    Senator Coleman. You stated, if SARS returns in the winter, 
and you note there is no evidence it may, that it is a seasonal 
condition. Do you disagree with Dr. Osterholm's statement at 
the first hearing where he said, ``I am convinced that with the 
advent of early winter in the Northern Hemisphere in just 6 
short months we will see a resurgence of SARS that could far 
exceed our experience to date?''
    Dr. Hughes. I think, like Dr. Osterholm, that we are at the 
beginning of the experience of SARS, not at the end. I think we 
will encounter it again. I think it is important to point out 
to you, it might not wait till winter, because we do not know 
the animal reservoir. We do not know how it got into people in 
South China. We do not know that it could not get back into 
people there sooner than the wintertime. So we are not going to 
be complacent here in the next few months while we are in the 
hot season. We have to be alert and vigilant now, but move as 
rapidly as we can for increased preparedness in the fall and 
winter because of the reasons we have talked about.
    Senator Coleman. When we talk about fall and winter, again, 
coming from a cold weather State, I think the reality is in the 
winter we tend to be grouped indoors in closer spaces versus in 
the summer we celebrate being outside. But it is that close 
contact that creates a great potential for an outbreak.
    Dr. Hughes. Yes, but I had the opportunity to go to that 
meeting in Kuala Lumpur that I mentioned and I passed through 
Singapore which is right on the equator and they had a very 
dramatic SARS outbreak there. So it is not going to be a 
problem just limited to colder climates in the winter-time, I 
am afraid.
    Senator Coleman. Thank you. Senator Pryor.
    Senator Pryor. Thank you, Mr. Chairman. Let me ask a 
question or line of questions about China specifically. I 
promise you, I do not ask this in any way to criticize China or 
to cast any disparities on China and how they responded to 
SARS. But I would like to hear your thoughts on lessons learned 
from China, maybe some of the mistakes they made or some things 
that we should be prepared for so we can handle this in the 
event that we do see an outbreak here. What have we learned 
from China?
    Dr. Hughes. Clearly, we have learned that the earlier a new 
and unusual problem is recognized to be something unique, the 
easier it is to confront and control. There is no question that 
there were major delays in recognition, and particularly in 
reporting of that occurrence.
    After it was recognized, some laboratories studies were 
done in China. There was some laboratory evidence, as I 
understand it, that supported the possibility that this illness 
was caused by an organism that is called Chlamydia pneumoniae, 
which is one of a number of organisms that we have in this 
country that does in fact cause atypical pneumonia. But it 
would have been unusual, I think, for a community-wide outbreak 
or outbreaks as they occurred in South China to have been 
caused by Chlamydia pneumoniae. So I think they were misled by 
that. They underestimated the gravity. They perhaps did not 
realize they were dealing with a new problem and then they 
obviously had major communication problems as well.
    So lessons are vigilance, sensitive surveillance supported 
by adequate laboratory capacity that allows you to rule in or 
rule out agents. By ruling out common agents, that leads you 
quickly to the suspicion that you may be dealing with something 
unusual. That's what happened with hantavirus pulmonary 
syndrome in the United States. You may recall back in 1993 in 
the Southwest a severe acute respiratory syndrome, when it was 
recognized, with a very high fatality rate where basic 
laboratory studies looking for common agents were negative. So 
very rapidly we and others got on to the fact that this was 
something unusual and moved quickly to identify the cause.
    That approach and the approach used here with SARS, once it 
was recognized to be unusual--you are familiar with the 
incredible levels of international collaboration and the 
rapidity with which this agent was identified and 
characterized.
    So in the modern age where we do have the tools--now, not 
every laboratory has these tools, but we need to continue to 
support and make sure that at the State and national levels 
these tools exist to rapidly recognize new infections when they 
occur.
    Senator Pryor. You mentioned surveillance in your 
testimony, and I noticed in some of the budget numbers that we 
have seen here in Washington, I believe the House has about $80 
million for global surveillance of disease, and I believe the 
Senate version has $130 million for global surveillance of 
disease. Are you familiar with those numbers?
    Dr. Hughes. Not those specific numbers, but I know that 
there are amounts in the bills.
    Senator Pryor. How do you watch this disease? How do you 
monitor it? What is that money used for and how can we use that 
money best and most strategically?
    Dr. Hughes. We and the World Health Organization are 
thinking about that and trying to work with the countries in 
Asia as well. We have had very close collaboration, I think you 
realize, with the Canadians. We have learned a lot from their 
experience. We have been to their meetings, they have been to 
ours. We had a liaison representative assigned to Health Canada 
and they to CDC throughout this. So we have learned a lot from 
the Canadian experience.
    We have worked closely, as you have heard, with colleagues 
in the countries in Asia. We have tried to help them assess 
surveillance needs. We have shared reagents with them. In some 
cases we have shared the virus or viral RNA with them, because 
they need to have in place surveillance systems for atypical 
pneumonia and that needs to be backed up by laboratory support 
at the national level. Of course, laboratory capacity at the 
national level in those countries varies quite a bit. It is 
quite substantial in Singapore and Hong Kong but less so in 
other parts of Asia.
    We have been talking with the Chinese about collaborating 
with them to strengthen their field epidemiology training 
program that they have and build up the laboratory capacity 
that is linked to that.
    This allows me to make what I think is another important 
point and it is just dramatically illustrated by the discussion 
this morning. For many years there has been quite a gulf in 
this country between the world of clinical medicine and the 
world of public health. Whether you are dealing with 
bioterrorism or antibiotic resistance or West Nile or SARS, we 
have to break down some of those traditional barriers. We have 
made a lot of progress. So there are a lot of opportunities 
provided now with this attention to SARS that we need to 
capture, and that will help with surveillance both in this 
country and in other countries as well.
    Senator Pryor. A few moments ago I asked the previous 
witness a similar question to this and that is, I said I 
noticed in a lot of the media reports, etc., that there are 
other diseases out there that seem to be spreading through 
various populations, monkeypox is one, SARS is another, West 
Nile is another disease out there. Those have received some 
media attention and some public focus but what other things are 
out there that we need to be concerned about as policymakers? 
What do we need to be preparing for?
    Dr. Hughes. Thank you very much for asking that question. I 
would refer you to this Institute of Medicine report on 
Microbial Threats to Health.\1\ They have a long list of many 
things that could keep you up at night, but I will tell you 
some of the things that I worry about. Obviously, I am 
extremely concerned about the threat of bioterrorism and we 
experienced that with a small attack involving anthrax, and we 
are intimately familiar with the consequences of that.
---------------------------------------------------------------------------
    \1\ See Exhibit No. 3 which appears in the Appendix on page 149.
---------------------------------------------------------------------------
    West Nile, we saw the dramatic sweep through much of the 
country last year. We are early in the season but it looks like 
we are at a level more or less similar to where we were this 
time last year, so we need to be prepared for that.
    Now in terms of other things that we have not talked about 
that I personally worry about, we have alluded to pandemic 
influenza. That next pandemic will occur and we need to be 
better prepared to detect early and respond to that.
    On top of that, I worry about antibiotic resistance, a 
major problem in health care settings and increasingly in 
community settings as well. It did not get much attention last 
year because of everything else that was going on, but for the 
first time in this country we found two cases of infection with 
a fully vancomycin-resistant strain of Staphylococcus aureus. 
You have been hearing perhaps for a few years about some 
strains of Staph. aureus that have had intermediate 
susceptibility to vancomycin, which is often the last line of 
antibiotic defense against that organism. Last year we found 
two cases for the first time that were fully resistant. 
Fortunately, they were susceptible to other antibiotics. But if 
we get a multiply-resistant Staph. aureus strain that is truly 
resistant to vancomycin then you are back in the 1920's in 
terms of dealing with people with common staphylococcal 
infections.
    The vector-borne and zoonotic disease arena is obviously a 
hot one. In addition to West Nile, dengue remains a global 
problem. There is always the possible threat of introduction of 
yellow fever into Asia. In a way we were lucky we got West 
Nile. We would not want to get Japanese encephalitis which is a 
genetically somewhat similar virus and a big problem in Asia 
that could be introduced into the United States.
    So the bottom line is, we live in a global village. We 
could encounter any infectious disease at any time that occurs 
anywhere else in the world, and a lot of our recent experience 
drives that home.
    Senator Pryor. Thank you, Mr. Chairman. That is all I have.
    Senator Coleman. Thank you very much, Senator Pryor.
    Dr. Hughes, a question about when SARS would recur. You 
have mentioned we are still not sure exactly how it got 
started. Is there a sense that once it is in the human 
population that it is dormant until something triggers it?
    Dr. Hughes. I do not think we have evidence that it is 
dormant. The illness itself, the people who are infected with 
it have evidence of viral activity in the first and 
particularly in the second week. Those who develop severe 
respiratory disease then may go on and be on ventilators for a 
prolonged period of time and some of them will die. The virus 
then, over time, disappears from those people though. We do not 
currently have evidence that I am aware of that there is any 
chronic carriage of the virus, although there are follow-up 
studies in progress to assess that possibility.
    We do not have evidence that there is much, if any, 
asymptomatic infection that occurs. But I think we have to keep 
an open mind and say the jury is still somewhat out on that it. 
We do not know in nature, as I have said, where it originated. 
To my mind, the most likely scenario would be that it jumps 
from animals back into people and spreads that way again.
    We have learned that in contrast to other coronaviruses 
that have been previously recognized, this virus survives a bit 
longer in the environment so you have to consider the 
possibility that there could be an environmental source. It 
does not survive indefinitely, but that is just another little 
complication of this microbe.
    Senator Coleman. Last comment, a concern again about rural 
areas. If somebody from Canada had a virus and brought it to 
Minneapolis-St. Paul and went to a concert at the Excel Energy 
Center in St. Paul and somebody from Hawley, Minnesota, a 
little town in the west, were to be there, they would bring it 
back to their community. Do you have a sense of confidence that 
folks in our rural communities have the level of preparedness 
that they need today to deal with this?
    Dr. Hughes. I think it starts with awareness. So we need to 
focus on rural as well as urban areas in terms of the 
professional education and the public education that needs to 
be done. That is one scenario that could occur, a person from a 
rural area sitting in the row in front of somebody from an 
affected area who is ill at the time could easily take it into 
a rural area. People from rural areas, obviously, travel to 
Asia also. So there is no assurance that--rural areas are 
certainly not immune to this, and probably on balance are less 
prepared to deal with it. Because of just the nature of the 
population not being as concentrated, one would hope if you had 
good surveillance in place, if it did occur in a rural area you 
would pick it up early when there might only be one or a couple 
of cases and therefore it would be easier to deal with.
    Senator Coleman. When we had the outbreak of SARS I know 
there were efforts made to educate airline passengers, kind of 
a proactive outreach. Do you have in your communication, 
education SWAT team, do you have that same kind of planning to 
get out there and proactively educate should the outbreak 
recur?
    Dr. Hughes. Yes, we do. We have not talked very much about 
this here today, but we were very active in working with 
Customs, Immigration, Agriculture, and other Federal colleagues 
in ports of entry in the United States to give information to 
passengers who were returning from SARS-affected areas. We 
actually distributed over 2.7 million of these health alert 
multi-language cards to people. We actually know that a number 
of people--I cannot give you precise numbers--but we know that 
a number of patients with suspect or probable SARS actually 
went to their physicians and showed them this card and said, I 
am here because I have been there and I have this card and 
maybe you ought to think of this. So that helped.
    We have other approaches to providing travel alerts and 
travel advisories to outgoing travelers. So we have systems in 
place to do that. We work closely with the airlines and the 
airline unions. I think there is more work to be done in that 
area to be better prepared for the next time this occurs. So 
there is progress, there are conversations, there is 
communication but there is more to be done.
    Senator Coleman. Dr. Hughes, I appreciate you noting that 
you are not going to be complacent at this time and that we 
will be doing the best we can to be ready for the next time.
    Dr. Hughes. Thank you.
    Senator Coleman. Thank you. With that, the record of this 
hearing will be kept open for 30 days for additional questions 
and comments. Some of my colleagues may be in touch with you, 
Dr. Hughes, or Dr. Kanof, with some additional concerns and 
questions. So with that, thank you for your participation. 
Thank you for your good work.
    This hearing is adjourned.
    [Whereupon, at 10:33 a.m., the Subcommittee was adjourned.]


                            A P P E N D I X

                              ----------                              


           PREPARED STATEMENT OF SENATOR FRANK R. LAUTENBERG
    Thank you, Mr. Chairman, for holding today's hearing on State and 
local preparedness as it relates to Severe Acute Repository Syndrome--
SARS.
    Mr. Chairman, one thing that struck me at the last hearing the 
Subcommittee held on SARS was that all of the witnesses attributed the 
absence of a widespread outbreak here in the United States, to some 
extent, to luck.
    New Jersey, my State, is developing guidelines for enhanced 
preparedness for an outbreak based on the CDC's recommendations. The 
three key elements to breaking the cycle of transmission are: (1) early 
detection; (2) intense surveillance; and (3) isolation.
    New Jersey followed this plan during the first SARS outbreak and 
did it well. But luck was involved, too, and I don't want to rely on 
luck. Sometimes, luck runs out.
    There is a lull in the SARS epidemic right now but we must remain 
vigilant: The resurgence in late May of cases in Toronto where the 
disease was thought to have been contained is a sobering reminder of 
the resilience of SARS and its capacity to surprise us.
    Disease prevention requires more than bolstering State and local 
preparedness and other domestic capabilities--as vital as all of that 
is. It also requires training experts in epidemiology in other 
countries and coordinating with agencies around the world.
    Diseases don't respect borders. If SARS persist in Asia for the 
long-term, it will continue to threaten us here in the United States. 
As Barry Bloom, dean of the Harvard School of Public Health, wrote in a 
recent issue of Science, ``The lesson here is that it is time to 
support a global war on disease.''
    Thank you, Mr. Chairman.

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