[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]


 
                  GLOBAL HEALTH EMERGENCIES HIT HOME:
                       THE ``SWINE FLU'' OUTBREAK

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


                                HEARING

                               BEFORE THE

                SUBCOMMITTEE ON AFRICA AND GLOBAL HEALTH

                                 OF THE

                      COMMITTEE ON FOREIGN AFFAIRS
                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED ELEVENTH CONGRESS

                             FIRST SESSION

                               __________

                              MAY 6, 2009

                               __________

                           Serial No. 111-56

                               __________

        Printed for the use of the Committee on Foreign Affairs


 Available via the World Wide Web: http://www.foreignaffairs.house.gov/

                                 ______



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                      COMMITTEE ON FOREIGN AFFAIRS

                 HOWARD L. BERMAN, California, Chairman
GARY L. ACKERMAN, New York           ILEANA ROS-LEHTINEN, Florida
ENI F.H. FALEOMAVAEGA, American      CHRISTOPHER H. SMITH, New Jersey
    Samoa                            DAN BURTON, Indiana
DONALD M. PAYNE, New Jersey          ELTON GALLEGLY, California
BRAD SHERMAN, California             DANA ROHRABACHER, California
ROBERT WEXLER, Florida               DONALD A. MANZULLO, Illinois
ELIOT L. ENGEL, New York             EDWARD R. ROYCE, California
BILL DELAHUNT, Massachusetts         RON PAUL, Texas
GREGORY W. MEEKS, New York           JEFF FLAKE, Arizona
DIANE E. WATSON, California          MIKE PENCE, Indiana
RUSS CARNAHAN, Missouri              JOE WILSON, South Carolina
ALBIO SIRES, New Jersey              JOHN BOOZMAN, Arkansas
GERALD E. CONNOLLY, Virginia         J. GRESHAM BARRETT, South Carolina
MICHAEL E. McMAHON, New York         CONNIE MACK, Florida
JOHN S. TANNER, Tennessee            JEFF FORTENBERRY, Nebraska
GENE GREEN, Texas                    MICHAEL T. McCAUL, Texas
LYNN WOOLSEY, California             TED POE, Texas
SHEILA JACKSON LEE, Texas            BOB INGLIS, South Carolina
BARBARA LEE, California              GUS BILIRAKIS, Florida
SHELLEY BERKLEY, Nevada
JOSEPH CROWLEY, New York
MIKE ROSS, Arkansas
BRAD MILLER, North Carolina
DAVID SCOTT, Georgia
JIM COSTA, California
KEITH ELLISON, Minnesota
GABRIELLE GIFFORDS, Arizona
RON KLEIN, Florida
                   Richard J. Kessler, Staff Director
                Yleem Poblete, Republican Staff Director
                                 ------                                

                Subcommittee on Africa and Global Health

                 DONALD M. PAYNE, New Jersey, Chairman
DIANE E. WATSON, California          CHRISTOPHER H. SMITH, New Jersey
BARBARA LEE, California              JEFF FLAKE, Arizona
BRAD MILLER, North Carolina          JOHN BOOZMAN, Arkansas
GREGORY W. MEEKS, New York           JEFF FORTENBERRY, Nebraska
SHEILA JACKSON LEE, Texas
LYNN WOOLSEY, California
               Noelle Lusane, Subcommittee Staff Director
          Sheri Rickert, Republican Professional Staff Member
                     Antonina King, Staff Associate


                            C O N T E N T S

                              ----------                              
                                                                   Page

                               WITNESSES

Rear Admiral Anne Schuchat, M.D., Interim Deputy Director for 
  Science and Public Health Program, Center for Disease Control 
  and Prevention.................................................     9
Anthony Fauci, M.D., Director, National Institute of Allergies 
  and Infectious Diseases, National Institute of Health..........    20
Dennis Carroll, M.D., Special Advisor to the Acting 
  Administrator, on Pandemic Influenza, United States Agency for 
  International Development......................................    37

          LETTERS, STATEMENTS, ETC., SUBMITTED FOR THE HEARING

The Honorable Donald M. Payne, a Representative in Congress from 
  the State of New Jersey, and Chairman, Subcommittee on Africa 
  and Global Health: Prepared statement..........................     4
Rear Admiral Anne Schuchat, M.D.: Prepared statement.............    13
Anthony Fauci, M.D.: Prepared statement..........................    22
Dennis Carroll, M.D.: Prepared statement.........................    40

                                APPENDIX

Hearing notice...................................................    64
Hearing minutes..................................................    65


     GLOBAL HEALTH EMERGENCIES HIT HOME: THE ``SWINE FLU'' OUTBREAK

                              ----------                              


                         WEDNESDAY, MAY 6, 2009

                  House of Representatives,
          Subcommittee on Africa and Global Health,
                              Committee on Foreign Affairs,
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 9:07 a.m. in 
room 2172, Rayburn House Office Building, Hon. Donald Payne 
(chairman of the subcommittee) presiding.
    Mr. Payne. This hearing will come to order. Let me begin by 
saying generally hearings do begin a bit later, but because we 
felt the urgency of this matter, we had to take the only time 
available so that we can vacate the room for another previously 
scheduled hearing; I appreciate all of you coming early this 
morning. This meeting, as I mentioned, will officially come to 
order, and thank you for joining the Subcommittee on 
African deg. and Global Health this morning for this 
hearing entitled ``Global Health Emergencies Hit Home: The 
`Swine Flu' Outbreak.''
    The recent outbreak of a new strain of influenza, a subtype 
H1N1 virus commonly referred to as ``Swine Flu,'' sparks 
significant global concern and attention and reminds us that 
global health challenges are challenges to the health of our 
own Nation and the entire international community. We truly 
live in a global village and it has been no more apparent than 
it is today. Indeed to date, our own hemisphere is most 
affected. The first identified cases occurred in Mexico in 
March where 590 cases and 25 deaths had been reported, followed 
by 286 cases and one death in the United States and 140 cases 
and 0 deaths in Canada. On April 29th the World Health 
Organization raised its influenza pandemic alert to level five, 
a strong signal that a pandemic is eminent. Many questions 
remains deg. as to the exact origin of the virus 
strain. And while it contains genetic material from flu strains 
usually found in swine, pigs have not yet been identified as a 
source of human transmission. The association with pigs could 
be injurious to the swine industry; and there has been a 
request that Members of Congress refer to the strain by one of 
its technical terms.
    There are many issues associated with this H1N1 virus. The 
WHO Phase 5 alert level carries with it a series of public 
health measures that countries are expected to adopt to avert a 
crisis. Among other issues, this hearing will focus on is how 
global health emergencies such as this one challenge the public 
health infrastructures of developing nations; and we hope to 
learn more about the assistance that the United States is 
providing to address these worldwide weaknesses. While no cases 
have been confirmed to date in African countries, I am 
concerned that the lack of reported cases of H1N1 in Africa may 
actually represent the absence of the ability to detect the 
virus strain, which could mean that the true impact of this 
strain is yet to be seen. Adding to concerns there have been 
several recent deaths in Southeast Asia and Africa caused by 
the avian flu. These issues underscore the need for greater 
investment in health systems in Africa in particular and in 
other developing regions.
    We will also discuss funding.
    As you know, the 2009 Supplemental Appropriations include 
$2 billion to fight pandemic flu--$1.5 billion which goes to 
Health and Human Services and Centers for Disease Control for 
Federal stockpiles, vaccines and detections. Of the remaining 
funding, $350 million goes toward State and local response, and 
$200 million for global efforts.
    President Obama has shown incredible leadership on global 
health this week, just yesterday, announcing $63 billion to be 
spent over the next 6 years, starting in Fiscal Year 2010 
shaped by a new comprehensive global health strategy. Under 
President Obama's new plan, $51 billion will go toward fighting 
HIV/AIDS, tuberculosis and malaria through the President's 
Emergency Plan for AIDS Relief, as we all know as PEPFAR. The 
remaining $12 billion will go toward other global health 
priorities such as child and parental health, neglected 
tropical diseases and an overall investment in building 
capacity in health systems. And this is something that African 
nations have said this is what we really need. As we get 
assistance to deal with the health crisis, we need to be able 
to build a health system, and that is what we will concentrate 
on. So when the need for overall assistance from the U.S. 
dissipates, the health systems will be in place.
    I commend the President for this quantum leap in global 
health funding. It shows the United States understands global 
health challenges and what we must do because these challenges 
can hit us here at home as we have seen in the outbreak of H1N1 
virus. As we may recall in 2007, the case of the Atlanta 
lawyer, Andrew Speaker, who traveled to Europe and back to the 
United States all while infected with the deadly extensively 
drug resistant tuberculosis strain known as XDR-TB. There is 
also a geopolitical dimension to the H1N1 outbreak. The World 
Health Organization cautions that those who are ill should 
delay international travel; however, warns that ``limiting 
travel and imposing travel restrictions would have very little 
effect on stopping the virus from spreading, but also would be 
highly disruptive to the global community.''
    Despite this warning, China has reportedly quarantined a 
number of Mexican nationals living in China. Mexico's response 
to this was a ban on flights to China. Last week, the European 
Union Health Commission urged Europeans to avoid nonessential 
travel to the United States and Mexico, following the 
confirmation of a case of the H1N1 virus in Spain. U.S. 
Homeland Security Secretary Janet Napolitano explained in a 
Senate Homeland Security Committee hearing here last Thursday 
stated that closing the United States-Mexican border would 
incur more costs and benefits to the United States Government's 
effort to stop the spread of the virus. I am sure these and 
other issues will allow us to have an in-depth discussion on 
this important topic.
    So we are pleased today to be joined by our distinguished 
panel of government witnesses. First, you will hear from Dr. 
Anne Schuchat, the interim deputy director for science and 
public health program at the Center for Disease Control and 
Prevention. Our second witness is a long-time friend, Dr. 
Anthony Fauci, director of the National Institute of Allergies 
and Infectious Diseases at the National Institute of Health. 
And last but not least, a long-time associate also, Dr. Dennis 
Carroll, who serves as special advisor to the acting 
administrator on influenza pandemic at USAID. And we will go 
through the biographies after we hear remarks from the other 
members.
    And at this time, I will turn to my colleague from New 
Jersey, the ranking member, Mr. Smith, for his opening 
statement.
    [The prepared statement of Mr. Payne 
follows:]Payne statement deg.





    Mr. Smith. Thank you very much, Mr. Chairman, for calling 
this very important hearing on the issue of the recent outbreak 
of the H1N1 influenza. I am particularly appreciative that our 
witnesses have taken the time to be with us this morning, as 
they are extremely busy addressing the current situation in 
their representative agencies. Thank you for your tremendous 
service on behalf of all those who potentially could become 
sick, as well as those who are. In its latest update, the World 
Health Organization has officially reported 1,516 cases of the 
influenza, including 30 deaths, 29 in Mexico. This count does 
not include the death of the first United States resident that 
is being reported this morning.
    Despite that tragic news, it seems that in general, the 
virus within the United States is no more infectious or deadly 
than the seasonal flu. It is still uncertain as to why Mexico 
experienced so many deaths from the Swine Flu and cases in the 
United States have been relatively mild. In any event, experts 
are warning that we must remain vigilant and take prudent 
precautions until more is known about the virus, and there is 
concern that a more dangerous reemergence of it could occur in 
the fall.
    Our country has benefited from procedures set in place 
during the Bush administration to respond to such a potential 
crisis. President Bush implemented the national pandemic 
strategy in 2005 and the domestic readiness group, a broad 
interagency panel, which he established to respond to national 
emergencies and has been active from the beginning of the 
outbreak. We have been fortunate to have a well-developed 
system in place for the new administration to utilize, and they 
have done so well.
    However, despite these efforts that have apparently served 
us well, so far some experts are asserting that we need to be 
doing even more to prepare for likely pandemics. The National 
Biosurveillance Subcommittee that was created by a presidential 
directive in 2008 is expected to release its first report soon. 
Dr. Larry Brilliant, chairman of that subcommittee, stated in 
an article published in last weekend's Wall Street Journal that 
the report concludes that our country and the world do not have 
adequately early warning biosurveillance capabilities. The NBA 
subcommittee will be recommending that ``governments need far 
better early warning systems for potential pandemics and other 
epidemic threats.''
    Dr. Brilliant added that the subcommittee is also 
emphasizing that public health be restored to a position of 
respect and be given resources commensurate with its duty to 
protect us from these and other threats to our health. I look 
forward to hearing from our witnesses whether they agree with 
this recommendation, and if so whether they have concrete ideas 
as to what actions our Government should undertake to address 
it. Mr. Chairman, the Global Health Initiative announced 
yesterday by President Barack Obama could be an early and 
timely response to this recommendation by the National 
Biosurveillance Advisory Subcommittee.
    In his announcement, President Obama referred to the 
outbreak of the H1N1 virus and the need to address public 
health challenges beyond our borders. The additional resources 
he is proposing could prove extremely useful to help save lives 
as we all become more aware of the importance of addressing 
health threats, not only within our own borders, but around the 
world.
    However, the President emphasized that his initiative will 
be pursuing a ``integrated approach to global health,'' and the 
administration has indicated that reproductive health is high 
on its list of priorities. Therefore this new initiative must 
be assessed in the context of the statements made by Secretary 
of State Hillary Clinton during a Foreign Affairs Committee 2 
weeks ago that this administration's definition of reproductive 
health also includes access to abortion.
    I would note with extreme concern that this announcement 
follows the President's rescission of the Mexico City policy 
that prevented taxpayer monies from going to foreign 
nongovernment organizations that perform and promote abortion 
as a method of family planning. As you know, Mr. Chairman, the 
bipartisan support that resulted in the passage of the Tom 
Lantos and Henry J. Hyde U.S. Global Leadership Act against 
HIV/AIDS, tuberculosis and malaria last year was the result of 
a consensus that rejected references to the integration and 
other linkages of reproductive health services with HIV/AIDS 
and malaria programs.
    Any attempt by this Congress or the new administration to 
break that consensus and to direct billions of dollars to 
organizations that kill unborn babies by way of chemical 
poisoning or dismemberment, and wounding their mothers instead 
of to organizations and programs that will save lives and 
improve the health of all children, born or unborn, women and 
men, will destroy that consensus.
    President Obama and his administration should be working to 
galvanize bipartisan political support to address the major 
global health challenges of our time, not to channel money to 
groups that seek to destroy the most vulnerable, the unborn 
child. I look forward to learning more from the administration 
as to how they will address this sensitive and extremely 
important human rights issue. The human rights of the unborn is 
the human rights issue of our day, and I believe, passionately, 
that the most persecuted minority in our world today are unborn 
children.
    In his brilliant article, Dr. Brilliant also describes his 
participation in eradication of smallpox and the importance of 
pursuing public health initiatives to prevent or end other 
health threats.
    Early in my tenure in Congress, I had personal experience 
of both the importance and the possibility of making public 
health a priority even in most difficult circumstances. During 
the FML conflict in El Salvador in the early 1980s, I visited 
on several occasions vaccination sites sponsored by UNICEF and 
the United States during which days of 
tranquil deg.lity were agreed to by both fighting 
factions. For 3 days the fighting stopped on one of those 
occasions so that upwards of 250,000 children could be 
vaccinated against polio, measles, diphtheria, tetanus and 
whooping cough.
    Since then, days of tranquility have been implemented in 
other countries including and Lebanon, Sudan, Iraq and Sierra 
Leone. This experience impressed upon me the public can be 
galvanized when people realize that the goal is to save the 
health and life of children. I am sure the same public will 
exist to address major health hazards that threaten our global 
community as a whole. It is extremely important for those of us 
in Congress to understand the health threats that face our 
world, including this new virus and the possible means of 
preventing or eradicating them. And again, I thank you, Mr. 
Chairman, and again, I welcome our distinguished witnesses.
    Mr. Payne. Thank you very much. At this time we will hear 
from our other subcommittee members. Ms. Woolsey, an opening 
statement?
    Ms. Woolsey. Thank you, Mr. Chairman. If everybody else 
would waive their opening statements, I will because we have a 
10 o'clock markup and these nice people have been sitting here.
    Mr. Payne. Thank you. Dr. Boozman.
    Mr. Boozman. I agree.
    Mr. Payne. Thank you. Ms. Lee. Thank you. Ms. Jackson Lee, 
do you waive your opening statement?
    Ms. Jackson Lee. Mr. Chairman, I will have to leave for a 
markup as well, so I will just simply say that because of the 
two deaths in the United States were in Texas, let me thank the 
witnesses for the faith they put on this cause. I do think we 
have a pending pandemic. And I want to thank the chairman for 
holding this hearing, and I hope to be able to engage with all 
of you as witnesses. Thank you very much. I yield back.
    Mr. Payne. Thank you very much. We have a very 
distinguished panel today. And we will hear from them. Dr. 
Schuchat, Dr. Fauci and Dr. Carroll. First, Dr. Anne Schuchat, 
the interim deputy director for science and public health 
program, has been at CDC since 1988 when she entered the U.S. 
Public Health Service as an epidemic intelligence service 
officer. She has made significant contributions to prevent 
infectious diseases in children through her work, informing 
vaccine and prevention policies, developing guidelines and 
disease monitoring systems, conducting pre- and post-licensure 
vaccine evaluations and collaborating with international, 
national and state partners to accelerate the availability of 
vaccine and prevention programs. Internationally she has worked 
in West Africa on meningitis and pneumonia vaccine studies, in 
South Africa on surveillance and prevention projects, and in 
China on SARS emergency.
    Dr. Schuchat graduated with highest honors from Swarthmore 
College and with honors from Dartmouth Medical School. She 
completed residency training in internal medicine at New York 
University's Manhattan VA Hospital. She has co-authored more 
than 180 scientific articles and received numerous awards, 
including the Public Health Services Meritorious Service Medal, 
and the Physicians Research Officer of the Year for her 
contributions to preventing group B streptococcal infections in 
newborns.
    Dr. Schuchat assumed leadership of CDC's National Center 
for Immunization and Respiratory Diseases in December 2005. In 
2006, she was promoted to the rank of assistant surgeon general 
within the U.S. Public Health Service; and in 2008, she was 
elected to the Institute of Medicine. In February 2009, she 
began a detail serving as CDC's deputy director for science and 
public health program.
    Next we have Dr. Anthony Fauci, who has been the director 
of the National Institute of Allergy and Infectious Diseases 
(NIAID) since 1984 and came to the National Institutes of 
Health in 1968. In his position, he oversees an extensive 
research portfolio on basic and applied research to prevent, 
diagnose and treat infectious diseases, such as, HIV/AIDS and 
other sexually transmitted infections, influenza, tuberculosis, 
malaria and illnesses from potential agents of bioterrorism. 
NIAID also supports research on transplantation in immune 
related illnesses, including audio-immune disorders, asthma and 
allergies.
    Dr. Fauci serves as one of the key advisors to the White 
House and the Department of Health and Human Services on global 
AIDS issues and on initiatives to bolster medical and public 
health preparedness against emerging infectious diseases such 
as pandemic influenza.
    Dr. Fauci received his M.D. degree from Cornell University 
Medical College in 1966 and completed his residency at the New 
York Hospital Cornell Medical Center. Dr. Fauci has made many 
contributions to basic and clinical research on pathogenic and 
treatment immunizing mediated and infectious diseases.
    He has pioneered the field of human immunoregulation by 
making a number of scientific observations that served as the 
basis for a current understanding of the regulations of the 
human immune response. In addition, Dr. Fauci is widely 
recognized for delineating the precise mechanism whereby 
immunosuppressive agents modulate the human immune response--I 
am going to end up being a doctor--Dr. Fauci is a recipient of 
many awards, including the Presidential Medal of Freedom, which 
is very prestigious, and 34 honorary doctorate degrees from 
universities.
    Finally, testifying on behalf of USAID is Dr. Dennis 
Carroll, who is the special advisor for the United States 
Agency for International Development's, acting administrator on 
pandemic influenza. He also serves as director of the USAID's 
Avian and Pandemic Influenza Preparedness and Response Unit, 
which oversees the agency's response to avian and pandemic 
influenza. From 1991 to 2005, Dr. Carroll served as the senior 
infectious disease advisor for USAID and was responsible for 
providing strategic and operational leadership for USAID's 
infectious disease program. Dr. Carroll has a Ph.D. in 
molecular biochemistry from the University of Massachusetts at 
Amherst with a specialized focus on tropical infectious 
diseases. He was a research scientist at Cold Spring Harbor 
Laboratory where he studied the molecular mechanisms of viral 
infections.
    At this time now, I will turn to our first witness, Dr. 
Schuchat.

 STATEMENT OF REAR ADMIRAL ANNE SCHUCHAT, M.D., INTERIM DEPUTY 
  DIRECTOR FOR SCIENCE AND PUBLIC HEALTH PROGRAM, CENTER FOR 
                 DISEASE CONTROL AND PREVENTION

    Dr. Schuchat. Good morning, Chairman Payne, Ranking Member 
Smith, and other distinguished members of the subcommittee. I 
am Dr. Anne Schuchat, the acting deputy director for science 
and program at the Centers for Disease Control and Prevention, 
and I appreciate the opportunity to speak with you this morning 
about the current outbreak of a novel H1N1 influenza virus and 
to focus on the global implications of the outbreak and the 
steps being taken by CDC and our global partners to mitigate 
this problem. We share the concern of people around the U.S. 
and the globe, and particularly those in Texas, who have been 
impacted by this outbreak, and are responding aggressively at 
the international, Federal, State and local level, to 
understand the complexities of this situation and to implement 
control measures. Our aggressive actions are possible in many 
respects because of investments and support of the Congress in 
U.S. pandemic preparedness, which has provided us with many of 
the tools we are using today to detect, track and control the 
outbreak and its impact. This support has also enabled the 
critical work of State and local public health officials across 
the country.
    In a global context the work of the committee in promoting 
global health through programs such as PEPFAR and the 
President's Malaria Initiative have been critical in improving 
the capacity of health systems that will be relied upon with 
this outbreak. Once again, we are reminded that global public 
health is inextricably linked with the health of the American 
people and that investments in global health have a direct 
benefit to our own health. I have noted in the written 
statement some of the important investments we have made in 
global pandemic preparedness, in global disease detection and 
the remarkable international collaborations taking place to 
address the threat from this new virus. In summary, without 
these global mechanisms to detect disease, share information 
across the globe and cooperate on response we would not be able 
to mount the effective response we have carried out to date.
    Influenza viruses are extremely unpredictable, making it 
hard to anticipate the course of this outbreak with any 
certainty. We have seen an increase in the number of cases and 
the number of States and the countries affected and we expect 
more. We are carefully monitoring the severity of illness 
caused by this virus. While the primary evidence as of today is 
encouraging we understand that this too could change. Amid this 
uncertainty, we hope to be clear in communicating what we do 
know, acknowledge the uncertainties, clearly communicate what 
we are doing to protect the health of Americans and people 
around the world and help people understand the steps that they 
can take to protect their own health and that of their families 
and their communities.
    As we look to the future, we will be looking carefully and 
are already providing assistance to countries in the southern 
hemisphere where influenza season is now beginning, both to 
help them respond and to examine clues about the direction that 
this epidemic will take. Unfortunately, as with many public 
health problems, lack of infrastructure and resources mean 
developing countries in particular can expect to bear a 
significant burden in this epidemic, and we hope to provide 
assistance to mitigate the impact that the epidemic may have.
    Influenza arises from a variety of sources. And in this 
case, we have determined that we have a novel 2001--2009 H1N1 
virus circulating around the globe that contains genetic pieces 
from four different virus sources. We have been able to move 
within 2 short weeks to identify this novel virus, understand 
the complete genetic characteristics and compare the genetic 
composition of specimens from U.S. patients to others around 
the globe to watch for mutations.
    We have also with unprecedented speed developed and 
deployed test kits for use in a widening network of 
laboratories, both here in the United States and around the 
world. These steps, along with capacity in place as a result of 
effective planning, have allowed for the rapid diagnostics in 
epidemiology that have contributed to a clearer understanding 
of the transmission and the current severity of illness caused 
by the virus. These scientific accomplishments have provided 
the basis for an evolving set of responses that greatly enhance 
our Nation's ability to address this threat. CDC has determined 
that this virus is contagious. It is spreading from human to 
human, similarly to the way that seasonal influenza spreads 
through causing or sneezing.
    Sometimes people may become infected by touching something 
with a flu virus on it and then touching their mouth or nose. 
There is no evidence to suggest that this virus has been found 
in swine in the U.S. and there have been no illnesses 
attributed to eating pork or pork products, so there is no 
evidence you can get this influenza from eating pork or pork 
products. As of this morning, according to the World Health 
Organization, a total of 1,516 cases have been confirmed in 22 
countries, including Guatemala, which was added to the list 
today. Here in the U.S., we have 403 confirmed cases and 702 
probable cases for a total of 1,105. Aggressive actions are 
being taken here as well as abroad.
    We are working very closely with state and local health 
officials around the U.S. to investigate and implement control 
measures. We are providing both technical support on the 
epidemiology, as well as laboratory support for confirming 
cases. We are working with our international partners on this 
outbreak, including a collaborative effort in Mexico to better 
understand the outbreak to enhance surveillance and strengthen 
laboratory capacity, and we are working closely with multiple 
Federal partners to ensure that our efforts are coordinated and 
effective.
    Yesterday we updated our guidance on school closings based 
on a more clear understanding of the severity of illness. A key 
message we have from CDC is that there is a role for everyone 
to play during an outbreak, at the individual level for people 
to understand how they can prevent respiratory infections, with 
frequent hand washing, staying home if you are sick, keeping 
your children home if they are sick and if you are ill not 
getting on an airplane or taking public transport where you may 
spread the infection. We think that personal responsibility for 
these things will help reduce the spread of this new virus as 
well as other respiratory illnesses. The path this outbreak may 
take may change and we need to be prepared for a return of this 
virus here in the U.S. in the fall.
    It is important that public officials continue to think 
about what might be needed if this outbreak deepens in 
communities here in the U.S. We have encouraged communities, 
businesses, schools and local governments to make specific 
plans for how to manage this outbreak if cases appear in their 
communities and advise parents to prepare for what they would 
do in terms of their own children's illness. We continually 
monitor the path and severity of the outbreak and have adapted 
our guidance accordingly, as we did yesterday with the change 
in our school guidance. We are mindful that science is a 
critical component in decision making about how communities 
respond and that there are many other considerations that 
communities must evaluate in making appropriate decisions. 
Whenever we see a novel strain of influenza, we begin to work 
toward the development of a vaccine in case one will need to be 
produced.
    CDC is working to develop a vaccine seed strain specific to 
this novel virus, the first step in manufacturing. We have 
initiated steps so that should we need to manufacture a vaccine 
in terms of the U.S. Government's role we can work toward that 
goal very quickly. And rapid progress will be possible through 
the combined efforts of CDC, NIH, FDA, BARDA and the 
manufacturers. Another critical component of our response has 
been our deployment of the strategic national stockpile of 
medications and personal protective equipment.
    Finally, it is important to recognize that with the strong 
support of the Congress, there have been enormous efforts in 
the U.S. to prepare for this kind of an outbreak and a 
pandemic. Our detection of this strain in the U.S. came as a 
result of that investment and our enhanced surveillance and 
laboratory capacity are critical to understanding and 
mitigating the threat. The investments made in global health 
and development will prove crucial pieces of the global health 
system that will be needed to respond.
    While we must remain vigilant throughout this and 
subsequent outbreaks, it is important to note that at no time 
in our history have we been more prepared to face this kind of 
challenge. And as we face the challenge in the weeks ahead we 
look forward to working closely with you in the committee and 
Congress in general to best address this evolving situation. 
Thank you.
    Mr. Payne. Thank you very much.
    [The prepared statement of Dr. Schuchat 
follows:]Schuchat deg.















    Mr. Payne. Dr. Fauci.

STATEMENT OF ANTHONY FAUCI, M.D., DIRECTOR, NATIONAL INSTITUTE 
  OF ALLERGIES AND INFECTIOUS DISEASES, NATIONAL INSTITUTE OF 
                             HEALTH

    Dr. Fauci. Thank you very much, Mr. Chairman, Ranking 
Member Smith, members of the committee, thank you for calling 
this hearing and thank you for giving me the opportunity to 
briefly describe for you today the role of the NIH's research 
efforts in addressing the problem that we are facing now with 
the H1N1 new novel influenza A. On this first visual I would 
like to first take a brief moment to describe the difference 
between what we call seasonal flu and pandemic flu. As you see 
on this visual, the influenza virus is made up of a number of 
components. We identify influenza by two proteins on its 
surface called hemagglutinin and neuraminidase, and hence, the 
terminology H and N and the designation here of H1N1; and 
seasonal flus also have H3N2.
    Each year, we have a relatively predictable annual 
occurrence of seasonal flu that from one year to another may 
modify slightly in what we call a drift, a little bit different 
from one year to another, which necessitates sometimes a 
modification of our seasonal influenza program for vaccination. 
However it doesn't change enough to leave the population 
vulnerable with no background immunity. Rarely in the last 
century--three times--we have a major change which we refer to 
as a shift. This situation is unpredictable. And the population 
is naive to this particular virus because they have never had 
any personal experience with it. That is the case that we are 
facing now with the novel H1N1.
    But before we go on, it is important to put into context 
seasonal influenza which is underappreciated as a serious issue 
with 36,000 deaths each year in the United States and about 
200,000 excess hospitalization and significant economic impact. 
The concern we all have is that will this turn into a pandemic. 
So if you look on this slide here, there were three historic 
pandemics in the 21st century. One which was catastrophic, the 
1918, what we call Spanish flu, in which about 50 million 
people died worldwide. In 1957 was another new virus that was 
moderately severe. And in 1968 was the first time we saw the 
H3N2, which, in fact, was relatively mild in the sense that it 
wasn't significantly different than what we see in a regular 
seasonal flu.
    So the point to be made is that pandemics occur for sure, 
but they vary widely in their degree of severity. So now 
quickly moving on what about the NIH and what we are doing in 
partnership with our sister agencies, the CDC and the FDA, our 
responsibility is the basic and clinical research. As shown on 
this slide, what we do is founded in a basic research study and 
research resources which we make available to the academic 
research community and the pharmaceutical companies. We also 
have clinical research networks that allow for clinical trials. 
All of this is directed to the ultimate goal of developing 
countermeasures in the form of therapeutics, diagnostics and 
vaccines. So, quickly, we will start with basic research.
    The CDC, as you have heard from Dr. Schuchat, has already 
isolated and characterized the virus and made it available to 
the NIH as well as to giving us the opportunity to make it 
available to our grantees and contractors to study intensively. 
And when we say study intensively, we do sophisticated work on 
delineating the molecular analysis or the molecular 
fingerprints that might predict which way this virus may go, 
because as you have heard, it is quite unpredictable; studies 
on transmissibility in animal models such as the mouse, the 
ferret and the nonhuman primate; how the virus might 
molecularly evolve; and importantly its pathogenesis and 
virulence, what are the molecular correlates for it being a 
very virulent virus or not; and finally, relevant to vaccine 
development, what kind of immune response does it elicit and 
what kind of immune response is protective.
    On the next visual, you see the map of the United States 
showing the network of a Vaccine and Treatment Evaluation Units 
which will be used in clinical trials of pilot lots that will 
be made from the seed viruses that the CDC is now growing in 
preparation for the multi-step process of developing a vaccine, 
which is shown on this next slide. It is a very well-delineated 
process that we go through when we develop a vaccine for any 
microbe, in this case, influenza. First you get the virus. The 
CDC has done that. You start to grow it up as a reference 
strain or aseed virus. This allows the further growth. And in 
this case we get that seed virus which is currently now being 
grown by the CDC and will be made available to the 
pharmaceutical companies to grow up for what we call pilot 
lots.
    A pilot lot is tested in humans for three things: Is it 
safe, does it induce an immune response that you would predict 
would be protective, and thirdly what is the right dose and 
dose regimen, how many doses would you need? The decision to 
scale up and manufacture tens of millions of doses has not been 
made at this point, nor has any decision been made regarding 
the administration. We are just in the early part of the step-
wise process of developing a vaccine. And on this final slide I 
just want to reiterate what we said in the very beginning. The 
relationship between the preparedness of seasonal influenza 
versus pandemic influenza. What we learn from one we apply to 
the other and vice versa. We had a pandemic plan from 2005 
which we have implemented. And the resources that have been put 
in thanks to the Congress and your support for us have allowed 
us to be at the level of preparedness where we are right now. 
Thank you very much. I would be happy to answer questions 
after. Thank you.
    [The prepared statement of Dr. Fauci 
follows:]Fauci deg.































    Mr. Payne. Thank you very much.

   STATEMENT OF DENNIS CARROLL, M.D., SPECIAL ADVISOR TO THE 
  ACTING ADMINISTRATOR, ON PANDEMIC INFLUENZA, UNITED STATES 
              AGENCY FOR INTERNATIONAL DEVELOPMENT

    Dr. Carroll. Chairman Payne, Representative Smith and other 
distinguished members of the subcommittee. First off, I would 
like to thank you for convening this committee. I think we all 
appreciate its significance and certainly the topic which 
brings us here today. But I would also like to extend the 
thanks of USAID to this committee for the strong support you 
have provided over the years to our global health program. In 
my written comments, I discuss at some length USAID's response 
to the recent events in Mexico as part of the larger effort by 
the United States Government.
    In these remarks today I would like to focus more 
specifically on two aspects of USAID's overall effort to 
address the threats posed by a pandemic with a particular focus 
on USAIDS deg.'s primary responsibility as the 
international response and humanitarian assistance role that we 
have. USAID has been helping to prepare for just such an event, 
as we have seen rollout over the last several weeks, over the 
past 3 years. And as a previous talker have referred to the 
efforts underway having to do with H5N1 avian influenza, work 
that we have been doing since 2005 specifically supported by 
this Congress, have really established a platform which has 
allowed significant capabilities that otherwise had not 
previously been available.
    What I would like to do is to just talk about some of those 
capabilities today and how they may play themselves out in the 
coming months. First off, in terms of a pandemic preparedness 
program focusing on global response capabilities: USAID has 
partnered through a U.N. family of agencies, the International 
Federation of Red Cross and Red Crescent Societies and a 
coalition of humanitarian response nongovernmental 
organizations to work with WHO, our colleagues at Centers for 
Disease Control and other international partners to focus on 30 
countries in Asia, Africa and Latin America that have been 
specifically identified as countries of high risk consequences 
in terms of a potential pandemic. And with these countries we 
have been working to mobilize pandemic preparedness planning. 
Whereas coordinated efforts to respond to disaster such as 
pandemics usually begin only after the disaster has occurred, 
the concerns of a global pandemic caused by avian influenza 
created an unprecedented opportunity to develop planning and 
coordination for a pandemic in advance of the event.
    Because of this work, a developing country's ability to 
respond to a pandemic today while still far from perfect will 
be both better and faster than it otherwise would have been 
possible in years past. While the world remains at Phase 5 
USAID is engaged in several critical activities to help monitor 
the progress of the H1N1 novel virus and assist countries in 
preparing for a possible Phase 6 pandemic. These activities 
include testing--first off, testing the appropriate of national 
pandemic plans. Just last week, USAID supported a regional 
pandemic readiness exercise as part of our avian and pandemic 
preparedness program in Addis Ababa, Ethiopia. Country 
representatives from seven east African countries were able to 
draw from their experiences developing national pandemic plans 
to test them in real-time context of a possible H1N1 pandemic. 
We have similar exercises already planned for South African 
countries in June and Asian countries in August. In addition, 
USAID is working closely with the Department of Defense and its 
specific and African combatant commands PACOM and AFRICOM to 
provide direct military-to-military assistance in these 30 
countries across Africa and Asia to strengthen their own 
readiness, the readiness of the military to work in concert 
with civilian authorities to ensure the military is fully 
prepared and capable of executing their responsibilities during 
a pandemic.
    And in just 2 weeks as part of USAIDS deg.'s 
pandemic preparedness program USAID will co-host with AFRICOM 
and PACOM and the U.N.'s world food program a joint pandemic 
preparedness exercise in Rome involving 27 countries and their 
military representatives from Africa and Asia. USAID will also 
continue to support activities that directly contribute to 
tracking the circulation of the novel H1N1 virus in both human 
and swine populations worldwide.
    As noted by President Obama, even if it turns out that the 
H1N1 virus is relatively mild in the front end, it could come 
back in a more virulent form during the actual flu season. It 
is important to note that in the 1918-1919 influenza pandemic, 
which also began the virus emerged first in the spring 
relatively mild for 6 months until the second pandemic wave 
revised in a much more lethal version that October. With the 
advent of influenza season in the Southern Hemisphere now it 
will be critical that we are able to monitor changes in the 
virus' virulence and transmissibility and mobilize effective 
response should it occur.
    USAID has also as part of its avian and pandemic influenza 
program, which we have now adapted to our H1N1 novel virus 
response, established an emergency stockpile of more than 
800,000 personal protective equipment kits, PPEs that include 
protective gowns, gloves, goggles and masks, 100,000 of which 
just this past Saturday arrived in Mexico City, the remaining 
being equivalently ready for rapid deployment as needed. These 
kits protect health care providers as well as case 
investigators.
    To date USAID has also prepositioned an additional 400,000 
kits in 82 countries for use in the event of a pandemic. But 
even as we mobilize to respond to the threat of H1N1 or the 
earlier emergence of the H5N1 avian influenza virus, it is 
important that we appreciate that their emergence is indicative 
of a broader dynamic that over the past half century has given 
rise to a steady stream of new and increasingly deadly diseases 
that originate in animals. In fact, 75 percent of all new 
emergent diseases that have emerged in the past 50 years their 
origin are animal.
    Having already identified this rising threat as a major new 
area of focus USAID coincidentally announced last Wednesday at 
a conference we had organized a new emerging pandemic threats 
program using Fiscal Year 2009 monies which we plan to have 
fully launched by October of this year, this program which we 
will initiate in strong collaboration with our colleagues from 
the Centers for Disease Control and prevention, as well as our 
colleagues from the U.S. Department of Agriculture, is intended 
to support the development of a global early warning system for 
the threat posed by diseases of animal origin that infect 
humans.
    The objective of this new program is, in fact, a preempt 
for combat at their source the emergence of new diseases of 
animals such as H5N1, H1N1 or even the earlier SARS or HIV that 
pose significant threats to public health. I need to be very 
clear that this effort builds on the agency's ongoing work for 
H5N1. Clearly the platforms which have been supported by this 
Congress to respond to H5N1 has given us new capabilities and 
understandings to address these threats and mobilize a global 
response that should allow us to better predict and respond and 
in effect put the canary back in the mine shaft.
    In closing, let me say that even as we do not yet know how 
severe the novel H1N1 pandemic will be or how long it will 
last, as the lead U.S. agency for foreign disaster assistance 
we will continue to provide emergency support to countries in 
response to this threat. However, even in the face of the 
immediate threat posed by H1N1 recent history has been very 
clear on a core lesson, we must remain vigilant in our response 
to the larger threat posed by emerging pandemic diseases if we 
are to be able to ensure a secure future for the world's 
population. Thank you very much.
    [The prepared statement of Dr. Carroll 
follows:]Carroll deg.











    Mr. Payne. Let me thank all of the panelists for your very 
insightful testimony. I will yield to the gentlelady from Texas 
who says she has to leave to conduct a hearing herself. And 
because of the death of a Texan, I will yield to let her ask a 
question before she leaves.
    Ms. Jackson Lee. Thank you, Mr. Chairman. I will, in 
essence, put these two questions on the record and probably 
will not be able to be here for the response, but I would 
greatly appreciate the response because I believe Texas has 
been the epicenter, particularly for its proximity to Mexico in 
the increasing number of cases that we seem to be determining. 
One, what will be the reimbursement procedures for health 
facilities, the clinics and city and county health entities 
that have been in the midst of this? And I convened a meeting 
of these individuals last Friday and they do have a long 
litany. Two, will you continue to provide the, I believe it is 
the laboratory resource network 1-day testing confirmation 
which is urgent?
    And three, will you as we move into the graduation season 
our school districts in Texas, universities, are in a flux 
about whether or not these large venues will be allowed to 
continue? And I would very much thank you for the answers to 
those questions. Mr. Chairman, thank you very much and I yield 
back.
    Mr. Payne. Thank you. We will now hear from the ranking 
member, Mr. Smith, and then we will hear from Representative 
Woolsey who also indicated she has to leave. If you want to go 
first Mr. Smith said that he would yield to you.
    Ms. Woolsey. I don't have to go right yet. I have about 5 
minutes.
    Mr. Payne. All right. Then I will yield to the ranking 
member.
    Mr. Smith. Thank you. Again, I want to thank our very 
distinguished witnesses for the great work you are doing, but 
also the insights you are providing to the committee today. 
First, Dr. Carroll. The USAID reported that the humanitarian 
pandemic preparedness initiative convened a 3-day conference or 
exercise to improve the capacity to avert and respond to the 
pandemic in east Africa. You indicated that some other similar 
types of exercises are likely to occur. What kind of 
deficiencies are we gleaning from that exercise as they exist 
among some of these countries? You talked about some 800,000 
personal protective equipment kits being deployed. And I would 
suspect that is for the health care workers especially so that 
they can go out and do their work without contracting the 
disease. But what was learned in terms of any gaps that need to 
be fixed from those exercises.
    Dr. Carroll. Congressman Smith, thank you very much for 
this question. And in fact, it is an important one because from 
a humanitarian response perspective, having the opportunity to 
prepare for a disaster in advance is a rare opportunity. For 
tsunamis or earthquakes, we are usually in a reactive mode. And 
one of the critical challenges and frequently one of the 
critical failures of an emergency disaster response is poor 
coordination. One of my colleagues who specializes in emergency 
response has frequently commented that when they write on the 
death certificate, the cause of death, more often than not, it 
should not be malaria or diarrhea, it should be poor 
coordination.
    I say that point because the exercises in Addis Ababa and 
shortly in Johannesburg, and then in Ho Chi Minh City are 
intended to bring national authorities together across civilian 
nongovernmental and military representatives to arc out and 
clearly identify roles and responsibilities, to establish in 
advance coordination principles, and to ensure that the lines 
of authority and the lines of appropriate action are there, 
understood and that they have an opportunity in these meetings, 
such as we just hosted in Addis Ababa, to go through a 
simulation exercise that allows them to test their plans, 
identify their weaknesses and then to be able to further 
improve and refine.
    The other advantage of these meetings, these regional 
gatherings is that there also is significant issues having to 
do with cross-border movement of populations. And these fora 
also offer that opportunity for national authorities to 
interact with each other and to identify what might be some of 
the critical issues which certainly have arisen in our own 
situation between the United States and Mexico.
    So those are the key issues. I can say Addis Ababa 
certainly benefited by the timing from H1N1. And we look 
forward to certainly the activities rolling out in Johannesburg 
and Ho Chi Minh City, and as I mentioned, we have a similar 
exercise in Rome with respect to the mill-to-mill activities as 
well.
    Mr. Smith. Just one quick follow-up. I have some more for 
the second round. Is any special attention being paid to those 
countries where the system really is broken, particularly in a 
dictatorship, particularly in a place like Sudan which could 
quickly find all of its current problems exacerbated and 
exponentially confounded by--or compounded, I should say, by a 
pandemic breaking out.
    It seems to me that the vulnerable become even more 
vulnerable. And what provision--we are talking about 
stockpiling Tamiflu and other kinds of interventions to help 
alleviate those who contract it. The developing world and the 
poor, will they have access to those as well.
    Dr. Carroll. Well, let me say two things: Part of the issue 
that you talked about was the ability to deliver, delivery 
services. That is one of the reasons we have gone into a 
partnership for instance with the International Federation of 
Red Cross and Red Crescents. They frequently act as a 
parastatal responsible for humanitarian response. And clearly, 
when you think about Sudan, they have a critical role to play 
in countries where governance is clearly an issue. In terms of 
the services that are looking to be provided, we are right now 
going through our Fiscal Year 2009 budget, and in particular, 
looking at our avian and pandemic influenza resources, to see 
to what extent we might be able to free up resources with an 
eye toward being able to make immediate contributions to the 
kind of expanded commodity support beyond that related to the 
protective equipment that we already have.
    And so we are working closely with our colleagues at 
Centers for Disease Control to identify what those resource 
needs might be and then look at how we might best be able to 
address both pharmaceutical and nonpharmaceutical as well as 
delivery competencies.
    Mr. Payne. Thank you very much. Representative Woolsey.
    Ms. Woolsey. Thank you, Mr. Chairman. Somebody has to help 
me with this, and I think you can, because I don't think I am 
the only one that is looking for the big picture in questioning 
how when we have for the seasonal flu 3 million to 5 million 
people getting the flu every year and internationally 250,000 
to 5,000 people dying.
    In the United States, the average is 36,000 deaths from 
seasonal flu. And so far this year, 13,000 deaths. Okay, where 
along this H1N1 line, where do we get to the point, and what 
are you looking for until this becomes ho-hum seasonal flu. I 
mean, because it just seems out of context. Go ahead, Dr. 
Schuchat.
    Dr. Schuchat. Seasonal influenza does have a large toll on 
health in the United States, despite the fact that we vaccinate 
many people for it, and that many people are immune already 
because of exposure to similar viruses. The difference with a 
new influenza virus like what we see right now is that we don't 
expect very many people in the general population to already be 
protected.
    So it means everybody is vulnerable. Your question of 
whether this particular new virus is going to look like 
seasonal influenza in terms of that 36,000 deaths in the U.S. 
will it look worse than that, substantially worse than that or 
not that bad, we unfortunately don't know.
    We know that this influenza virus can cause severe disease 
just like the seasonal strains can, and we know that it is 
easily transmissible, as we have seen in the New York City 
school outbreak, and so forth. But we don't know whether over 
the weeks ahead it will just fizzle out or not come back in the 
fall season or whether it will mutate and become a bit more 
severe or whether it will have a similar amount of severity as 
it has right now. If it keeps this similar severity, we are 
concerned that among the people who are sick and who are 
becoming hospitalized are younger persons who don't usually get 
hospitalized with flu, seasonal flu.
    So unfortunately, we don't have that crystal ball and with 
influenza, a new strain in particular, our predictions really 
need to be cautious.
    Dr. Fauci. Just to add to that, Congresswoman Woolsey, as 
we have said all along, influenza viruses are inherently 
unpredictable anyway. When you have a virus that you have never 
had experience with before, that compounds the 
unpredictability. So I don't think any of us are going to feel 
this will become ho-hum, as you said. We have to continue to 
watch what it is doing and what happens in the fall and winter. 
So there are a lot of things that we are still uncertain about, 
as Dr. Schuchat said. So I don't think this will become a ho-
hum thing. Even if it remains relatively mild and acts like a 
seasonal flu, we are going to be watching this very carefully.
    Ms. Woolsey. Mr. Chairman, just a remark because I do have 
to leave. I was in Tanzania over the Easter break. The women 
giving birth have to bring their own gloves to the clinics and 
their own supplies. How are you going to distribute these kits? 
I just can't see how that can happen.
    Dr. Carroll. Thank you. Congresswoman, obviously it is a 
challenge. There is no question about that. Africa has been a 
remarkable challenge in terms of meeting the infrastructure 
needs, and the human resource issues plaguing the health 
systems there are enormous. Quality control issues are a major 
challenge. Let me say we have drafted an initial plan about 
service delivery, part of it having to do with infection 
control within health facilities, within the various settings 
that you are talking about. So part of this review we are going 
through right now is to really focus in on those countries 
where we feel the vulnerabilities are greatest and what lines 
of action questions take. Infection control, as you were 
describing, right now is clearly a major issue. So we will be 
working with our international and U.S. colleagues to assess 
how we can most effectively do this in an environment, as you 
know, that is very, very challenging.
    Ms. Woolsey. Thank you, Mr. Chairman.
    Mr. Payne. Thank you. Congresswoman Lee.
    Ms. Lee. Thank you very much, Mr. Chairman, and good 
morning. I want to thank all of our witnesses for being here 
and presenting your very clear and succinct testimony. Let me 
ask you, going back to the continent of Africa, noting that 
there have been no reported H1N1 diagnoses, surveillance we 
know is an issue on the continent. What health care systems in 
terms of labs, in terms of health care workers is an issue? 
Infrastructure. What do you think is going on on the continent? 
Can we anticipate cases or do we believe that for whatever 
reason there just are no cases on the continent of Africa, and 
also what should we be doing?
    And I was just reading the President's statement, which I 
think is a great statement, and I am going to also commend him 
for his leadership because we all recognize that not only is 
this a public health emergency and a humanitarian crisis, but 
also a national security issue that we have to recognize as 
such. And this is the way to address it within a comprehensive 
fashion. So in terms of the continent of Africa, what do you 
think are some of the key investments that we need to make to 
really begin to address this in a big way in terms of the 
spread of this disease and other diseases, and also what do you 
think the real reason is that we don't see any signs yet on the 
continent? And none of the countries, as I look at this chart, 
have any cases at all.
    Dr. Schuchat. I can start with the issue of what is going 
on in Africa. One of the values of the investments that have 
been made in global health is the international network that we 
have on--the CDC has people in over 45 countries working on a 
variety of issues, things like PEPFAR, polio eradication, 
measles, and our Global Disease Detection Program, and we have 
been holding very frequent phone calls with all of our 
international staff to both share information of what is going 
on here and learn from them situational awareness of what is 
happening. Also they have facilitated our providing these 
diagnostic kits for the new virus so laboratories in some of 
these countries will be able to test right there without 
shipping to one of the WHO labs or here to the U.S. at the CDC. 
We don't yet have confirmed cases from Africa, but I share your 
suspicion that that doesn't mean they haven't happened yet. 
There are lots of variables in terms of temperature and 
populations and travel.
    So where the disease has been confirmed so far, it has been 
related initially to travel exposure to Mexico. At this point, 
with disease in the United States and Europe and New Zealand 
and many other places, the risk for Africa continues. So one of 
the issues is how do we find out what is going on, and I think 
that is through our investments in laboratory capacity, 
epidemiologic capacity, training, so that the next generation 
in these countries will be able to detect and respond, 
communication and information technology, so that we can know 
what is going on and share that information, and really the 
governance that allows the different networks to interact. We 
are working not just with the CDC network, with the WHO 
network, with Pasteur Institute, of course with the USAID 
missions.
    So I think that--and then the other comment is that some of 
Africa is in the Southern Hemisphere, where we would expect a 
reverse season from what we are seeing. In particular, we have 
a strong collaboration with South Africa, which does have very 
good laboratory capacities, and that is a place we are going to 
be looking intensively to understand whether this virus emerges 
in the summer.
    Mr. Carroll. And if I might add to the answer, I think it 
is reasonable to assume that this virus will show up in the 
subcontinent of Africa. The problem of detecting it will be 
significant. There are steps--your question really had a two-
part component, temporal component. What can we do now to make 
sure we can pick up this virus at the earliest possible moment 
for the purposes of being able to track it, monitor it, and 
deliver life saving interventions as needed? But the second 
part of your question had to do with seeing this as symptomatic 
of a broader array of challenges within Africa in terms of 
picking up new diseases and being able to respond.
    Specifically, I can tell you two things about that from 
USAID's side and again with our partnership with Centers for 
Disease Control. We are looking to have a consultation with CDC 
next week that will hopefully include WHO and FAO. That will 
identify immediate actions that we can take and part of this 
reprogramming of some of our resources will be specifically 
asking: How can we make investments immediately with resources 
on hand to increase the likelihood of picking up this virus? So 
create a better, more focused and coordinated effort toward 
that end.
    The second part of the question has to do with the broader 
issue of being able to pick up diseases before they become 
large public health threats within the region. I mentioned to 
you that we have launched an Emerging Pandemic Threats Program. 
This is a 5-year down payment program that has as a central 
part of it investing in a network of laboratories within 
Africa, specifically intended to increase our ability to 
diagnose both within animal and human populations new emergent 
pathogens that we will be in a better position to signal when 
something novel is occurring and help us to more effectively 
respond. So that is part of a systems approach toward 
responding to the larger, more long-term challenges.
    So two-part, immediate consultations, reprogramming funds, 
and creating an opportunity to diagnose now and take 
simultaneous steps for the longer term.
    Mr. Payne. Thank you very much. At this time, we will hear 
from Congresswoman Watson.
    Ms. Watson. Thank you, Mr. Chairman. And one thing I would 
ask of the witnesses, can you get to the media and ask them to 
stop identifying this as Swine Flu? I think that educating the 
general public about this new strain is very, very important. 
And as I monitor the media, both written, television, and 
radio, they are referring to it--that gets people in an uproar, 
and it is not Swine Flu. So if you could help us with that, I 
would appreciate it.
    Let me direct this to Dr. Fauci. I understand there are two 
vaccines already, Tamiflu and Relenza, that are on the market 
that are sensitive to H1N1. But how close are we--and all of 
you can jump in--to finding a particular vaccine that would be 
specific to H1N1?
    Dr. Fauci. Thank you for the question, Congresswoman 
Watson. Tamiflu and Relenza are treatments that are used to 
treat people who get infected to mitigate the severity of 
disease, and sometimes used as prophylaxis to prevent. Your 
question about vaccines is one that we have already started the 
process on, the multi-step process toward developing a vaccine. 
And as this--I don't think you heard it in my opening 
statement, but very briefly what happens when you get into a 
situation like this is you isolate and characterize the virus. 
The CDC has already done that. They are currently in the 
process of developing what we call reference strains or seed 
viruses. Seed viruses are grown up for the purpose of 
collaborating with our pharmaceutical company partners, to give 
it to them so that they can start growing it up in large 
amounts for two reasons, sometimes in parallel. It is to 
develop what we call pilot lots of a vaccine. We are not there 
yet because we are still at the process of the seed virus 
growing up to be able to give to them. Pilot lots are then put 
into what we call clinical trials by the company themselves or 
more often than not by the NIH's clinical trial network to 
determine three things. Is it safe, does it induce the kind of 
immune response that would be predictive of being protective, 
and what is the right dosage and number of doses? At that point 
then you have the option, a decision that has not yet been 
made, of scaling up a manufacturing, what we call manufacturing 
scale-up of tens of millions of doses. You then make a decision 
at an another critical point in that process--what you are 
going to do with it. Are you going to administer it, what are 
you going to do? So right now the very earliest of the stages 
of that step-wide process has already begun.
    Ms. Watson. Thank you for the information. I am a bit 
confused as to who is most susceptible. Is this H1N1 a flu or 
strain of flu running across age levels or young people, middle 
age, older people? I have heard several different things over 
the media.
    Dr. Schuchat.
    Dr. Schuchat. Sure. Of the cases that we have confirmed 
here in the United States, they are primarily in the age groups 
of 5 to 50. This is different from the usual influenza season 
where we see a lot of disease in seniors as well. We don't know 
yet whether this disease will become quite common among older 
persons or whether people over 50 may have some protection 
against this virus, perhaps because of viruses they saw when 
they were young or perhaps because of other factors. But it is 
also possible that in the U.S. the virus first emerged in 
teenagers and young adults and their social networks are such 
that they are spreading to each other before we eventually see 
disease in older age groups.
    So right now we don't see the pattern of lots of 
hospitalizations in very older people and very young people. 
Even the hospitalizations that we have primarily are in that 
group of 5 to 50.
    So it is confusing because the seasonal flu doesn't look 
that way in terms of the risk groups we talk about. I would 
say, though, that we do have some information already that 
people with underlying medical problems might be at higher risk 
in terms of our hospitalization data. It is very preliminary, 
but as we review those data we do note that some of the people 
who are requiring hospitalization have underlying medical 
problems that would be classical risk factors for influenza.
    So unfortunately, I gave a really long answer, 
unfortunately it is early and things may change. But right now 
we have a little bit of difference with the seasonal flu and a 
little bit of similarity with the underlying diseases.
    Ms. Watson. And finally, some of the schools--I am out in 
Virginia--are opening back up. Parents are very confused and 
they want to be able to plan their lives, and I know that is 
kind of improbable at this particular time. But some of the 
smaller schools, the private schools are staying closed.
    What does that indicate?
    Dr. Schuchat. This is a challenging time for families and 
communities because information is changing quickly and of 
course when our children are involved that hits right to the 
heart. The CDC has been working with the State and local public 
health officials on the response. We issue guidance to--always 
saying that local and State decisions really are important 
because of the circumstances in the community, the locals have 
so much more information than we do. Yesterday we announced 
updated guidance that the schools that were closed could reopen 
and that people could really focus on making sure sick children 
stay home and that the teachers and parents are attuned to 
whether their children are ill and we try to keep the ill 
children out and let the other children benefit from school and 
school lunches, and so forth.
    So I think it is a challenging time and each of those 
school authorities are making decisions hopefully in 
conjunction with the local public health officials. There are 
other circumstances, like whether the teacher has left town and 
is able to be back and reopen. So I do think in the next 
several days there will be variability. And we want to make 
sure that as we find information we get it out and people can 
react appropriately.
    Ms. Watson. Thank you. Thank you, Mr. Chairman.
    Mr. Payne. Thank you. Dr. Schuchat, you mentioned in your 
testimony that CDC funds over 30 countries in pandemic 
preparedness to improve their ability to detect and respond to 
pandemic flu. Would you be able to tell us generally what 
countries these are that you are funding?
    Dr. Schuchat. Yes. We actually--I believe for influenza we 
either directly or indirectly support more than 50 countries. 
Some of that is through a person assigned to work in the 
country, either with the World Health Organization or the 
Ministry of Health. Some of that is through cooperative 
agreements where we provide funding for the countries and some 
of it is through networks that we are part of. We can provide 
the committee a list of the countries. Originally we had some 
priority countries related to where the H5N1 virus, the avian 
flu virus, was emerging, primarily in Asia and some in Africa. 
We have actually expanded to make sure that we have support 
really to all of the developing country regions, often through 
the World Health Organization regional offices, sometimes 
through PAHO.
    So even though our eyes were really keenly pointed toward 
Asia, we have been working with Latin America on the pandemic 
preparedness. But we will be able to offer you a list of the 
individual countries. We do have a number of countries in 
Africa, and we have 11 countries in the Southern Hemisphere 
that have gotten support from us.
    Mr. Payne. In Europe, what organization do you work with? 
Is it through the EU or individual countries? What is their 
CDC/NIH component? Is it the European Parliament?
    Dr. Schuchat. There are a number of organizations, and of 
course that is one of the important aspects of this, is 
coordinating across the governments. We work with the World 
Health Organization working in all regions. We also work with 
the European CDC. Our CDC in Atlanta has secunded an influenza 
expert to the European CDC in Stockholm, and we have been 
working very closely with our colleague there over the 
situation in Europe. We also have liaisons assigned to the FAO 
and the OIE related to all of this human-animal interface work 
and understanding what is going on in the animal populations 
around the world as well as in the wildlife.
    So I think that we are trying to stay connected. A lot of 
the leadership globally comes from the World Health 
Organization in Geneva with the Director General Margaret Chan.
    Mr. Payne. I think I heard you mention some of the 
military-to-military, AFRICOM, and so forth. Is there any 
component in NATO since that tends to be a quasi-political 
although military organization? Have you worked with them in 
this area?
    Mr. Carroll. Thank you, Chairman. We have not worked with 
NATO. The reason we are working with AFRICOM and PACOM is that 
we did essentially a risk analysis. Were there a pandemic virus 
similar to the one that emerged in 1918, and I can say we did 
this with the Central Intelligence Agency, we basically 
identified how that might play itself out around the world in 
terms of mortality and morbidity using a variety of modeling 
factors. Those countries largely fall within the Africa and the 
Asia region. Our focus is clearly going after where the risk is 
greatest, the burden is maximum.
    So where we entered into the agreements with PACOM and 
AFRICOM is with a focus toward those countries in that region 
where the vulnerability is greatest. With respect to NATO, that 
is not something we have direct engagement with.
    Thank you.
    Mr. Payne. Now, with H5N1, everyone was expecting it to 
come back. And in Egypt, where I think there was a real problem 
with that, it seems that they went and killed 350,000 pigs. Do 
you think it is an overreaction or is it tied into their fear 
of the H5N1 and whether there could be a connection between 
H1N1 and H5N1?
    Mr. Carroll. Again, thank you, Mr. Chairman. Let me first 
off say in terms of the Government of Egypt, we have a very 
strong and very good program with them, specifically with 
respect to H5N1, and they have shown extraordinary leadership 
and effectiveness in their program over the last couple of 
years. The events over the last week where swine throughout 
Egypt have been targeted quite frankly is an unfortunate one. 
There has been no documentation of H1N1. It clearly is an 
overreaction at this point. And there is no apparent public 
health value.
    We have been in direct consultation with the Government of 
Egypt with respect to this issue, and we will continue to do 
so. But our focus remains strengthening their H5N1. And even as 
we talk about H1N1, this is an issue of H5N1 that we need not 
lose focus on. It remains a very dangerous virus, mortality 
rates continue to be in excess of 60 percent. And if I may just 
add, H5N1 has been one of those success stories over the last 
couple of years. Were we sitting here 3 years ago in 2006, we 
would be talking about 53 countries with reported, confirmed 
outbreaks of H5N1. We have just finished what is in effect the 
H5N1 transmission influenza season end of April. This past 
2008-2009 influenza season, that number has gone from 53 down 
to 9 countries, and of those 9 countries, 4 countries account 
for 95 percent of all outbreaks involving animals or humans. So 
there has been a tremendous progress in terms of moving this 
virus back, and the platforms that have been invested in for 
surveillance, for coordinated response, for communications, for 
laboratory strengthening, those are the very platforms we are 
looking now to adapt in other parts of the world where the H5N1 
is less of a risk now to this broader agenda of dealing with 
other emergent disease threats.
    So the support you have provided quite frankly has been 
hugely successful, led to huge success with this respect and 
the U.S. Government across the board has played a 
disproportionate leadership role in delivering support for this 
global effort. Egypt continues to be a point of concern.
    Mr. Payne. Thank you. My last question, and I will yield 
back to the ranking member. Dr. Fauci, I am just curious. The 
1918 flu had just come out and, you know, 50 million deaths 
resulted. There was nothing like it before and nothing like it 
after. Is there the potential for another Spanish flu type? Or 
what was so peculiar about 1918? Do you know--I mean, it was 
just unbelievable that it caused more deaths than the war going 
on.
    Dr. Fauci. Well, the answer to that is it gets back to what 
we had been saying just a little bit ago about the 
unpredictability of pandemics, the unpredictability of 
influenza, particularly when you have a brand new virus to 
which the community has never been exposed. That was the 
scenario in 1918 when you had the first H1N1. And as you know, 
historically it came in the spring and was acting in a way that 
was not substantially different than what you would expect from 
a flu. But then it came around in the following fall and 
winter, came back with--as we say, with a vengeance and was 
very devastating. We don't know the reason for that. We have 
studied from a molecular biological standpoint how some of the 
signatures that might be related to virulence or not are 
spread. But it still remains a mystery how and why that 
happened, which is always the case with potential pandemics, 
which is one of the reasons why we are so vigilant now and we 
take this seriously and continue to take this seriously. We 
don't want to get anyone alarmed that it is a 1918 type at all, 
and I don't think we should even be talking about that. But the 
fact is when you are dealing with brand new viruses, influenza 
viruses, to which the population does not have any experience 
with, no background immunity, you have to have an overabundance 
of diligence and caution, which is what you are seeing right 
now in how we are responding right here.
    Mr. Payne. And just the last point, how was the breakdown 
of the 50 million here in the United States and Europe?
    Dr. Fauci. There were 500,000 people in the United States 
who died. The 50 million, 40-50 million were distributed 
throughout the rest of the world. But in the United States, 
there were at least 500,000 people who died in the 1918 
pandemic.
    Mr. Payne. Thank you. And we won't talk about it anymore, 
like you said. We will try to go forward. Thank you.
    Mr. Smith.
    Mr. Smith. Mr. Chairman, thank you very much. Dr. Schuchat, 
if you could with regards to the Global Disease Detection 
Program, the GDD centers in Kenya, Guatemala, Thailand, 
Kazakhstan, Egypt and China, do they operate in a regional 
mode? And are there any countries that are outside of their 
reign of influence?
    Dr. Schuchat. Yes, the intent of the Global Disease 
Detection Centers is to both work with a country through the 
Ministry of Health and also to provide regional leadership for 
training, for laboratory and epidemiologic capacity 
development. At this point, there are six full GDD centers. 
There are a few other sites that are carrying out some of the 
components, but we don't really have the entire globe covered. 
We are making sure that where we do have these integrated 
centers, they are able to provide services way beyond the 
national borders. But there are some gaps probably around the 
world.
    Mr. Smith. For the record could you provide what countries 
to date have not been included in that regional coverage? It 
seems to me an opportunistic infection if all a sudden 
something breaks out and it goes less than it could have been 
detected had we had that kind of surveillance. If you could 
provide that for the record, I would appreciate that.
    With regards to our operations in China, what protections--
and this would be for all of the countries of course. But I 
spend an enormous amount of time working on human rights 
issues, vis-a-vis China, and have grown increasingly alarmed 
about their--I even had a hearing in this room on the 
transplantation of organs, which is done routinely in China 
through the death of the prison or the inmate population. And 
there is great concern that Falun Gong, political prisoners, 
other political prisoners become fodder for experimentation. 
And I am wondering with regards to China in our interface with 
them, what protection, what kind of best practices, ethical and 
otherwise, do we insist upon--and this would go for any of our 
distinguished witnesses--so that human subjects are protected 
and the most vulnerable, someone who is a prisoner, is not 
compelled into signing a disclosure or an informed consent when 
he or she had no ability to resist and then they become the 
subject of an experimentation? How do we protect human 
subjects?
    Dr. Schuchat. The CDC has quite a number of collaborations 
in China, including our Global Disease Detection and Response 
Program there. And when we are involved in activities, the 
international standards for human subjects research are always 
followed. The NIH also probably wants to comment on this, but 
this is a U.S. Government-wide requirement. We are not allowed 
to provide funding to entities that don't follow the 
appropriate institutional review board.
    Mr. Smith. But are we able to exercise a kind of oversight? 
We know that when it came to drugs, there were some serious 
problems with drugs that were manufactured in China, even baby 
toys and children's toys were laden with lead, which raised 
serious problems about quality control. But the record on human 
rights in China is an abysmal record. It is beyond poor. It is 
among the worst in the world. And it would seem to me if we are 
not checking that ethical standards are being consistently and 
aggressively applied, human subjects, especially if we get to 
the point of another Spanish flu-like situation where panic 
sets in and we have got to find an answer to this becomes the 
modus operandi, human subjects could very quickly become 
utilized in experimentation.
    Dr. Schuchat. Yeah. The ethics of what we do is vital, and 
I would say that the exchange in collaborations that we have 
with China are a very positive step in terms of ability to 
influence each other and work in a transparent way. We have 
probably advanced this quite a bit in the past several years.
    Mr. Smith. Could you as a result of this question maybe 
look into it even further? And I raise that again. Again, we 
had a guard testify here who Harry Wu smuggled out of the 
country, who told how they would not kill the prisoner, but 
then they would kill them, he or she, through a capital 
punishment regimen, only after they took the desired body 
parts, mostly internal organs, and we had an enormous amount of 
collaboration for that. And I would hate for us to be less than 
vigilant in ensuring that no human subjects are abused, 
particularly the prison population, political prisoners 
especially.
    Dr. Fauci, did you want to--okay.
    With regards to Russia, are they involved with the GDD 
center? How do we interface with Russia, which could be 
experiencing----
    Dr. Schuchat. One of our centers is in Kazakhstan, so that 
is the regional place. So some of the places we have 
established centers are ones where enhancing capacity would be 
very valuable and other times it has been a place of strategic 
importance. So our work in Russia is not necessarily through 
our Kazakhstan center but more bilaterally at this point.
    Mr. Smith. Just briefly because we are running out of time. 
Dr. Fauci, you mentioned that the H1N1 virus is sensitive to 
Tamiflu and Relenza. But experience tells us that resistance to 
influenza and to viral medications frequently emerges. What 
other potential treatments are in development?
    And finally, Dr. Carroll, refugee populations, the 25-plus 
million who are of interest to the UNHCR High Representative, 
any special concerns being expressed by the UNHCR working with 
WHO, with us, to ensure that we don't get a massive outbreak in 
the close confines of a refugee camp or something like it?
    Dr. Fauci. Let me answer the first question about 
resistance. That is one of the reasons we have a very active 
and aggressive program of drug screening and drug development. 
There are already a number of compounds that are in the 
pipeline, some of which are being tested, some of which are in 
preclinical development to try and, as we say, keep a pipeline 
of drugs available in the eventuality that we might see 
resistance. And we have seen resistance, on and off, to various 
anti-influenza drugs through the regular pandemic flu season. 
Fortunately, we have not been in a situation where there has 
been resistance to all of them. There has been resistance to 
one or the other. But the precise answers deg. to your 
question is that is the precise reason why we have a very 
active drug development and screening program.
    Mr. Carroll. Congressman Smith. Thank you very much for the 
question about the vulnerability of refugee and migratory 
populations. It is clearly a major one. And I mentioned in my 
comments that part of our strategy for pandemic preparedness 
was to enter into an alliance with the family of the United 
Nations that includes, in fact, UNHCR and IOM. In addition to 
the 30 countries that we are working with to develop pandemic 
preparedness plans and test those out, we have been working 
explicitly with UNHCR and IOM to make sure that the large 
populations of refugees that fall within the world have 
adequate planning capability and identification of needs. So we 
have been working very aggressively with them, and it is a 
major part of our effort and they are a major recipient of 
support from us.
    And I might just add that today in Paris, yesterday and 
today in Paris, all of our U.N. and international partners are 
in fact, including UNHCR and IOM, are explicitly addressing the 
issues of refugee populations and migratory populations.
    Mr. Payne. Thank you very much.
    Representative Lee.
    Ms. Lee. Thank you, Mr. Chairman.
    Dr. Schuchat, at the end of your testimony--let me just 
read you one paragraph. You said the government cannot solve 
this alone and, as I have noted, all of us must take 
constructive steps. If you are sick, stay home. If your 
children are sick, keep them home from school, wash your hands, 
take all of those reasonable measures that will help us 
mitigate how many people actually get sick in our country.
    I read this and I said, okay. Is this a teaching moment? 
And I say that because these are standards that we should 
follow each and every day in terms of public health, in terms 
of prevention, in terms of making sure that transmission of 
infections and diseases are reduced.
    And so one is, is this a teaching moment? Can we mount a 
public information campaign so that people understand how to 
prevent the transmission of other types of infections and 
diseases? And also, secondly, is there anything else we need to 
do as it relates to H1N1?
    Dr. Schuchat. Thank you for that comment. The advice about 
hand washing and these sort of basic guidances are prudent for 
this particular virus, but as you say, they are also helpful 
for other respiratory infectious diseases, and we are very 
pleased that the Harvard poll results came out a few days ago 
and said that 59 percent of Americans say that they are washing 
their hands more than they ever did in the past. I think it is 
going to be important to sustain that type of behavior, not 
just when you are fearful because you are bombarded on TV, but 
over the long haul because it can really help a lot of 
infectious disease transmission.
    I think there is another thing we can do long term. It is 
really important for people to know that seasonal influenza is 
an important public health problem. We hope this new H1N1 
strain will not become more severe and cause lots of problems, 
and, of course, we are working aggressively to attend to what 
needs to be done in the short term. But year in and year out, 
36,000 people die from seasonal influenza in the U.S., and we 
do have a better vaccine manufacturing capacity than ever and 
we really want people to know they can protect themselves from 
that infectious disease year in and year out. A lot of steps in 
play for vaccine development work against this new strain. But 
that is the kind of long-term guidance that we think is 
important.
    Ms. Lee. But with this new strain, are there any additional 
precautionary measures that people should take?
    Dr. Schuchat. The other thing that is important is to plan 
ahead. The behavioral advice we have made about washing hands 
and stuff will help with reducing respiratory infections, but 
if we do see a substantial increase in illness, 
hospitalizations and social disruption, we think people need to 
be prepared for how they are going to manage that kind of 
disruption in the family or the workplace. We are also reminded 
we are coming into hurricane season, tornado season, these 
types of things and knowing how to handle the types of 
disruptions with your family, the family communication plan, 
the provisions that you have, the way you are going to stay in 
touch with people, those are important steps, whatever the 
disaster or emergency is.
    Ms. Lee. Thank you very much. Could I ask one more question 
of Dr. Fauci? Dr. Fauci, good to see you again.
    Of course concerns many of us have regarding the impact of 
H1N1 now and in the future on underserved communities, 
particularly communities of color, the uninsured here in our 
own country, and of course outside of the country. So what 
steps are we taking to ensure that individuals who are not 
insured are educated properly with regard to prevention but 
also have access to the preventive types of measures and the 
type of treatments, if, in fact, they are uninsured, no 
insurance and end up in the emergency rooms. You know what I am 
talking about. So, you know, we have an additional problem here 
in our own country with 47 million uninsured.
    Dr. Fauci. Well, I am always happy to answer your 
questions. That is not an area at the NIH that we are involved 
in. One of the things that has been done, and I think very 
well, by the CDC is to get the message out broadly to everyone 
that you possibly can get to. We always are faced with a system 
of health care issues in this country and people who are 
underserved and any disease generally, particularly people in 
poverty tend to do more poorly than others, and we have seen 
that with virtually every disease that I have ever testified 
before this committee for and other committees, and that is 
just something that hopefully that will improve as we get the 
health care delivery system better.
    Ms. Lee. Thank you very much, Mr. Chairman. Because I think 
as we look at H1N1 and all these other diseases, within the 
context of developing a universal health care system, we have 
to look at how we rev up in communities that are left behind.
    Thank you.
    Mr. Payne. Representative Watson.
    Ms. Watson. Yes. At the end of this month a codel is going 
down to South Africa to take a project to our library in 
Soweto, an information center. Possibly if we have a CDC 
location down in that area, we might take some time. We are 
going to fly into Johannesburg, and we are going to look at a 
PEPFAR program relative to USAIDS deg.'s. Since there 
seems to be no reported cases on the continent, we might want 
to go to a CDC center and get an update. Do we have a CDC 
center in that area?
    Mr. Schuchat. The CDC has a large program in South Africa 
based in Pretoria and----
    Ms. Watson. We are going to Pretoria.
    Dr. Schuchat. Most of the activities are PEPFAR, TB 
related. But there is actually influenza work going on as part 
of the CDC cooperation with South Africa. And if you are in 
Johannesburg, you would be able to see it right there.
    Ms. Watson. Very good. Thank you.
    Mr. Payne. Thank you. Overall would you say the CDC's work 
focuses on building capacity of health systems, particularly in 
Africa and Latin America? Is that one of your goals?
    Dr. Schuchat. We certainly think that improving capacity is 
vital to the long-term protection of populations in Africa as 
well as in the United States. So the strategies that we have 
for our investments and collaborations in Africa are not just 
one-time interventions but really with a mind toward 
sustainability. Part of our PEPFAR strategy is to work directly 
with the ministries of health and really improve their ability 
to long-term strengthen the health services, the evaluations, 
the ability to improve policies and such.
    So I think that it is a huge mission, but we do try to do 
our technical support in a way that will be capacity building.
    Mr. Payne. Thank you very much. How about USAID's work in 
this area also focusing on capacity building in particular but 
not just to combat pandemic influenza but overall to combat 
HIV/AIDS, tuberculosis, malaria, neglected tropical diseases 
and things of that nature? How does USAID work in this area?
    Mr. Carroll. Thank you, Chairman. First off, I think it is 
worth noting that the efforts in these countries are all part 
of a very well-coordinated U.S. Government response. So as we 
speak about what USAID is doing, I think we also are reflecting 
what CDC and other colleagues are doing as well. PEPFAR, the 
President's Malaria Initiative, the TB programs that we are all 
supporting clearly have at their center the investments in 
local capacities. These are insidious diseases. They are only 
going to be solved if--solved for the long term if there are 
the local capacities at national, provincial, district, local 
levels to be able to carry out these activities.
    So there is a major investment, and I think it was 
reflected yesterday in President Obama's announcement. The 
whole issue of health systems that has been a major area of 
challenge over the last decade as we have rolled out other 
programs and understanding and investing in the system 
capacities to deal with HIV/AIDS, to deal with malaria, that is 
a centerpiece for our work, for Centers for Disease Control's 
work as part of these larger programs.
    So I think the answer to your question is, yes, capacity 
building and indigenous strengthening is a part of our program, 
but I think it is the U.S. Government's program at large.
    Mr. Payne. Dr. Schuchat, in your testimony you mentioned 
the CDC's Global Disease Detection Program, the GDD centers in 
Kenya, Thailand, Kazakhstan, Egypt and China. And Mr. Smith 
mentioned it also. Do each of these centers have the capacity 
to detect this H1N1 strain and what other diseases, if they do, 
can they detect at the center, such as MDR and XDR-TB? And what 
are we doing to build lab capacity in general as we dealt with 
MDR and XDR-TB. Once again as you mentioned earlier in your 
testimony, South Africa had the capacity to have labs. We found 
out that there are 20 labs in all of sub-Saharan Africa that 
could detect MDR and XDR-TB and 19 of the 20 were in South 
Africa and one in the rest of the other 52 sub-Saharan African 
countries. So there is definitely a disparity and a very lack 
of ability to really detect. And so when we were trying to 
determine the severity, we knew the damage that MDR and XDR-TB 
were doing in South Africa. Archbishop Desmond Tutu sent a 
letter to me about 2 years ago where he mentioned that at a 
hospital in Cape Town there were 53 patients that were HIV 
positive and the MDR strain of tuberculosis was detected in 
that particular ward. Out of the 53 patients, 52 died within 2 
weeks from either MDR or XDR-TB. We got a $50-million 
additional appropriation--overnight really and then a large 
amount I think, 400 million or 500 million, to deal with MDR 
and XDR. But how do we stand in that area?
    Dr. Schuchat. One of the strategies for the Global Disease 
Detection and Response Centers is to strengthen laboratory 
capacity for the known, but it is also to strengthen the 
ability to detect the new or unknown. So, yes, we have had 
respiratory infectious syndromes as a priority for the GDD 
centers and they have been trained to recognize the typical and 
then the unusual respiratory infections, including unusual 
influenza strains, and of course we have recently shipped out 
these new kits for the novel H1N1 strain. But the centers also 
work in an integrated way, the laboratory strengthening with 
epidemiologic and rapid response teams, to really respond when 
there is an unusual cluster and we don't actually know what it 
is, so that their investigation will permit us to find the new. 
One of these sites in Thailand was very helpful in the SARS 
epidemic in assisting in other countries in that region and 
understanding what that new particular virus was.
    So with infectious diseases, certainly something like MDR-
TB is a major concern and a priority. But we also need to be 
ready for the new and unpredictable and have high quality, 
trained laboratory staff who can adapt some of the molecular 
techniques for one infection and look at others and really know 
how to work in partnership with reference support.
    So I would say that there is lots more readiness that we 
could have for a long list of important infectious diseases, 
but it also a strategy of ability to respond to something new 
and potentially concerning.
    Mr. Payne. Thank you very much. Mr. Smith.
    Mr. Smith. Thank you, Mr. Chairman. Just one final 
question. It was reported that the woman who died this morning 
apparently attributed it to H1N1 influenza. She was pregnant. 
She had a cesarean section and her baby was born apparently 
healthy. Every year, about 4 million babies are born in the 
United States. If this comes back especially more virulent and 
our worst nightmare, what thoughts are being given and what 
precautions are being taken? What special protocols perhaps are 
being devised to ensure that pregnant women who may need a 
different kind of case management, if they get sick, are 
protected as well as their unborn child? We are talking about 
two patient, mother and baby. I am not sure you could tell us, 
our committee, is this like HIV/AIDS where HIV contagion can be 
transferred during the birthing process, and we know that 
certain drugs can mitigate that which are now mother-to-child 
transmission has been cutting significantly. So I don't know 
that answer and I really would like to know. Again this baby 
was born via C-section. But 4 million kids and their mothers 
could be at risk if this comes back and depending on how long 
it does last.
    Dr. Schuchat. We know from seasonal influenza and studies 
in the past that pregnant women are at higher risk for 
complications of regular influenza, and they are one of the 
groups that we have always recommended get influenza vaccines 
each year to help protect them and their babies. The 
preliminary information that we have right now on the cases in 
the United States doesn't as of today suggest that pregnant 
women are at greater risk than the general population. But it 
is an important issue that we are monitoring. We have also 
issued interim guidance for care of pregnant women, the ways to 
diagnose and treat pregnant women, because as you know many 
medicines are not necessarily tested as fully in that 
population and yet physicians and their patients need guidance.
    The third comment is that the anti-viral drug, Oseltamivir, 
had not been licensed for use in young children under 1. And 
one of the things that happened in the past 10 days was an 
emergency use authorization was approved through the FDA and 
CDC and HHS so that use of that drug for younger age, not for 
newborns, but for older babies would be available under certain 
circumstances.
    So I think, though, the vulnerable infants, newborns, the 
pregnant women are always a concern and influenza is a 
particular challenge in those populations, but we are trying to 
stay focused on it.
    Mr. Smith. Does the virus go through the umbilical cord or 
is it stopped? If the mother has it, does the baby get it?
    Dr. Schuchat. Yeah. I am not familiar with that as a route 
of infection. But with a new virus we always are mindful that 
there are lots of things to learn. So this particular H1N1 
influenza virus I am not aware of that we have any mother-to-
baby transmission. But with viruses, that can happen for many 
of them.
    Mr. Smith. But we are looking for that to see if that is a 
possibility?
    Dr. Schuchat. We are looking actively at all routes of 
transmission right now.
    Mr. Smith. Thank you, Mr. Chairman.
    Mr. Payne. Let me certainly thank each of you for your very 
important testimony. It is something that we are proud that we 
are able to be prepared. As you have indicated there, years ago 
we would not have all of these various procedures in place. And 
so I really commend the work that CDC, NIH, USAID and all of 
you that work in government agencies are doing. Also once 
again, I commend President Obama for the $63 billion over the 
next 6 years that will really continue our vigilance in working 
to try to eliminate HIV and AIDS and tuberculosis. Malaria is 
really getting a tremendous amount of attention; we are seeing 
very good results in other tropical diseases that have not 
gotten the attention, river blindness and other kinds of 
tropical diseases. So we are very, very pleased.
    Congresswoman Jackson Lee has additional questions, which 
we will forward to our witnesses and we will ask that you 
respond to these in a timely manner so that we can get the 
answers back to her, and we certainly greatly appreciate your 
participation.
    Before closing I want to ask for unanimous consent for 
members that have 5 days to revise and extend their remarks and 
submit questions for the record. Without objection, so ordered.
    Once again, thank you. We had such a distinguished panel 
here testifying this morning and with kind of short notice. 
Thank you again, and the meeting stands adjourned.
    [Whereupon, at 11 o'clock a.m., the subcommittee was 
adjourned.]
                                     

                                     

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