[Senate Hearing 108-136]
[From the U.S. Government Publishing Office]
S. Hrg. 108-136
SEVERE ACUTE RESPIRATORY SYNDROME (SARS)
=======================================================================
HEARING
before a
SUBCOMMITTEE OF THE
COMMITTEE ON APPROPRIATIONS UNITED STATES SENATE
ONE HUNDRED EIGHTH CONGRESS
FIRST SESSION
__________
SPECIAL HEARING
MAY 2, 2003--WASHINGTON, DC
__________
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COMMITTEE ON APPROPRIATIONS
TED STEVENS, Alaska, Chairman
THAD COCHRAN, Mississippi ROBERT C. BYRD, West Virginia
ARLEN SPECTER, Pennsylvania DANIEL K. INOUYE, Hawaii
PETE V. DOMENICI, New Mexico ERNEST F. HOLLINGS, South Carolina
CHRISTOPHER S. BOND, Missouri PATRICK J. LEAHY, Vermont
MITCH McCONNELL, Kentucky TOM HARKIN, Iowa
CONRAD BURNS, Montana BARBARA A. MIKULSKI, Maryland
RICHARD C. SHELBY, Alabama HARRY REID, Nevada
JUDD GREGG, New Hampshire HERB KOHL, Wisconsin
ROBERT F. BENNETT, Utah PATTY MURRAY, Washington
BEN NIGHTHORSE CAMPBELL, Colorado BYRON L. DORGAN, North Dakota
LARRY CRAIG, Idaho DIANNE FEINSTEIN, California
KAY BAILEY HUTCHISON, Texas RICHARD J. DURBIN, Illinois
MIKE DeWINE, Ohio TIM JOHNSON, South Dakota
SAM BROWNBACK, Kansas MARY L. LANDRIEU, Louisiana
James W. Morhard, Staff Director
Lisa Sutherland, Deputy Staff Director
Terrence E. Sauvain, Minority Staff Director
------
Subcommittee on Departments of Labor, Health and Human Services, and
Education, and Related Agencies
ARLEN SPECTER, Pennsylvania, Chairman
THAD COCHRAN, Mississippi TOM HARKIN, Iowa
JUDD GREGG, New Hampshire ERNEST F. HOLLINGS, South Carolina
LARRY CRAIG, Idaho DANIEL K. INOUYE, Hawaii
KAY BAILEY HUTCHISON, Texas HARRY REID, Nevada
TED STEVENS, Alaska HERB KOHL, Wisconsin
MIKE DeWINE, Ohio PATTY MURRAY, Washington
RICHARD C. SHELBY, Alabama MARY L. LANDRIEU, Louisiana
Professional Staff
Bettilou Taylor
Jim Sourwine
Mark Laisch
Sudip Shrikant Parikh
Candice Rogers
Ellen Murray (Minority)
Erik Fatemi (Minority)
Adrienne Hallett (Minority)
Administrative Support
Carole Geagley
C O N T E N T S
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Page
Opening statement of Senator Arlen Specter....................... 1
Statement of Julie Gerberding, M.D., M.P.H., Director, Centers
for Disease Control and Prevention, Department of Health and
Human Services................................................. 2
Statement of Luther V. Rhodes, M.D., chief, Division of
Infectious Disease, Department of Medicine, Lehigh Valley
Hospital and Health Network.................................... 7
Statement of Anthony S. Fauci, M.D., Director, National Institute
of Allergy and Infectious Diseases, National Institutes of
Health, Department of Health and Human Services................ 16
Statement of Dr. John Combes, Senior Medical Adviser, Hospital
and Health System Association of Pennsylvania.................. 23
Questions submitted by Senator Arlen Specter..................... 32
SEVERE ACUTE RESPIRATORY SYNDROME (SARS)
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FRIDAY, MAY 2, 2003
U.S. Senate,
Subcommittee on Labor, Health and Human
Services, and Education, and Related Agencies,
Committee on Appropriations,
Harrisburg, PA.
The subcommittee met at 9:29 a.m., room 140, Pennsylvania
State Capitol, Hon. Arlen Specter (chairman) presiding.
Present: Senator Specter.
opening statement of senator arlen specter
Senator Specter. Good morning, ladies and gentlemen. The
hour of 9:30 having arrived, we will begin our hearing promptly
on time.
This is a hearing of the Appropriations Subcommittee on
Labor, Health and Human Services and Education, and this
subcommittee has jurisdiction over the budget of the Department
of Health and Human Services which includes the National
Institutes of Health and the Centers for Disease Control and
Prevention.
The world is now suffering from an enormous problem of
SARS, originated in China, has been a problem in many parts of
the world, recently in Toronto and also in the Lehigh Valley in
Pennsylvania.
The subcommittee has taken up the subject on two occasions.
Once when the Secretary of Health and Human Services, Tommy
Thompson, testified earlier this year about the budget for NIH,
CDC and his entire department.
Then we had a hearing a few weeks ago where Dr. Gerberding
and Dr. Fauci testified, and in light of the continuing problem
and a great deal of public concern, really public worry, about
what is happening here, it seemed to us that it would be useful
to convene a hearing and to have an update.
In the world of Washington activities so much happens that
it is hard to focus on any one subject when we are battling the
problems of Iraq and North Korea, economy and the tax cuts, et
cetera, so it seemed a good idea to come to a local setting.
I very much appreciate Dr. Fauci's being here and Dr.
Gerberding's being here. And I asked them not once, but several
times if it was an unduly imposition on their time to come and
testify.
We can find very much concern that they spend their time on
the substance of the problem, but a very big issue here is
informing the public with the current threat, and I hear it
from many, many constituents, what is the problem, what is
happening, what is the risk to my family, what will be the
risks this summer when more people are outdoors?
Then we also have the issue of adequacy of funding which is
a very grave concern of the subcommittee. And I have already
expressed these concerns in Washington, but they bear
repeating.
We are calling upon the Centers for Disease Control to
undertake enormous new responsibilities to prepare for
potential bioterrorism, and SARS is an unexpected problem; but
when we take a look at the funding for the Centers for Disease
Control, it is really totally inadequate not to use other
language which might be more expressive or more emphatic, but
the Centers for Disease Control was cut by some $175 million
this year.
For fiscal year 2003, the Centers for Disease Control was
funded at $4.49 billion, and this year it is at $4.32 billion
which is a $175 million cut, and it is hard to see how the
Centers can function with all of its increased responsibilities
on bioterrorism, to say nothing of a unique problem like SARS.
It is difficult to say this, but the Centers for Disease
Control is in a dilapidated state, something that Senator
Harkin and I, the Ranking Member of this committee, we found
out and revisited Atlanta several years ago and undertook an
expansion program, but this year that expansion program has
been curtailed with a reduction of the planned funding by $152
million.
I think it is important for people everywhere to know what
is happening, because this is a matter of public concern, and
candidly, public pressure on the Congress and on the
administration to provide the funding necessary to do the job.
That is by way of a very brief introduction on the overall
issues of the funding. And now we come to the substantive
problem. Today we will take up what is happening now on the
containment of SARS, what is happening with the problem posed
in China, which is really, as I understand, it is out of
control; but there have been limitations as to where people can
travel and quarantines, and we have had some good results which
will be detailed by our witnesses here today and they will be
taking a look at what is going to happen in the future and what
we need to do to have an adequate system to deal with problems
like this one.
Then in the local scene we will be hearing from Dr. Luther
Rhodes, who is chief of the Division of Infectious Disease at
Lehigh Valley Hospital and Health Network, where they recently
treated a man with SARS.
We will be hearing from Dr. John Combes, senior medical
adviser for the Hospital and Health System Association of
Pennsylvania, to get some insights as to Pennsylvania's ability
to handle the problem and really perhaps illustrative of what
is happening nationally.
STATEMENT OF JULIE GERBERDING, M.D., M.P.H., DIRECTOR,
CENTERS FOR DISEASE CONTROL AND PREVENTION,
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Senator Specter. Our first witness is the celebrated Dr.
Julie Gerberding. She has been celebrating since she has become
the star of television in the course of the past few weeks.
Something I think she did not desire.
That is one of the facts of life. She is the director of
the Centers for Disease Control and Prevention. She has a
bachelor's and M.D. from Case Western Reserve, and a master's
in public health from the University of California, Berkeley.
Dr. Gerberding, thank you for joining us, and we look
forward to your testimony.
Dr. Gerberding. Thank you. It is great to be here and
especially in this excellent, gorgeous building. This is an
extraordinary architectural design here and it is filled with
history; so I am especially pleased to be here, participate in
this hearing with you and I thank you for your leadership and
your interests. You have been a great friend of CDC's and
Public Health and I think we really respect and appreciate that
you are taking time to focus in on SARS, especially at the
local level where so much of our efforts really do have to come
to fruition.
I want to give you a brief recap of where we are right now
with the epidemic. We recognize that there was a problem in
China last November, and it took about 4 or 5 months before the
WHO could get information about the details of the evolving
problem in that part of the world.
Senator Specter. As a matter of format we are going to run
this hearing a little differently than we run hearings where
there is a great distance between Senators and the witnesses.
I wanted to set this up in a very informal way. And you and
I have discussed this matter on a number of occasions, so I am
familiar with where you are going, and I think we would have a
better description if I do kind of a conversation with you as
opposed to a regular type of testimony procedure.
Why did it take so long for CDC to find out about the China
problem?
Dr. Gerberding. Well, the Chinese Government was unwilling
to provide the information to the global health communities for
quite some time. I think initially they misunderstood the
problem as being caused by chlamydia infection or some other
infectious disease.
We could not access information, we do not have people
there on the ground who can independently assess or provide
technical assistance----
Senator Specter. Dr. Gerberding, the Chinese authorities
have been criticized for really stonewalling this issue, and I
think that is one point which needs to be made, not to attach
political blame, that is not our interest in criticizing
Chinese officials, but to make the point that when a Nation
faces a health problem that they do not understand, that they
need to communicate that to people who do understand it.
Is there any agency in the world which compares to the
Centers for Disease Control in the United States and experience
and understanding of this kind of a problem?
Dr. Gerberding. I think we have tremendous experience and
laboratory support and technical support and we work very well
with the World Health Organization that has the international
jurisdiction for being the first point of contact for many
health problems. So we certainly would have wanted to help if
we had been asked.
Senator Specter. We are going to circulate this transcript
far and wide. I think that is the first point to be made, and
that is when a country faces a health problem, they ought to
communicate it to the World Health Organization, Centers for
Disease Control, so you can start to get some assistance.
On a communications level, in our prior discussions you
have commented to me about the lack of communications and the
difficulty in correlating materials.
Could you expand upon that issue?
Dr. Gerberding. We need a global system for detecting and
diagnosing and responding to emerging infectious disease
threats. In fact, the Institute of Medicine just issued a
report which said exactly that, that CDC and the Department of
Defense and the USDA need to come up with a coordinated global
interface for identifying these emerging threats.
We have some capacity to do this in some parts of the
world, but the network is not complete, the laboratory
capability is inadequate in many regions such as China, and we
have a lot to do before we really get that network to encompass
the entire global community.
Senator Specter. Before coming to the steps which are
necessary to correct those kinds of problems, let us focus at
the outset on the problem posed to the United States by SARS.
Dr. Gerberding. At the moment we have 56 cases of probable
size in the United States and we have not had any transmission
from those individuals to contact their healthcare workers for
more than 20 days, which means we have contained the problem
here, at least for the time being.
We are continuing to alert travelers to the hot spots, and
the hot spots right now are China, Hong Kong and Taiwan, where
there is very active transmission and new cases being reported
every day.
We are also alerting travelers to other parts of the world
that have recently had problems with SARS--which is Canada and
Vietnam--but we do not have travel advisories to those areas
that have brought the disease under containment.
So the threat in the United States right now is primarily
from travelers returning from the hot spots, and we have to
continue to be vigilant and identify people at the earliest
possible moment so that we can prevent spread.
Senator Specter. What is being done when people do come
back from China, Hong Kong or Taiwan, the so-called hot spots?
Dr. Gerberding. Well, first of all, we advise them not to
go to those hot spots unless they have essential business
there, and when they come home they would see the travel alert
card at the airport.
I just got one yesterday coming home from Toronto, as a
matter of fact, and it advises if they develop any illness in
the next 10 days that they should contact their physician so
that the healthcare system can initiate the infection control
precautions before they even arrive in the doctor's office.
When they arrive at the doorstep they will have the mask
protection and the air protection necessary----
Senator Specter. If they start to show some signs that they
might have something?
Dr. Gerberding. Symptoms, exactly.
Senator Specter. And what are those symptoms so that people
will be able to recognize them perhaps if they or their
children are afflicted?
Dr. Gerberding. The most common symptom is fever. But some
people do not start out with a fever, they start out with aches
and pains or coughing. Sometimes they have diarrhea. And mostly
they just feel exhausted and weak like we all do when we are
coming down with a virus infection.
It is not specific, and that is why we are trying to cast
this broad net. If you do not feel well, make contact and let
the doctor help you sort it out if there is anything to be
concerned about.
Senator Specter. Is that sufficient if somebody is coming
back from China, they have essential business as you
characterize it, and they come back and they are given a
warning as to what to look for, but they are obviously in a
position to have contact with a lot of other people and the
disease is spread in an infectious way on person-to-person
contact.
So what risks does the community run by having somebody
back from China or Taiwan or Hong Kong that are mingling in the
community?
Dr. Gerberding. So far, our science tells us that you are
not at risk to the community until you get sick. So if you are
incubating it, you are not likely to be infectious.
But once you start developing the symptoms of your own
infection, and probably when you start coughing, and you are
having the illness, then you become an efficient transmitter to
other people around you.
Senator Specter. So it depends upon the individual then
being responsive at that early moment to report to a hospital
so that person can be effectively isolated or quarantined?
Dr. Gerberding. Exactly. We do one additional thing in this
country, and that is, if you are a traveler and you have been
evaluated for SARS or admitted to the hospital for SARS, we are
asking anybody who has been recently exposed to you, such as
the people who live in your house with you, to participate in
an active monitoring program. So the health department will
make contact with these individuals on a daily basis to make
sure that they are not developing early SARS so they can
capture them before they pose a risk to additional people.
Senator Specter. What has the experience been on this
approach? Do people make the reports in time or is there some
SARS transmitted from people that have traveled and do not
recognize the symptoms early enough or take precautions to
notify public health authorities to not come in contact with
other people?
Dr. Gerberding. We have had good, but not perfect success
with this. We have had some people such as an individual
admitted to the hospital here in Pennsylvania who was not
recognized as being at risk for SARS at the first point of
contact in the healthcare system.
We have had 1 of the 56 SARS patients, who was a healthcare
worker exposed to another patient, and one was a household
contact of another patient. So kind of two transmissions
outside of the travelers, per se.
Senator Specter. Is that in the Pennsylvania situation?
Dr. Gerberding. No, not in Pennsylvania. The containment
here seems to be completely successful at this point in time
and we are not aware if there has been any change since their
most recent update, but the health department and the
clinicians here were very aggressive about monitoring the
exposed people and have a very good system for isolating the
patient in the hospital. They actually evaluated the healthcare
workers who were exposed and requested that they voluntarily
quarantine themselves for ten days just to be absolutely sure
that they did not pose a risk.
One of the frightening things that we have seen over and
over again in China, in Vietnam, in Taiwan and in Canada, is
that the threat starts with the healthcare workers.
The healthcare workers are the people who are at most risk
for getting this in-country, and so our highest priority is the
protection of the healthcare workers and the other patients in
the healthcare system. That is why an aggressive approach, such
as was taken here, is something that we would totally support.
Senator Specter. Has there been any consideration given to
the more extreme measures, such as quarantining the people who
are returning back from the hot spots?
Dr. Gerberding. We have not needed to do that in this
country yet. It would be a very challenging task to quarantine
everybody because we are talking about hundreds of thousands of
people who are still traveling.
Senator Specter. Hundreds of thousands of people are coming
back----
Dr. Gerberding. Over time, yes.
Senator Specter [continuing]. From China and Taiwan and
Hong Kong?
Dr. Gerberding. We still have a large volume of
international travel. You know, some people who are traveling
to other areas have to pass through Hong Kong to get back to
the United States, but right now the pattern of transmission
does not indicate that that step is necessary.
We have seen in other countries that containment can be
achieved without quarantining incoming travelers.
Senator Specter. What countries have you seen that
containment can be achieved without quarantining?
Dr. Gerberding. Vietnam has been able to achieve
containment, and that is very important because they started
out with a very bad healthcare outbreak, and that is where Dr.
Urbani, the physician scientist who first recognized the
problem there, he himself acquired SARS and died from it.
So there was a cascading epidemic in Vietnam. By using the
same kinds of high level protection for the healthcare workers,
we sent CDC experts there to help get the precautions in the
hospital organized and implemented.
They had to close the hospital temporarily and they had to
do some steps that we have not had to take here, but they have
had no new cases in Vietnam for more than 20 days, which means
that they are two incubation periods away from the last case,
and that by definition is containment.
Senator Specter. But they had to close the hospital?
Dr. Gerberding. They did have to close the hospital and
they did have to quarantine some of the healthcare workers
because they did not get the transmission stopped without
taking the next step.
I was in Toronto yesterday. One of the specific things that
I was interested in learning about was in Ontario what steps
were taken in the hospitals there when they were involved in
this outbreak and could not get it under containment with the
basic steps, what enhancements did they use, and quarantining,
expressed healthcare workers, was an important aspect of their
plan and it works.
STATEMENT OF LUTHER V. RHODES, M.D., CHIEF, DIVISION OF
INFECTIOUS DISEASE, DEPARTMENT OF MEDICINE,
LEHIGH VALLEY HOSPITAL AND HEALTH NETWORK
Senator Specter. Let us turn to Dr. Rhodes just to
interrupt your testimony for a few minutes here, Dr.
Gerberding, with the Urbani issue, to Pennsylvania where we do
have it. Your testimony is up to this point.
So I would like to turn to Dr. Rhodes, who is the Chief of
the Division of Infectious Disease for the Department of
Medicine at Lehigh Valley Hospital and Health Network.
He has his M.D. from Loyola University. Thank you for
joining us, Dr. Rhodes, we are very interested, anxious to hear
what your experience has been and what the status is of the
Pennsylvanian who had contracted SARS.
Dr. Rhodes. Thank you. Senator Specter, members of the
community, my name is Luther Rhodes. I was a native of
Lewistown, Pennsylvania, right up the street, so to speak. I am
an infectious disease clinician.
I have been in the private practice of infectious diseases
for about 27 years, all in the Allentown, Lehigh Valley area.
Most of that time I have been chief of a very dynamic--and
blessed to have an excellent division of infectious diseases
and infectious control. We are unusually well-supported by our
health network.
I would like to summarize for this community today what
happened with our two cases, actually, that were reported
through appropriate channels, and I will discuss both
separately to show you the different kinds of things that can
happen at the community level.
I am honored to be in the presence of the esteemed national
experts, Dr. Gerberding and Dr. Fauci, and our State is
represented by Dr. Combes and myself, but I am basically the
local doc trying to present the situation on SARS as it runs
forward in our community.
About March 11 of this year Hong Kong officials published
on an Internet site known as Pronet, at least if I watch them,
any other infectious disease folks read. They described at that
time an outbreak in Hong Kong of a pneumonia which had not yet
been called SARS, but which was, and what riveted my attention
was involving healthcare workers in large numbers, and I would
say Dr. Gerberding and Dr. Fauci will tell you, that gets your
attention right away because of the large number of healthcare
workers and my experience is twofold; one, that is a problem
medically for the people involved; the other is, we positively
have to ensure that healthcare workers themselves are proven,
effectively proven, prepared, otherwise there is an eminent and
present danger of the healthcare system collapsing on itself.
The cases initially described I think 3 days later by the
WHO as cases of pneumonia which I think on March 14 were being
called SARS for the first time.
What attracted my attention was they were now in Canada,
Indonesia, Philippines, Singapore, Thailand, and Vietnam; and a
worldwide alert was issued, that was a Saturday, the 15th of
March.
Because again of the Internet and access to that
information, we put the five emergency rooms in our area on
alert by direct phone calls and faxes, et cetera, to say much
of travelers from Asia, if they come in with fever and cough,
put a mask on them and put a mask on yourself.
Senator Specter. So you did this before when the incident
occurred with the man who had SARS?
Dr. Rhodes. Yes, Senator. The WHO, at least in my reading,
I have not seen worldwide alerts come out like that, and I also
could not get beyond the very compelling information on the
large numbers of healthcare workers.
I envision my own institution, you know, your own world
where you work and spend your time, and I hearken back to when
I was 2 months out of my fellowship, brand new, wet behind the
ears, I showed up in Allentown the summer of 1976, and about my
second month there the City of Allentown and the State of
Pennsylvania was paralyzed with fear about a mystery pneumonia.
We had several dozen American Legionnaires who died a great
mystery. There was hints about terrorism in the air. That was
all new to me. The observation was----
Senator Specter. What year was that?
Dr. Rhodes. That was August 1976.
Senator Specter. That is when the Legionnaire's Disease hit
Philadelphia and Bellevue and----
Dr. Rhodes. Absolutely. Absolutely. The Legionnaire's
outbreak or Legionnaire disease was a mystery pneumonia that
affected Pennsylvania American Legionnaires because it was a
statewide convention.
At that time all we knew in Allentown was we had seven
people in Allentown Hospital with mystery pneumonia that was
killing people throughout the State.
Of course everybody and their brother and their sister had
an opinion as to what was causing it, and the hospital's
ability to go to their healthcare was impacted severely.
That is a lesson that sticks in my mind, and when I see
things like SARS where the healthcare workers are directly
threatened, I see a couple of problems.
One is the patient themselves. Two, the healthcare team.
Three, the ability of my community to deliver healthcare.
People still have heart disease, diabetes, diabetic
repercussions and the like, they need healthcare.
What I see in Toronto, and it is compelling information,
the greater Toronto area appears to be in disarray, getting
better, but in disarray; and I translate that to my own
community, and it is painful, it is threatening.
It requires not panic, but a focus and continued
notification of people in the township as to what is going on.
Fortunately we have first-rate quality national resources.
The CDC, if anything, provides us so much information, you
have to go there two or three times a day. And national
response from my perspective is superb. Our statewide response
and capabilities are getting better by the hour and are very,
very good.
My concern is how do we incent and how do we prepare people
at the community level, and by that I mean how do we strengthen
the private practice of the health infrastructure in a
meaningful way so that we can respond and respond promptly to
that world class information.
This tremendous information is coming out from the Centers
for Disease Control, WHO. I mean I have tons of record-setting
information available at my fingertips.
When I go to my peers in those five or six area hospitals
in Allentown, I have got to be able to put that into a
meaningful package, because one case coming through where you
have unrecognized, and goes through the institution, is
catastrophic.
Senator Specter. Dr. Rhodes, come to your case. The one
case that did come through, tell us exactly what happened.
Dr. Rhodes. Yes. First of all, the very first case, about 2
weeks after we put our prevent preparation in the ER, just shy
of 2 weeks, a 42-year-old businessman from Lehigh Valley
returned on March 19--within 1 week I should say, on March 19 a
42-year-old businessman from Lehigh County returned from China,
directly from China, where within the past week he had had
fever, cough, shortness of breath.
He came back to Lehigh Valley and came to our emergency
room, and because of a couple things, preventative preparation
allowed us to give his family a mask. They took a mask out and
met him at the tarmac, basically at the airport, put a mask on
him. He was left in our emergency area, and the entire time he
was there, there was essentially no exposure to the healthcare
workers, so we could do our job in safety.
Senator Specter. He was given a mask?
Dr. Rhodes. He was met at the terminal, at the airport with
a mask, and so that went unusually well. He fortunately has
done very well. He is home. In fact, his testing to date has
not confirmed SARS, but we reported him as a suspect case----
Senator Specter. Did he come directly from the airport to
the hospital?
Dr. Rhodes. Yes. His family gave us a heads-up that there
was a family member who had possible--this mystery pneumonia--
was coming back, and what to do.
Senator Specter. Coming back from Toronto?
Dr. Rhodes. Coming back actually from China, right around
China. The second case is the Toronto connection. Two different
situations that occurred. First occurs, like you say,
flawlessly, or as close to that as you can get, the gentleman
is doing well, fine and dandy.
Senator Specter. Did the first man coming back from China,
was he diagnosed with SARS?
Dr. Rhodes. He was tested for and considered a suspect
case. His testing to date has not confirmed, is not completely
finished, but does not confirm, so he remains a suspect case
with final testing pending. He has done excellently and he is
already back to work.
That was the first experience we----
Senator Specter. You were able to intercept him after
notice from the family, you met him coming in from the airport
with the mask so that it is an illustration of an excellent
move on your part having been aware of the generalized problem,
the cooperation from the family, and taking it right into a
situation where you could minimize exposure.
Dr. Rhodes. Again, we translated the information to WHO and
CDC provided to us to have those prevent preparations in place,
and that on the surface you would say, well, okay, we are ready
for this, bring it on, so to speak, but that was very resource
consumption. Despite our precautions, our employees were
nervous for several days after that.
They still wanted to know because every day they pick up
their paper they read healthcare workers--there was more dying
in other countries and so on, so if there is not----
Senator Specter. I want to say for the record, Dr. Rhodes,
we are not mentioning names because names are confidential.
Dr. Rhodes. The second case is on April 14, a 52-year-old
resident of Pennsylvania, gentleman presented to the emergency
department at one of the three LVH campuses, this is the
Bethlehem campus, for cough, shortness of breath and recent
fever.
Now, this gentleman, in the 11 days prior to coming to the
hospital, no airplane travel, no travel to Asia, he had set out
to care for himself at one other hospital and a doctor's office
during that 11-day time he was ill.
They actually looked at the thought of, both places, could
this be SARS? And discounted it because at that time the
diagnosis or the definition did not include travel to Toronto.
And he persisted with his symptoms and presented on the 14 to
the Middleburg campus in Bethlehem, Pennsylvania, Lehigh Valley
Hospital.
Even then when he came in with that history of having been
checked, got so-called ruled out, and having another chest x
ray, our emergency room physicians, after about a 2\1/2\ hours
period of time, increasingly escalated their concerns,
increasingly escalated their precautions--point of fact, 2\1/2\
hours he was put in the full precaution that they put the other
patient in on day one.
Same institution, same prevent preparation, a little more
experience, so to speak, about why the difference. Well, the
definition changed. That is my concern, and I think that is the
concern of all of us here is this clinical definition we use
now, whether it has traveled to this, this, this, this and
this, is a phony definition. It will change with time. It has a
purpose. It is like the Legionnaire disease.
The definition of Legionnaire disease in 1976 was you had
to have spent a week in the Middle East effort. Imagine in
retrospect how silly those folks felt that diagnosed
Legionnaire's with a history of having been in a hotel in
Philadelphia.
So things changed, and if nothing else they must translate
this world-class rapid development of information by Dr.
Gerberding and Dr. Fauci and the Federal Government, what are
they provided with, and translate that. That takes time, effort
and energy and commitment. And I would say the private sector
has to do this in partnership with public health. Public health
infrastructure in my opinion is fragile, fragile at best at the
local level.
Senator Specter. Is patient number 2 isolated at the
present time?
Dr. Rhodes. Patient number 2 went through a hospital stay
for pneumonia. He was Pennsylvania's first and only case.
Senator Specter. You said Pennsylvania's first case. I
believe it is the only Pennsylvania case.
Is that correct, Dr. Gerberding?
Dr. Gerberding. The first patient is on the suspect case
list and has not had positive virology. The patient that was
the second individual here has a probable diagnosis and our
laboratory test is positive, so he is now being considered a
probable case with laboratory confirmation.
Senator Specter. But are there any other Pennsylvania
cases?
Dr. Gerberding. Not at this time.
Dr. Rhodes. Fortunately this gentleman is home now
recovering, but because of that 2\1/2\ hours, we had six
healthcare workers who had not been protected at the time of
their initial encounter.
We furloughed those individuals and monitored their health
for 10 days at home as an extra precaution. They are doing very
well.
Senator Specter. Dr. Rhodes, are they doing well enough so
that you can rule out SARS having been contracted by them?
Dr. Rhodes. The entire amount is close to 100 percent at
this point because of the number of days that have gone by, and
again----
Senator Specter. When you say close to 100 percent, there
is still some risk, however minimal, existing?
Dr. Rhodes. Current CDC guidelines recommended our final
testing 21 days after the original exposure and I do not
think----
Senator Specter. And they are still being isolated at this
time?
Dr. Rhodes. Well, their 10 days of incubation or quarantine
is over. So they are actually now back to work and doing well.
Senator Specter. Why are they permitted to be back at work
after 10 days if it requires 21 days to be absolutely sure?
Dr. Rhodes. The testing, if you go to Version 10 of testing
in a new disease, that is the testing is--without question the
testing is getting more and more sophisticated such that I am
reasonably certain we will be able to do as they do now for
strep throat and emergencies.
It is something that you vote, vote out, and say you have
SARS or you do not have SARS. That level of testing will
improve expeditiously. We are weeks to months into this
diagnostic testing, so it is an imperfect test and I think
caution is proper at this point, and the CDC has decided 21
days for reasons I am sure that they have great sense. It is
new information that I suspect will be really nice.
Senator Specter. Dr. Gerberding, let us hear from you on
that point. If you are not absolutely sure until 21 days, what
is your evaluation, that there is sufficient assurances after
ten days to take the minimal risk?
Dr. Gerberding. We are really talking about two different
things. One is, at what point do we determine that people are
not going to develop the disease SARS and that incubation
period is ten days.
So if you were exposed, you would wait 10 days, and if
nothing happened to you in those 10 days, you would be assured
that you are not going to develop the illness SARS.
The 21 days comes in as an antibody test. If you have SARS,
it takes 21 days for your antibody test to become positive. So
if we want to diagnose someone or we want to see whether or not
they actually have the coronavirus infection, when we test them
at the beginning of their illness it is usually negative
because the antibodies take time to develop. But we repeat the
test after 21 days. It will be positive then. And that will
tell us for sure, yes, there was coronavirus infection or, no,
there was no coronavirus infection.
So you are asking both questions with your patients. One
is, are the healthcare workers who are exposed safe, and if it
has gone 10 days without infection, they are safe.
But if you are asking, does the patient have the infection
or did they develop an asymptomatic infection, you would have
to test them 21 days after exposure to be absolutely sure.
Senator Specter. So it is a determination that a patient
with a 21-day test as opposed to the 10-day incubation period?
Dr. Gerberding. Correct.
Senator Specter. But there is no possibility of
transmission between the 10th day and the 21st day?
Dr. Gerberding. We have not seen any evidence of
transmission after 10 days here, but obviously we are still new
in this and we have probably looked at 56 probable cases here,
so we do have an open mind and we are not abandoning the
follow-up of individuals who have been exposed.
Senator Specter. In some of the commentaries there is an
issue raised as to recurrence. What is the scientific thinking
that SARS can recur in an individual even after there is some
judgment that he or she is safe to be around others, Dr.
Gerberding?
Dr. Gerberding. I spoke with Dr. Heyman from the World
Health Organization about this yesterday, we have more than
5,000 probable cases of SARS internationally, and so just this
week there were no reports of recurrence in any country.
The only country that is reporting recurrence right now is
Hong Kong, in 12 patients. What is unique in Hong Kong is that
when the patients are in the hospital with the severe
pneumonia, they get started on steroids to cut down their
inflammation.
What they think they are seeing is that the steroids are
artificially disguising the inflammation in the lungs, and when
they stop the steroids, the patients get sick again. So it may
not be an infection recurrence. It may be an unmasking of the
problem that was really there and that the steroids were
artificially covering it up, and also the steroids were
preventing the sick person from developing immunity to the
infection and it was delaying their recovery.
That is just a speculation right now, but that is the kind
of question that is being asked there. We can answer the
questions with some laboratory testing and some better clinical
observation of the patients. We do not treat our patients here,
typically, with steroids, in part because most of them have not
been that ill, and in part because we have no evidence that
steroids are particularly effective.
Now with this new information there is some concern they
could even be harmful. But in this country and in Canada and
the other countries that we have good, quality information, we
have not seen evidence of recurrence.
Senator Specter. Dr. Gerberding, you said in response to my
question only two of these instances in Pennsylvania and you
said nothing else ``at this time.''
Do I detect some concern in your answer not at this time
that it is an open question as to further problems in
Pennsylvania?
Dr. Gerberding. Can I just have the last graphic there? We
all like to think that we have successfully contained this
here, but I think this graphic that your staff kindly prepared
for us illustrates the situation in Canada where----
Senator Specter. Dr. Gerberding, bring the graphic up here.
Dr. Gerberding. Can you bring that up here?
There was just one person----
Senator Specter. It was not for me, Dr. Gerberding, it was
for the television camera.
Dr. Gerberding. This was reprinted from a newspaper
article. There was just one person in Toronto who came back
from Hong Kong with SARS, and that individual infected members
of the family, they went to the hospital, all of these people
in the hospital became infected, patients were admitted to
other hospitals.
That one patient created this whole cascade of SARS
patients in Canada, and it is this cascade of transmission that
resulted in the closure of hospitals, the travel advisory by
the WHO that had a terrible impact on the Canadian economy and
great fear and concern on the part of the healthcare workers.
Many hundreds of people needed to be quarantined and so forth.
So you can see what happens when just one patient slips through
the cracks of the system and the terrible consequences that can
result from that.
We know we have to continue to be vigilant because there is
no reason why this patient could not have arrived in the United
States instead of Canada. And so the kinds of things that Dr.
Rhodes talked about have to go on in every single emergency
room and every single physician's clinic around our country
right now. It is a big challenge and we just cannot relax.
Senator Specter. I do not want to be unduly provincial with
respect to Pennsylvania, but are there SARS problems in any of
the surrounding areas, Ohio, New York, West Virginia, Maryland,
New Jersey?
Dr. Gerberding. There have been, and I did not bring my
State-by-State list with me this morning, but I can certainly
provide to you that information.
Senator Specter. That is very interesting. You tell me what
it means.
Dr. Gerberding. This is just simply a list of today's
updated information and the number of probable cases, in places
across the United States. You asked about Ohio. There is one
probable case of SARS in Ohio. You asked about----
Senator Specter. Where in Ohio? The Indiana border?
Dr. Gerberding. I do not know the answer to that and I hope
it is not close to Pennsylvania.
Senator Specter. Why do you say that? You are a national
officer.
Dr. Gerberding. I am trying to be thorough. The States that
have the largest number of cases right now are California,
Illinois, Massachusetts, New York, and Pennsylvania.
Senator Specter. How many does New York have?
Dr. Gerberding. New York has a listing of 26 suspect cases
and 7 probable cases. Pennsylvania is listing one probable
case, so that presumably would be the individual we are talking
about, and has evaluated over time a total of 10 suspect
patients here throughout the State.
Senator Specter. Where are the other non-suspect cases, if
you know?
Dr. Gerberding. I can find out for you and let you know.
Senator Specter. How about New Jersey?
Dr. Gerberding. New Jersey is demonstrating three suspect
patients and one probable patient today.
Senator Specter. And West Virginia?
Dr. Gerberding. West Virginia is not reporting any probable
or suspect patients at the present time.
Senator Specter. Maryland?
Dr. Gerberding. Maryland is reporting three suspect and no
probable cases.
Senator Specter. Do you know what precautions are being
taken as to the other eight suspect cases in Pennsylvania?
Dr. Gerberding. The precautions that are being taken are as
we described. The other patients in Pennsylvania are not
necessarily in the hospital.
When we say suspect patient, this has been a very difficult
thing to explain. We wanted to cast the widest net we possibly
could so that every patient was included in the catchment, even
if we did not have a strong suspicion that they had SARS.
So if a patient has traveled to any of the countries I have
mentioned and they have any respiratory illness--they could
have the common cold--they get included in the suspect case
list until they have a chance to be evaluated and ruled out.
Senator Specter. What precautions are being taken as to
those suspect cases?
Dr. Gerberding. It depends on how ill they are, but they
are not in the hospital. Most of them are over the period----
Senator Specter. Who is following them?
Dr. Gerberding. Local clinicians and the local public
health agencies.
Senator Specter. Do you keep track of those?
Dr. Gerberding. We have a State team and we have a specific
person who is responsible for tracking each State.
Senator Specter. And how many people from CDC do you have
in Pennsylvania?
Dr. Gerberding. We had a team of three people assisting Dr.
Rhodes in the investigation of this particular scenario. Those
individuals have now returned to CDC. They have done their work
here and they are in the process of following up some of the
laboratory testing----
Senator Specter. Would you provide the subcommittee with
the specifics on those eight suspect cases and what precautions
are being taken to see to it that those individuals do not
infect other people, or are not infected with the capacity to
infect other people?
Dr. Gerberding. Absolutely, and I can get that information
probably while we are in this room if Mr. Gimson would just
simply call the Pennsylvania team at CDC, we can get that for
you.
Senator Specter. That would be fine. We would like that. We
may have to prolong this hearing, but we would like to know
that because those assurances are very important to the people.
Dr. Rhodes. Just one important point to follow up.
Senator Specter. Sure, Dr. Rhodes.
Dr. Rhodes. My concern is--and I am sure we all share
this--this is what keeps me up at night--this patient, for
example, could be presenting to any of the counties--any
hospital in Pennsylvania tonight, and be, instead of Asia or
Toronto, be returning from the Indian subcontinent, we know
that the Indian subcontinent is just now getting involved with
SARS.
That person could end up and go to a hospital in
Pennsylvania and our meeting today, or this meeting would be
all about the catastrophic event that occurred in one of the
Pennsylvania hospitals; whereby, 14 healthcare workers, nurses,
doctors, medical students, et cetera, and numerous family
members, had become infected with SARS.
Right now we are looking at a definition where we see
people from Asia, Toronto, when we get to the traveler part,
one part of it, my concern is that is our official, borough
official, and someone is going to get burned when the first
person comes from India or some other place and brings SARS in
and gets admitted, et cetera. That is what happened in Toronto.
We should not let that happen here because we cannot afford it.
Senator Specter. How do you suggest we prevent it?
Dr. Rhodes. My recommendation is the clinicians are asked--
I am sure it has been around the table about 15 times an hour--
as an infection doctor, my recommendation is a patient who has
a fever and a cough, both the person taking the interview and
the patient, should have a mask on at the earliest possible
moment.
Now, that sounds heavy gambit and that is because we do not
have record diagnostic tests, but there are other things that
you do not catch with somebody who has a fever and coughing,
tuberculosis, influenza, and the like, and it is a lot easier
to take that mask off and maybe even giggle about it later
saying it was overkill, than it is to find out on the second or
third or fourth hospital day----
Senator Specter. How do you identify the individuals coming
into the United States where you ought to take those
precautions?
Dr. Rhodes. Fever, cough, travel would be a good general
screening.
Senator Specter. Traveled anywhere?
Dr. Rhodes. International travel.
Senator Specter. Is that realistic and practical, Dr.
Gerberding?
Dr. Gerberding. Well, what Dr. Rhodes is really describing
is what you do recommend as the standard of infections within
this country which is a concept of standard precautions. That
is, if you have a patient with a fever and a cough, then put a
mask on the patient until you've had a chance to evaluate the
situation. And if the patient is too sick to have a mask, that
the healthcare personnel should be masked. The problem is that
people do not take that seriously unless there is a specific
reason or a specific scenario that is sounding the alarm.
So the vigilance of doing that is not as high as it should
be for a lot of complicated reasons, but it is one of the areas
that I think we have learned a lesson with SARS. I do agree
with you that while we are relying on the WHO and the whole
international community right now, it is extremely vigilant
about detecting SARS in each of the countries that you have
mentioned. There is no guarantee that someone is not going to
pop up in a new country and import a case from a new area of
the world.
Senator Specter. When you say international travel, cough
and fever, that would implicate many, many, many people. Is it
realistic to try to identify them, what you are suggesting in
sending out an advisory for everyone on international travel
with a cough and a fever to identify themselves when they
disembark to be met by a public health expert?
Dr. Gerberding. No. I think that right now we have
confidence that the WHO recognizes the hot spots in the world,
and remember, it is not just travel, it is travel to an area
where there is more than a case of SARS. It is travel to an
area where there is ongoing transmission in the community, and
so, travelers who go about their business run into infected
people and pick up the infection.
Senator Specter. Are there any countries on the WHO list
besides the so-called hot spots you mentioned, China, Hong
Kong, and Taiwan?
Dr. Gerberding. Singapore is an area that is bringing the
problem under control, but right now there still is a travel
advisory because of the kind of transmission risks going on
there.
STATEMENT OF ANTHONY S. FAUCI, M.D., DIRECTOR, NATIONAL
INSTITUTE OF ALLERGY AND INFECTIOUS
DISEASES, NATIONAL INSTITUTES OF HEALTH,
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Senator Specter. Let me turn to Dr. Fauci at this point to
get your input on what we have already heard. Dr. Anthony Fauci
is the director of the National Institute of Allergy and
Infectious Disease at the National Institutes of Health. He has
been at NIH since 1968 and has had a remarkable career there,
obtained an M.D. from Cornell University Medical College, and
is a world-renowned expert on infectious disease.
Dr. Fauci, I would like your evaluation first as someone
who studied the SARS problem very closely. What is your
evaluation as to risk to people in the United States at the
present time?
Dr. Fauci. I think at the present time given the burden of
cases that we have now, the level of alertness that we have
been put on, the measures that the CDC has taken in
surveillance and public health and infection control, that the
risk is relatively small.
In fact, when we say that, I think it is important to
underscore what Dr. Gerberding and I have said many times and
even before you hold a committee hearing in Washington, is that
we still need to be on a state of alert and to take this very,
very seriously. But the realistic risk is small, and that is
the reason why we say we should not panic, but in the same
breath we need to underscore that we need to take it very
seriously and follow it on a real time, day by day basis as we
had been doing.
I think the testimony of Dr. Rhodes--I was really quite
shook--I must tell you, Mr. Chairman, because what he was
saying was in the trenches playing out of what we would hope to
have seen in response to what the CDC is doing on a national
level. He was monitoring the information that was coming out,
and as soon as he heard it, he made the appropriate steps to
how he handled, how his colleagues handled cases that were
suspected of being SARS.
I think if we maintain that degree of, one, alertness, two,
seriousness and, three, implementation of the kind of
directives that come from the CDC, my evaluation as an
infectious disease physician is that the risk will remain
small, but we need to keep alert.
Senator Specter. Dr. Fauci, what is your evaluation as to
steps to be taken, but yet countries like China who tell World
Health Organization or CDC or other health officials what is
happening so that we do not have a four to five-month delay and
have the spread and tremendous problems which emanated from
China with SARS?
Dr. Fauci. Well, I think prior to SARS it would have been
difficult to change the combination of cultural, political, or
other factors that go into a country's reluctance to
communicate on an open forthcoming basis with the rest of the
world regarding health.
It certainly is inexcusable and unconscionable not to do
that. I believe with all of the pain and unfortunate events
that have subsequently happened because of the reluctance of
the Chinese early on to be forthcoming, I see that as being now
a global wake up call to any country, as recalcitrant as they
may be, to see what the dire consequences, not only for the
rest of the world, but within their own country, that keeping
silent--because right now China is bearing the brunt of not
only the responsibility in some respects to what is going on,
but some significant duress from their own country.
Part of the problem of the disruption that is going on in
China right now, and one of the major stumbling blocks in their
being able to implement what they are trying to do is that the
people just do not believe the government anymore.
That was a self-made situation. Hopefully they will correct
that, and as they in good faith implement good public health
measures, there will be a return of confidence in the
government and the government will, in fact, realize that from
the beginning they should have done it correctly.
I think that example will be a wake-up call to any other
country of what the dire consequences are of not being
forthcoming when it comes to health.
Senator Specter. You have identified a very serious
political problem which faces China internally now and also a
very substantial economic problem, tremendous--not loss of
tourism, absence of tourism, and breakdown of the function of
the economy. So let us hope that that is an impetus, but more
is going to have to be done on the international level as a
follow up.
Dr. Gerberding, in our discussions before, you emphasized
to me a number of problems which need to be implemented, such
as the access for CDC to specimens from other countries, and
there is a whole range of items which you identified, such as
having personnel who are trained in countries like China or
Africa and the ability to get specimen are problems. What about
the adequacy of people in China or Third World countries in
Africa to identify a problem like SARS which might spread
around the world, including the United States?
Dr. Gerberding. We talk about the neglected public health
system in this country, and we are fixing the system here. But
the international public health system is in even worse shape.
And of course some countries basically have no system at all.
They have no laboratories, they have no disease detectives who
can respond to an outbreak. So we are only as strong as our
weakest link.
Senator Specter. We have CDC in Africa. I know I traveled
there last August with Senator Shelby and we found CDC people
on the AIDS issue, but that is such an international crisis,
that we are willing to stand that, but to what extent are CDC
personnel available in other countries?
Dr. Gerberding. We have CDC people in 12 African countries
and two Caribbean countries for AIDS. In Asia we have a
beginning of a regional center for emerging infectious diseases
in Thailand. We also have a very small field station inside of
China that we support with some dollars but we do not have any
personnel there. We have very small investments in some
laboratories throughout Asia, the Soviet Union, and Eastern
Europe that help us detect the new flu viruses that come out
every fall or spring, and we work with those laboratories.
It is a very small investment. I think something like
$30,000 per lab to help get the specimens back to CDC so that
we can predict what we need to put in the new----
Senator Specter. $30,000 per lab?
Dr. Gerberding. It does not take a lot of money and the
resource per area to make a huge difference in the capacity to
detect new problems, but the lab is not the only piece because,
of course, you have to have the collaboration and the
integration with the ministers of health and the in-country
resources and the doctors.
Senator Specter. Dr. Gerberding, how should that be
undertaken? Can the World Health Organization handle it? Is it
something that is necessary for CDC, as you specified already
been quite a number of countries? How expensive is it? Is it
realistic for CDC to undertake it? Is it necessary for CDC to
undertake a greater presence around the world to protect
Americans here in the United States?
Dr. Gerberding. WHO is clearly the essential coordinator of
all of it, but as we learned last week, I have 400 people at
CDC working on SARS, WHO had 39 people. So if we are going to
realistically create a global safety net for emerging
infectious diseases, we are going to have to utilize U.S.
resources to support that. Again, the Institute of Medicine
just took up this problem and they have men at NIH, CDC, USDA,
and the DOD bring our existing resources together into a single
uniform network and then identify the gaps----
Senator Specter. Dr. Gerberding, Pennsylvania's 67
counties, they are going to ask you a question, should the
United States be the doctor of the world? I asked the question
whether the United States should be the doctor of the world.
The willingness of the American taxpayers to undertake this
kind of expense might turn directly on the nature of imminence
of the threat to the people here in the United States.
If we are really at risk on infectious diseases like SARS,
I mean the only way we can protect ourselves is to have a
dispersal of CDC personnel around the world, is to have them in
some spots, that might be persuasive, but to what extent is
there a list of people in the United States from these emerging
infectious diseases?
Dr. Gerberding. I do not think we can argue about the
absence of a risk any longer. SARS is here--it is here now in
this country and it is affecting people in Pennsylvania. We saw
West Nile come in from other parts of the world. West Nile is a
problem across our Nation this year. So we live in a global
community and we are a resource-rich Nation, we have to do our
share to----
Senator Specter. We are not talking about a share. We are
really talking about doing it.
Dr. Gerberding. We are talking about both things. We do
some things independent of WHO. We also do a lot of things in
collaboration with WHO as a partner in the global community. So
certainly our Canadian partnerships and partnerships with other
countries that have resources--sort of the global fund idea for
AIDS--to be in the area where we need lots of people to
contribute.
Senator Specter. Dr. Gerberding, as we go through a
checklist of things that you would like to have in order to
limit infectious diseases, the Congress is going to need what
it would cost. And then it would be a matter for public
discussion, public debate, and an evaluation of the risk of
infectious diseases contrasted with what the cost would be; but
it sounds to me when we have 400 people in the CDC and in the
World Health Organization, 39 you said, then it is really
pretty much asking the United States to be the doctors of the
world.
Let us pick up some of the other things which are sore
points or inadequacies. You talked to me about the difficulty
of getting the specimens in your laboratories and the
impossibility of getting airplanes and the pilots to bring them
to CDC. Could you discuss that problem with us for the record?
Dr. Gerberding. This is a huge challenge every time there
is a new infectious disease problem. We know how to package
stuff and move them safely from one point to another, but when
there is fear, we cannot get pilots of the contracted aircraft
to move the specimens, and the people on the ground to handle
them in the baggage plane, et cetera.
Senator Specter. You have had specific experience with
that?
Dr. Gerberding. I have just recent experience in the last
month trying to get specimens out of Hanoi to CDC in Atlanta
and having them sit on the ground for several days until the
point where they were no longer valuable as specimens, because
any chance of recovering virus in them was lost because they
are sitting in the baggage area.
Senator Specter. So what is the answer? Authority to the
CDC to lease planes?
Dr. Gerberding. We need to evaluate what our authority is.
We do have an authority to lease aircraft because of our
stockpile responsibilities, our national pharmaceutical
stockpile responsibilities; but we do need clarity of whether
or not that applies internationally and whether or not we can
not just lease the aircraft, but whether we could use it for
this particular activity and whether or not we could also
contract or lease pilots. Because unless we really have trained
pilots that are comfortable and experienced in moving
infectious disease specimens, it is not enough to have a plane,
you have to have somebody to fly it.
Senator Specter. So you can work it out, you can find
pilots and baggage handlers, et cetera, who will handle it if
they are trained right, but you need authorization from
Congress and obviously funding to do that?
Dr. Gerberding. Yes. We need to get back to you about the
authorities and the resource needs for this. As I said, we do
have some authority, but we have to get a legal opinion about
whether or not it would extend to this particular enterprise.
Senator Specter. You also told me about the difficulties
you have which frankly surprised me not having the state-of-
the-art diagnostic equipment in Atlanta. Do you have to send to
California for some analysis or could you elaborate upon that?
Dr. Gerberding. Well, as you know our laboratories are
undergoing rehabilitation in large part to the efforts that
this committee and your leadership have shown. So part of our
buildings and facilities really is to rebuild our lab. That is
work in progress and a lot has been done, but today if you came
to CDC to look where we sequenced the coronavirus or where we
at first identified it in the electron microscope, you would
probably still be frightened by the environment that you would
enter.
Our scientists--before SARS started, we had no dedicated
scientists for the coronavirus. Obviously we are going to have
to develop some enhanced capacities in this regard.
Senator Specter. No scientists who knew how to handle the
coronavirus?
Dr. Gerberding. They knew how to handle, but they were not
specialists in coronavirus. So we pulled people from our
respiratory pathogens activity to work on this virus because
they understood related viruses and related problems, you have
to have what we would call probably a pathogen discovery team
of scientists who are experts at looking at an unknown illness
and figuring out what is causing it.
They did that with Hanta virus, they have done it with this
one, we contributed to the Legionella pathogen detection. So we
know how to do this, but today, due to the good work that is
happening at the NIH, we have tools and resources that allow us
to identify organisms on the basis of their genetic
fingerprint, as opposed to growing them, culture, isolating
them in petri dishes----
Senator Specter. You are on two points now. You talk about
state-of-the-art diagnostic facilities. One item is equipment
and another item is personnel.
Dr. Gerberding. That is true.
Senator Specter. Start with the equipment. You had to send
to California for the equipment or have California make the
diagnosis on state-of-the-art equipment which they had and you
did not have.
Dr. Gerberding. We actually did make the discovery at CDC
using the more traditional methods, but we wanted to see if we
could get it as fast as possible and some scientists at the
University of California have a gene chip that allows a much
more rapid screening for the kinds of viruses that could
potentially have been involved here. And we did not have that
capacity at CDC. We collaborated with----
Senator Specter. Is it adequate for you to collaborate, or
as a matter of timing do you need to have the state-of-the-art
diagnostic facilities at the CDC headquarters?
Dr. Gerberding. I believe we could do it either way, but we
need to have agreements and the arrangements and the support
for the collaborators in place ahead of time so that we can be
working on these things in advance and to speed up the whole
process when we need to.
Senator Specter. You need to tell this subcommittee and we
will tell the rest of the Congress just what you need, and if
you can do it collaboratively without additional expense, fine,
but you tell us what it is you need.
You also mentioned to me the need for test compounds for
animals. Can you elaborate about what is involved there?
Dr. Gerberding. We have animal facilities at CDC and have
large BSL for state-of-the-art laboratories going up right now
that will allow us to do some kinds of research, but right now
the question people keep asking us is, do you know whether a
viral treatment worked, and in order for us to answer that
question quickly, we need to have an expanded capacity to test
compounds and inoculate animals with this virus at CDC.
We do not have the facilities and the resources to do that
kind of rapid screening of test compounds. We can test them and
tested with NIH and the Department of Defense over at Fort
Detrick. We are screening now, thanks to Dr. Fauci's support.
A large number of compounds and pharmaceutical companies
are making double off their shelf, but we need animal models at
CDC to help accelerate our discovery as well as our drug
testing on site as we are learning about new emerging problems
like this. We are also going to need the capacity to determine
resistance to antivirals or antibacterials as they emerge and
we need animal models for some of those studies as well.
Senator Specter. You also told me in our prior
conversations about the need for quarantined areas, that there
are only six to eight entry areas which would have adequate
quarantine if we face an epidemic coming in from overseas.
Could you elaborate upon that?
Dr. Gerberding. The CDC has the quarantine authority to
protect our borders from incoming infectious diseases. Right
now we have a very small number of quarantine stations, less
than ten around the country, but we have many ports of entry,
over 20 ports of entry just from Asia alone.
So we need to make sure that when you have a situation
where we have to go to the borders, hand information to people,
or screen passengers who are ill with infections on airplanes,
that the personnel are there at the time that the passenger
arrives, a little bit like the experience Dr. Rhodes had in
Pennsylvania where when somebody comes in off the plane, they
have to be met by health officials. And the Federal Government
has the responsibility for doing that at the international
ports of entry. When we----
Senator Specter. So what would you do today if you had a
problem and needed a quarantine?
Dr. Gerberding. Well, what we had done in the emergency
situation is we had deputized other Federal employees who had
some of the skills necessary to go and conduct an assessment,
so we pulled them from other duties and gave them this
temporary position to help us out because it is such an urgent
problem. But I think over the long run we need to really
develop a better plan and better coverage of our ports of entry
generically, and we certainly cannot rely on this emergency
solution if this SARS problem is going to go on very long
because we are going to wear out.
Fortunately, the Department of Homeland Security has helped
us tremendously with distribution of the alerting parts,
particularly at the Canadian border, so we are making
arrangements with other Federal agencies to help out with some
of those. But the health assessment has to be done by medically
qualified CDC quarantine officers and they are few and far
between right now.
Senator Specter. But if you were to effectively quarantine,
you would have to isolate people. Do you have facilities to do
that if the need arose?
Dr. Gerberding. The agreements are made on a site-by-site
basis. Some of the international airports have clinics onsite
and can isolate people until they can be transferred to the
appropriate healthcare facility.
We have different agreements and different locations, and
we can make that work. It is just a matter of identifying what
is the best local solution.
Senator Specter. Dr. Rhodes, in your hospital do you have
sufficient facilities to isolate if you should have a serious
problem or a bioterrorist attack?
Dr. Rhodes. Yes, we do. We have approximately between 60
and 65 isolation rooms and that is unusually high. Again, I
would stress that the healthcare facilities we have in Lehigh
Valley are for a lot of reasons, they do not represent most
small hospitals, most small--the bulk of what I see of
Pennsylvania medicine at the practical level in the trenches,
doctor's offices, small hospitals. We are blessed by having a
lot of assets and an unusually cooperative local public health,
long-term healthcare in particular, to form a partnership with
them, and that is not most places.
I can think of 15 hospitals in my immediate area who would
have a great deal of trouble handling any degree of isolation
beyond perhaps----
STATEMENT OF DR. JOHN COMBES, SENIOR MEDICAL ADVISER,
HOSPITAL AND HEALTH SYSTEM ASSOCIATION OF
PENNSYLVANIA
Senator Specter. Dr. Rhodes, that is a good transition to
bring Dr. Combes in. Dr. Combes is the senior medical adviser
for the Hospital and Health System Association of Pennsylvania
and the American Hospital Association.
Do you have a hunch, Dr. Combes, of bioterrorist attack,
and we are going to come to that with a question to Dr.
Gerberding and Dr. Fauci in a few minutes, but while we are
talking about isolationism and quarantine, how well-equipped
are our Pennsylvania hospitals?
Dr. Combes. I think on the average, hospitals are fairly
well-equipped to meet this kind of challenge and I think in
this whole epidemic that we have been seeing here in the United
States the response has to be very similar, of course, as we
have seen the excellent response from the Lehigh Valley
Hospital.
As Dr. Gerberding pointed out, there have only been two
cases of secondary spread here in the United States and I think
that is the unique cooperation between the public health
services in the country and the acute care community and the
local physician community. But the point that you made earlier
about the funding for CDC and it has been referenced several
times in terms of the weakness of the public health system here
in this country, was very important for this issue, and all
these unexpected issues, including bioterrorism, the same can
be applied to hospitals as well and if the capacity becomes an
issue, it has to do with concerns about funding of hospitals
and their ability to keep meeting these challenges.
We face new challenges every day. Hopefully we rise to the
occasion like Lehigh Valley does, but when the system is itself
in some crisis state, we have the same problems that the CDC
has in terms of being able to respond to all the demands that
are out there, and there are multiple demands upon us.
Senator Specter. Dr. Fauci, you and I had discussed the
significant assistance which has been given to the public
health system in the United States as a result of
appropriations which were initiated by this subcommittee
putting in a bid at $100 million year before last and $1.4
billion this year and projecting another significant increase,
another $1.4 billion hopefully next year if we can find the
money in our budget. All of that remains to be seen.
But to what extent has that improved the ability of
hospitals, local hospitals, in States like Pennsylvania to cope
with these problems, the isolation problem, for example?
Dr. Fauci. Well, certainly if you look at the public health
infrastructure at the local level, which is mostly State and
local public health authorities, they get the primary benefits
of that $1.1 billion and $1.4 billion in the future.
Senator Specter. Dr. Fauci, is it not true that the public
health in American pretty much starved before we took a look at
the problem of bioterrorism and----
Dr. Fauci. Yes. If one looked at the public health
infrastructure at the State and local level prior to the
beginning of the rejuvenation that this committee has run to
that prior infusion of resources, it has been unfortunately,
and just about anyone in the business would recognize that, it
was a local health infrastructure that had been left to go in
disarray.
Almost a victim of our own successes, in that with the
advent of successful vaccinations and antibiotics and infection
control, a very competent infrastructure that was perfectly
suited for the kinds of things that we face in the 1930s and
the 1940s and the 1950s, were left essentially behind.
We now have to play some catch-up role. The first couple of
years that this committee has allocated that money has been
enormously helpful, but to rejuvenate a public health
infrastructure system will take years.
That is why we are very heartened, Mr. Chairman, by the way
you put it, that we have not only the money from last year and
this year, but it needs to continue because we are not going to
fix the problem in one or two years. It is going to have to be
a sustained commitment to that. But before the monies that you
infused, it was in rather sad shape.
Senator Specter. Dr. Combes, this is something that the
subcommittee would like your help on a follow-up basis as to
what is needed in Pennsylvania. I have visited many, many
hospitals and the response I get consistently is that there are
insufficient funds to handle the issue. Senator Santorum and I
visited UPMC not too long ago and we found there some real
steps have been taken to have a receiving unit where people
would shower in an area close to or such an area that
contained. But from what I hear generally, we are really just
getting started. The public health system and SARS and then the
impetus of bioterrorism threat activated some real concerns, so
we were able to put up some money.
I would like for you to give us a projection as to what it
would take to really be able to handle the problem in our
setting.
Dr. Combes. First of all, I do want to thank you on behalf
of Pennsylvania hospitals because some of the bioterrorism
money does flow directly through the public health agencies to
hospitals to help their preparedness, but as you have pointed
out it is really just beginning to scratch the surface.
Certainly issues of emerging new diseases, resistance of
current diseases, those are things that are not being budgeted
for in terms of what hospitals have to deal with, yet we deal
with it every day.
What is the overall--what do we need to do our business in
terms of dollars? It is a hard number to come up with, but I
know that in a State where we are facing severe Medicaid cuts
for hospitals where I know the House and Senate have worked to
restore some of the Medicare dollars for us and we are
appreciative of that; but still our costs are rising, we have
work force shortages, we have a professional liability crisis
which is driving lots on costs, all of those things need to be
dealt with. We certainly can come back to you with a number
that it will take to get us to the level of preparedness.
The other point I want to make out is just a commitment of
healthcare professionals. The thing that I was impressed about
Dr. Rhodes' testimony as well was the time that he and others
in hospitals all over the country spent monitoring excellent
resources, those of the CDC, and applying it pre-event to their
hospitals.
This is something that we do in addition to what we
actually get funded for. This requires the dedication of
professionals and administrative professionals in hospitals and
we would like to work with your committee recognizing that and
understanding how we can further that as we move forward
because it is really this frontline action that will prevent
the secondary spread of diseases like SARS and keep this
country safe when other cities have had a major problem with
this disease.
So think in your costs as we go forward, and it is not only
facilities, it is how we encourage and develop that
professionalism and the education surrounding issues like this.
Senator Specter. Tell us what it will take.
Dr. Combes. We certainly will, Senator. You have been a
good friend to us and we will keep you informed.
Senator Specter. We have the responsibility under the
Constitution to decide what to appropriate, but we cannot
decide that unless we know what is needed. I am not saying that
there will be a political will to do it, but you will find it
in the subcommittee.
Yes, Dr. Rhodes.
Dr. Rhodes. Talking numbers, speaking numbers, I looked in
the last report, our hospitals, network of three hospitals
received about $60,000, again courtesy of Mr. Reed's efforts
for the Homeland Defense Corporation. We spent that on
communications here, decontamination here----
Senator Specter. How about the $750,000 which the
subcommittee awarded the last year? Do not forget that.
Dr. Rhodes. I am going to right here in the dollars that
came back.
Senator Specter. Those are dollars that came right to your
hospital.
Dr. Rhodes. $750,000?
Senator Specter. We allocated $750,000 on earmarks to each
of the three hospitals in Lehigh Valley.
Dr. Rhodes. I only saw $60,000.
Senator Specter. You better go back and make sure the books
are not----
Dr. Rhodes. My point is this, we were at that time
targeting and of course particularly focusing on anthrax, and
so our $60,000 was well-spent and there may be more now, but we
have spent almost that much, and a lot of effort and overtime
and people just dedicated to the issue. There are hospitals
with children who spend zero hours on that. Lehigh Valley
Hospital, we spent a lot of time preparing it. That took away
resources from other places.
Now, I would say hospitals then that do that and
participate personally want to account for these dollars. We
should be all held accountable for what we do. And there should
be an issue of dollars I think generated incenting people to
perform--maybe that is being done. I am just talking from a
perspective of a infectious disease physician.
I asked before I came down here, how many dollars came down
to our hospital complex, the number $60,000 was given to me,
and where was it spent? Again, decontamination, radio and
special protective equipment which was needed.
I am sure it was well-spent, but I am going to say over the
last 5 months we have been dedicated, we have had a very
complicated and I think world-class program to get our
healthcare center ready for smallpox immunization and a program
in trouble nationally because of support. And then we felt
compelled to do it right and sustain the common effort and
energy to offer our smallpox vaccination. Now, this issue, just
our two cases and as well as they seemed to go, I would guess
that we spent probably $30,000, maybe more, on just those two
cases.
So the money goes fast and I think we have to account for
it at the local level. And I am wondering about all of the
other hospitals. I do not know what the exact number is, but
what number do you take to hospitals in Pennsylvania of say
$100 or less of the total number?
Dr. Combes. In Pennsylvania actually a majority of our
hospitals would be small rural hospitals numberwise, and that
number is probably around 70 to 80 of that class. They would be
the biggest class of hospitals. We have many small rural
hospitals.
Senator Specter. If you ask many more questions, Mr.
Rhodes, I am going to have to make you co-chairman of the
Senate Committee.
Dr. Rhodes. That is my burning passion. If you say that
many hospitals, I would say probably none, if any, have
infectious disease consultative services or expertise, and
probably have marginal infectious control because they are so
tasked with many other duties, and that is who put the program
like this together.
Senator Specter. Dr. Gerberding, let me come back to the
long line of concerns you have about being adequately funded in
CDC and you talked about information technology and Internet
and ways of getting communications as to what is happening in
the five foreign corners of the world which come right back to
our doorstep in Lehigh Valley and elsewhere. What do you have
in mind on information technology which you would like to see?
Dr. Gerberding. Can I just say, to frame this discussion,
that what we have been doing over the last 2 years, anthrax,
smallpox, terrorism preparedness, West Nile virus, SARS is
responding to emerging crises when they come up and going full
force with effort and diligence of the whole system. Everyone
has stepped up to the plate and we have received congressional
and presidential support for these programs when they emerge.
So we have been given a lot. But what we are doing right now is
solving crisis problems, and we are not thinking about how to
fix the system in the long run.
So, when I talk with you about the global safety network
for emerging infectious diseases or a state-of-the-art
information system that connects us from the hospital to the
CDC to the NIH to China, I am talking about systematic longer
term solutions to the problem that I think, in the long run,
would pay off and take us out of crisis mode and put us into a
system where we have a better infrastructure for managing these
problems.
But in terms of information technology, as you know in
Pennsylvania where there are some excellent surveillance
systems involving the private sector and the public health
department----
Senator Specter. That is in the Pittsburgh area where they
have a new software computer model coming out of the University
of Pittsburgh Medical Center where they are able to track in
various locales, doctors' offices and hospitals, symptoms which
can be correlated into an early warning of a biological attack
or poisoning or something in the water.
Is that the sort of a national or international system you
are looking for?
Dr. Gerberding. We want an international early protection
system that will identify SARS, will identify arsenic
poisoning, it will identify Anthrax or smallpox or any other
threat as it pops up in the world.
Senator Specter. You are going to have to tell us what you
need, give us a model. Tell us what you have to do from a
responsive approach.
You had commented to me--moving away from SARS for just a
few minutes onto the bioterrorism issue which is also your
responsibility, and Dr. Fauci and I have had quite a number of
discussions about the smallpox issue; but you made a particular
point about insufficient knowledge as to chemical threats.
Would you tell us what the problem is there?
Dr. Gerberding. I think we have a lot of work to do in
bioterrorism, but as we learned during some of the recent
orange alerts, chemical terrorism is also an extremely
important threat in this country.
With bioterrorism we can get a vaccine potentially to help
us out. With chemical terrorism we have invested so little in
understanding what to do about antidotes or what we have not
studied, what is the best decontamination method. The science
is not keeping up with the need in the chemical arena and you
really need some solid public health research here to help us
even begin to develop sensible and prudent protocols.
Senator Specter. Could that come, Dr. Fauci, from NIH?
Dr. Fauci. Fortunately it can. It is the development of new
and better improved antidotes against some of the chemicals. We
now are dealing with antidotes that are good, but that have
been in use for decades and decades and decades. So we do not
have any improvements. I am not saying that the ones we have
are bad.
We also have detection capability, and as Dr. Gerberding
mentioned. One of the critical issues is how you decontaminate
if there is, for example, nerve gas. Nerve gas comes in
different forms, liquid form, vaporized form. And when health
workers are going to be called in to take care of individuals,
we know from the experience of, for example, the sarin attacks
in the Tokyo subway, that there was not a lot of basic
knowledge or understanding of decontamination of materials such
as clothing and facilities that would get contaminated. So we
do have a ways to go, some of which would be contributed to by
the NIH's research endeavor.
Dr. Gerberding. I would just like to add that I talked with
Dr. Zerhouni a little bit about the continuum of the research
necessary to address some of these problems and there are many
institutes like NIH that have an interest and the capacity to
contribute to this knowledge. What we want to do is have a
pipeline from NIH to taking that science and implementing it
and evaluating it for new containment and new intervention
protocols. So we need to work together on this and I know
Secretary Thompson is helping us make sure we act as all one
department.
Senator Specter. NIH may be in a position, in fact Scott
May is in a position. The NIH has been funded. Senator Harkin
and I set out thinking that NIH was the crown jewels of the
Federal Government. Maybe except for CDC the only jewel in
Federal Government.
But we have increased the funding from $12 billion to $27-
plus billion. Now, NIH has a lot of responsibilities on
research on Parkinson's and Alzheimer's and heart disease and
cancer, but there are funds available there which, $4 billion-
plus with CDC I guess, there are times of an emergency, and set
our priorities, which NIH has to do.
NIH has to determine the priorities for the $27 billion
which it has. But it would seem to me that research and these
chemical issues that Dr. Gerberding talks about--you talked
about terrorist compounds which are readily available for
industrial purposes. All of those really we need a line of
defense on.
Dr. Fauci. Can I make a comment in that regard, Mr.
Chairman? Over the past 3 months in recognition of the precise
point that you are making, I called a series of meetings of
individuals in different sectors, particularly the Department
of Defense, who had been the major players thus far in both
chemical, radiologic, and nuclear defense. Fundamentally for
the military we brought them together to get a feeling for what
the scope of the landscape of what we have available, what are
the gaps and how can we begin to fill those gaps.
So we are already starting to move into the arena. We are
fundamentally in the arena of biological terrorism vis-a-vis
microbes. We are now moving into the arena of chemical
radiological and nuclear to determine if there is anything that
we can contribute to NIH.
Senator Specter. The Department of Defense has its own
independent laboratories doing all that work? Do they work with
NIH on that?
Dr. Fauci. They do now. In fact, it was through these
meetings since--well, it started in a low level before
September 11, but subsequent to September 11 and when we got
the very large appropriation that you generously gave us, Mr.
Chairman, we called in for even further intensification of
interactions between ourselves and the Department of Defense.
And we now already have very strong interactions with USAMRIID
and we are now developing much stronger interactions with the
chemical/medical unit of the Army as well as the
radiobiological unit of the Navy.
So it is coming together, as Dr. Gerberding says, but we
are really having interaction.
Senator Specter. Well, this subcommittee may be in a
position to help you. CDC has $4.3 billion and NIH has $27.5
billion, but I am not sure, but I think the Department of
Defense has more?
Dr. Fauci. They have more----
Senator Specter. Do not pause too long.
Dr. Fauci. The answer is yes.
Senator Specter. Dr. Fauci, I want to move now to the
subject of vaccines. I know you are working on a vaccine for
SARS. Tell us what your progress is.
Dr. Fauci. Yes. What we had done--there are several levels
of generations of vaccines that are likely to be successful
with SARS. The first and easiest thing to do is to get the
virus, grow it up, kill it, and vaccinate an animal. And CDC
isolated the virus within a very short period of time. They
gave the virus to us in our laboratories up in Bethesda and it
is now growing in quantities enough to start the following
experiments.
The first generation of vaccine is what we call whole
killed or whole inactivated. Very simple. Nothing molecularly
sophisticated. You grow it up, you kill it, you infect an
animal with a live virus, you show that the animal can get
sick, in this case the monkey, then you vaccinate the animal
with the killed virus and you challenge the animal with the
live virus. Those experiments are undergoing implementation
right now. Within the next several months we should, by the end
of this calendar year, have proved the concept that you can or
not protect an animal from challenge.
The reason why we are cautiously optimistic that this would
be the case is that in fact we know that in the vast majority
of people who get infected with SARS, their immune system can
successfully contain the virus, which tells us that from a
conceptual standpoint that is likely possible. That is very
different from HIV/AIDS in which individuals who are infected
and have established infection, their natural body's capability
does not allow them to clear the virus at all.
There are virtually no instances of that. So we are
cautiously optimistic. Simultaneously with that first
generation of killed whole virus vaccine, we are entering into
several other levels. One of them is the recognitive vector.
And by that we mean we take a simple virus that develops a
benign virus like adenovirus. Now that we have the sequence of
all of the genes of the SARS virus we can selectively take
certain genes with codes for the protein that would induce
protection if you would vaccinate, insert them into the vector,
let them express themselves and then vaccinate individuals with
that. So you have the safety of a benign virus, like an
adenovirus, but the recognition of the SARS virus itself.
Second best, second generation. That is already ongoing. We
have entered into a collaborative agreement and a contract with
a company called GenVec which will assist us in the ability to
do that with HIV.
The other is producing large quantities of purified protein
by a certain vector that when you instill the gene and stick it
in the bottom and let it rotate for a long period of time, that
just spits out endless amounts of protein.
The fourth one is a DNA vaccine approach where you take the
purified DNA or complementary DNA that we can get from the
virus and use that as a vaccine.
The final one is the one that is the most difficult, but
ultimately will have the greatest chance of being very
effective, and that is a live attenuated vaccine, similar to
the concept of the original Sabin polio vaccine.
So there are at least five concepts, two of which have
already hit the ground and I would expect that I know we are
going to be interacting over the next year on how progress is
coming along.
Hopefully by the end of this calendar year you can say we
have proven a concept. The actual development of the vaccine
could be available for distribution, but even at its most rapid
pace will take a few years, a couple years at least, 2 or 3
years.
Senator Specter. Any way to expedite that?
Dr. Fauci. Yes. I think the way to expedite it is to put on
the afterburners and just get as many resources and as many
people involved in that.
There are certain things you cannot rush----
Senator Specter. Take the full $27 billion away?
Dr. Fauci. I do not think we will take the full $27
billion, but we will certainly use some of that, you bet.
Senator Specter. I will put the afterburners on it.
Dr. Gerberding, I saw a message from Garcia. Perhaps we
answer the other eight spots in Pennsylvania?
Dr. Gerberding. Yes. I am going to ask if I could tell you
the locations of the patients when we go off the air because
some of these are small communities and I do not want to say
anything that would identify a specific patient in a small
town.
Senator Specter. Excellent idea. What are the communities,
just a few? We will do it off the record.
Dr. Gerberding. I would like to be respectful of that
issue, but I can tell you that none of them have been at risk
for transmitting infection to anyone else.
Senator Specter. None of the others are in the hospital?
Dr. Gerberding. None are in the hospital.
Senator Specter. You can say that with respect to those
eight other instances there is no risk factor?
Dr. Gerberding. Exactly.
Senator Specter. I had asked Secretary Ridge when we had
Homeland Security and had them both before the Appropriations
Subcommittee on Wednesday and before the Governmental Affairs
Committee, I am on both those committees and I discussed this
issue with Secretary Ridge.
He is reluctant to get involved in health issues, per se,
but I think this may be a matter for Homeland Defense on SARS
depending on where it goes if he has not closed the door.
With respect to the issues on bioterrorism and the costs
involved there, I am glad to see the Department of Defense in
it, but that is Homeland Defense core function and they have
$38 billion so they should be working with you on that as to
require a joint coordinated effort.
As we have identified so many areas that need to be
covered, I come back to the issue of what it is going to take
to do it and I know that there is sometimes a little reluctance
on the part of the executive branch that share the experience
and expertise, but Congress has the responsibility under the
constitution to appropriate and we need the information to
determine what the appropriation levels should be and we are
facing really enormously serious problems for the American
people on healthcare for SARS or life problems as we are from
bioterrorism.
So, Dr. Gerberding, I understand the constraints under
which you operate, but I want for the official record directly
from you, the expert, your professional judgment concerning
what resources CDC needs to protect the public health.
I would like you to address all the relevant public health
issues such as terrorism, homeland security and emerging
infectious disease, including SARS, buildings, facilities, the
obesity epidemic and other critical research that needs to be
done by your agencies and I am requesting this information be
made available to our subcommittee in ten work days, 16th day
of May at the outset.
I know that is a tall request, but we are going to be
putting together for the budget and we are going to have to
assess the needs you identify with the needs that we have as
you know, not only health human services, but education and
labor; so we have a lot of work to do to assess priorities.
So can you do that?
Dr. Gerberding. Yes, sir, I will do that and I appreciate
fulfilling the recommendation and I also appreciate the
priorities that your committee places.
Senator Specter. And, Dr. Fauci, I would ask you the same
question, recognizing the constraints under which you operate,
but I want for our official subcommittee record, addressing
that record, directly from you the expert, your professional
judgment, what resources NIH needs to protect the public health
concerning public health issues, terrorism, homeland security,
emerging infectious diseases including SARS, what your building
and facility needs are.
We have a big problem with the obesity epidemic, strange to
fit it in here, but it is part of our allocation of resources
and other critical research that needs to be done, and I
request this information for the subcommittee, you get it to us
within 10 working days by May 16 if you would. Can you
undertake that assignment, Dr. Fauci?
Dr. Fauci. I will.
Senator Specter. Okay. This has been a very informative
hearing. It is a little different format than sitting around a
roundtable, but we really appreciate your coming, Dr. Fauci and
Dr. Gerberding.
I repeat for the record my repeated inquiries to you as to
how this would impact, but I think it is very important to hear
the assurances which have been given today to the people.
This will be noted far beyond the borders of the
Commonwealth of Pennsylvania, and we thank you, Dr. Rhodes, for
what you have done in the emergency situation and I admire your
background and your ability to cope with it.
It was your technical proficiency in all the hospitals in
America. We would not give so much money to NIH and CDC, we
just rely on you folks.
Dr. Rhodes. I found the rest of the money. The $60,000 was
the amount allocated for bioterrorism by hospitals in our area.
The rest of the money was put into not only resources, but
education, et cetera.
So everybody knows where all the money is. I do not want to
leave you nervous that we lost it.
Senator Specter. And, Dr. Combes, thank you for joining us.
I understand what the Pennsylvania Hospital Association does
and we have attached you with some responsibilities to tell us
what you need.
I cannot promise, I am only one vote out of 100, but then
we have the House of Representatives, but our subcommittees are
starting to and we have shown that we have put resources behind
needs, and our first subcommittee and the Congress are
committed to it, and the Congress has the constitutional
responsibility to decide what the priorities are, where the
public's money should be.
We have a $10 trillion national economy and a $2 trillion,
$200 billion Federal budget, so we can do it. We have a lot of
problems in this country, but we are up to the challenge.
Dr. Combes. While I wrote down your request of Dr.
Gerberding and Dr. Fauci, I would be very happy to have us
submit the same type of information to you by May 16 if that
would be helpful to you and the subcommittee.
Senator Specter. Consider yourself bound.
additional committee questions
There will be some additional questions which will be
submitted for your response in the record.
[The following questions were not asked at the hearing, but
were submitted to the Department for response subsequent to the
hearing:]
Questions Submitted by Senator Arlen Specter
public health protection
Question. I understand the constraints under which you operate, but
I want, for the official record, directly from you, the expert, your
professional judgment concerning what resources NIH needs to protect
the public's health.
Please address all relevant public health issues, such as terrorism
and Homeland Security, emerging infectious diseases, including SARS,
buildings and facilities, the obesity epidemic, and other critical
research that needs to be done by your agency. I am requesting that
this information be delivered to the Subcommittee within ten (10)
working days at the latest.
Answer. At the time the preliminary fiscal year 2004 budget was
developed in the spring of 2002, NIH's professional judgement budget
requested a total of $29,560 million. Detailed information on the
professional judgement request for selected programs with high impact
on public health are provided below. In reviewing this information,
please keep in mind that neither the operating division request to the
Secretary nor the HHS request to OMB was constructed in the context of
other national priorities or government-wide budgetary limitations. We
believe that the President's Budget is strong in its efforts to protect
the public's health, especially in the context of all health priorities
and needs. As I have stated publicly, I support the NIH request in the
fiscal year 2004 President's Budget. The information provided on
biodefense and emerging diseases was provided by Dr. Anthony Fauci,
Director, National Institute of Allergy and Infectious Diseases.
PROFESSIONAL JUDGEMENT OF RESOURCE NEEDS FOR SELECTED NIH RESEARCH AREAS
[In millions of dollars]
------------------------------------------------------------------------
Fiscal years
--------------------------------------
2003 2004 2005
------------------------------------------------------------------------
Biodefense....................... 1,488 1,886 2,296
Emerging Infectious Disease (inc. 200 504 609
SARS) \1\.......................
------------------------------------------------------------------------
\1\ Excludes resources for emerging infectious diseases included in
biodefense line.
Biodefense Research.--Additional resources would accelerate the
research and development of countermeasures against biological agents
of terrorism. Funding increases will support the expansion of basic
research, additional construction of regional high- containment
laboratories for extramural researchers, and expansion of applied
research with academia and industry to accelerate the research and
development of the countermeasures.
In addition to supporting the advanced product development of the
next generation smallpox vaccine, the funding will also accelerate and
support the advanced product development of candidate countermeasures
against botulism toxin, plague, tularemia, and viral hemorrhagic
fevers, such as ebola and rift valley fever.
Emerging Diseases Research (including SARS).--Implements a
comprehensive research agenda to combat SARS. Funding will support a
multiprong strategy to rapidly expand research to develop multiple
vaccine candidates to prevent SARS. Also initiates research on immune-
based therapies while expanding screening and testing of thousands of
compounds for therapeutic activity against the SARS virus. Includes the
rapid expansion of: basic research, including the pathogenesis of the
disease; clinical research and infrastructure to test candidate drugs,
vaccines and diagnostics; and the advanced product development of the
most promising vaccine candidates.
Obesity.--In fiscal year 2004, the NIH professional judgement
request for obesity research is $390 million. These funds will
facilitate progress in NIH research to address the increasingly severe
obesity epidemic and its serious implications for public health. The
recently formed NIH Obesity Research Task Force has identified the
following topic areas as critical areas for expanded research. Examples
of potential studies are listed below each topic area.
--Identifying the Genetic, Behavioral, and Environmental Factors that
Cause Obesity and its Associated Comorbidities.--The results of
such research will open new avenues to investigate the causes
and potential therapies for obesity.
--Understanding the Pathogenesis of Obesity and Associated Co-
Morbidities.--The results of such research will provide
fundamental knowledge to fuel the search for new strategies to
prevent or treat obesity.
--Prevention and Treatment of Obesity.--Research in this area would
be designed to analyze the efficacy of different approaches to
prevention and treatment of obesity on weight loss and
associated diseases, to test innovative approaches to prevent
inappropriate weight gain, and to understand the molecular and
behavioral factors underlying weight change.
--Policy, Health Surveillance and Services, Economics, and
Translation to Practice.--Research in these areas will
facilitate the translation of obesity research discoveries into
practice to improve public health. Additionally, NIH-supported
research will provide a scientific foundation to inform policy
decisions.
--Enabling Technologies.--Recent in advances in computer technology,
robotics, miniaturization and molecular biology have already
changed many aspects of our lives and promise to provide a new
lens to examine the fundamental processes in biology.
Application of these approaches to bridge the gap between our
knowledge of the human genome and human health and disease
holds particular promise in obesity research.
--Development of Multi-disciplinary Teams.--Research towards
understanding, preventing, and treating obesity will benefit
from increased efforts to enhance collaborations among
scientists with fundamental laboratory research expertise,
behavioral scientists, and clinicians, as well as
collaborations among investigators from a variety of
disciplines within these fields.
Buildings and Facilities.--In fiscal year 2004, the professional
judgement request for Buildings and Facilities is $350 million. These
funds would provide for the completion of the John E. Porter National
Neuroscience building in fiscal year 2004, as well as increased funds
for essential fire and safety programs, such as asbestos abatement, and
rehabilitation of animal research facilities, in addition to increased
funds for repairs and improvements.
CONCLUSION OF HEARING
Senator Specter. Thank you all very much for being here.
That concludes our hearing.
[Whereupon, at 11:19 a.m., Friday, May 2, the hearing was
concluded, and the subcommittee was recessed, to reconvene
subject to the call of the Chair.]
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