[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]



 
    MEETING THE CHALLENGE OF DRUG-RESISTANT DISEASES IN DEVELOPING 

                               COUNTRIES
=======================================================================


                                HEARING

                               BEFORE THE

                 SUBCOMMITTEE ON AFRICA, GLOBAL HEALTH,

                        GLOBAL HUMAN RIGHTS, AND

                      INTERNATIONAL ORGANIZATIONS

                                 OF THE

                      COMMITTEE ON FOREIGN AFFAIRS

                        HOUSE OF REPRESENTATIVES

                    ONE HUNDRED THIRTEENTH CONGRESS

                             FIRST SESSION

                               __________

                             APRIL 23, 2013

                               __________

                           Serial No. 113-56

                               __________

        Printed for the use of the Committee on Foreign Affairs


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                      COMMITTEE ON FOREIGN AFFAIRS

                 EDWARD R. ROYCE, California, Chairman
CHRISTOPHER H. SMITH, New Jersey     ELIOT L. ENGEL, New York
ILEANA ROS-LEHTINEN, Florida         ENI F.H. FALEOMAVAEGA, American 
DANA ROHRABACHER, California             Samoa
STEVE CHABOT, Ohio                   BRAD SHERMAN, California
JOE WILSON, South Carolina           GREGORY W. MEEKS, New York
MICHAEL T. McCAUL, Texas             ALBIO SIRES, New Jersey
TED POE, Texas                       GERALD E. CONNOLLY, Virginia
MATT SALMON, Arizona                 THEODORE E. DEUTCH, Florida
TOM MARINO, Pennsylvania             BRIAN HIGGINS, New York
JEFF DUNCAN, South Carolina          KAREN BASS, California
ADAM KINZINGER, Illinois             WILLIAM KEATING, Massachusetts
MO BROOKS, Alabama                   DAVID CICILLINE, Rhode Island
TOM COTTON, Arkansas                 ALAN GRAYSON, Florida
PAUL COOK, California                JUAN VARGAS, California
GEORGE HOLDING, North Carolina       BRADLEY S. SCHNEIDER, Illinois
RANDY K. WEBER SR., Texas            JOSEPH P. KENNEDY III, 
SCOTT PERRY, Pennsylvania                Massachusetts
STEVE STOCKMAN, Texas                AMI BERA, California
RON DeSANTIS, Florida                ALAN S. LOWENTHAL, California
TREY RADEL, Florida                  GRACE MENG, New York
DOUG COLLINS, Georgia                LOIS FRANKEL, Florida
MARK MEADOWS, North Carolina         TULSI GABBARD, Hawaii
TED S. YOHO, Florida                 JOAQUIN CASTRO, Texas
LUKE MESSER, Indiana

     Amy Porter, Chief of Staff      Thomas Sheehy, Staff Director

               Jason Steinbaum, Democratic Staff Director
                                 ------                                

    Subcommittee on Africa, Global Health, Global Human Rights, and 
                      International Organizations

               CHRISTOPHER H. SMITH, New Jersey, Chairman
TOM MARINO, Pennsylvania             KAREN BASS, California
RANDY K. WEBER SR., Texas            DAVID CICILLINE, Rhode Island
STEVE STOCKMAN, Texas                AMI BERA, California
MARK MEADOWS, North Carolina


                            C O N T E N T S

                              ----------                              
                                                                   Page

                                WITNESS

Tom Frieden, M.D., director, Centers for Disease Control and 
  Prevention.....................................................     7

          LETTERS, STATEMENTS, ETC., SUBMITTED FOR THE HEARING

Tom Frieden, M.D.: Prepared statement............................    12

                                APPENDIX

Hearing notice...................................................    44
Hearing minutes..................................................    45
The Honorable Eliot L. Engel, a Representative in Congress from 
  the State of New York: Prepared statement......................    46
The Honorable Christopher H. Smith, a Representative in Congress 
  from the State of New Jersey, and chairman, Subcommittee on 
  Africa, Global Health, Global Human Rights, and International 
  Organizations: Material submitted for the record...............    48
Tom Frieden, M.D.: Material submitted for the record.............    53


    MEETING THE CHALLENGE OF DRUG-RESISTANT DISEASES IN DEVELOPING 
                               COUNTRIES

                              ----------                              


                        TUESDAY, APRIL 23, 2013

                       House of Representatives,

                 Subcommittee on Africa, Global Health,

         Global Human Rights, and International Organizations,

                     Committee on Foreign Affairs,

                            Washington, DC.

    The subcommittee met, pursuant to notice, at 3:05 p.m., in 
room 2172, Rayburn House Office Building, Hon. Christopher H. 
Smith (chairman of the subcommittee) presiding.
    Mr. Smith. The subcommittee will come to order. And 
welcome, Dr. Frieden. Good afternoon. Today's hearing will 
examine a deadly phenomenon involving both natural and manmade 
elements: Diseases that are resistant to most or all available 
methods of treatment. While this is a growing problem of 
increasing concern throughout the world, the subcommittee will 
be focusing today on the impact of such diseases, known as 
superbugs, in developing countries and the challenge to 
preventing and treating these diseases in this part of the 
world.
    There is a family of germs that occur normally in 
everyone's digestive system. They can cause infections when 
they get into the bladder, blood, or other areas where they 
don't belong. That is the natural part of this growing problem. 
Gut flora are absolutely essential for health and an 
effectively functioning immune response, and the increasing use 
of things like probiotics is testimony to the fact that more 
and more people are understanding that.
    There are about 100 trillion microorganisms in our 
digestive systems, 10 times the number of cells in our bodies. 
Most of them help break down the foods that we eat, they help 
us with our immune systems. Those that are not helpful usually 
can be treated with existing medicines such as antibiotics.
    The manmade part is that antibiotics have been increasingly 
used to treat naturally occurring germs, but many of them have 
become resistant to such treatment. These so-called superbugs 
pose a threat because of overuse or misuse of antibiotics, but 
they also pose a threat because of what some call a drug 
discovery void in which there has been insufficient research 
and development of new medicines to treat emerging mutating 
infections.
    This situation recently has become much more serious. In 
the last 10 years, these drug-resistant diseases have been 
identified in patients in more than 200 hospitals in 42 States 
in this country. Over that period, there prevalence rate has 
increased from 1 percent of patients to some 4 percent for 
those in short-term care, but for patients in long-term care 
facilities, the rate is as high as 18 percent.
    Half of all patients who contract these diseases do not 
survive. MRSA, one of the better known of these superbugs, now 
kills as many as 19,000 Americans each year and a similar 
number in Europe. That is higher than the annual rate of deaths 
from HIV/AIDS.
    Last year the World Health Organization identified strains 
of gonorrhea and tuberculosis that are currently completely 
untreatable, as well as a new wave of what might be called 
``super superbugs'' with the mutation known as NDM-1. These 
frightening new strains were first seen in India, but they have 
now spread worldwide. The spread of the H7N9 birth flu in China 
is also causing considerable concern, with more than 100 
confirmed cases and 22 deaths reported thus far. According to 
the AFP, the WHO said yesterday that there was still no 
evidence that H7N9 was spreading in a sustained way between 
people in China. I know Dr. Frieden will speak to that because 
we are working with the Chinese on that issue.
    According to WHO, artemisinin, when used in combination 
with other drugs, is now considered the world's best treatment 
against malaria, but malarial parasites resistant to the drug 
have emerged in western Cambodia, along the border in Thailand, 
as well in parts of Burma and in Vietnam.
    In the developed world, we pride ourselves on having top 
flight medical care widely available to patients. If we lose 
half of all patients who contract these drug-resistant 
diseases, what about patients in the developing world where 
statistics are often scarce and effective medical care can even 
be scarcer?
    Using accepted protocols for treating these diseases, their 
rate of infection can be curbed. In Israel, infection rates in 
all 27 of its hospitals fell by more than 70 percent in 1 year 
with a coordinated prevention program. By following accepted 
protocols for handling these diseases, the Colorado Department 
of Public Health and Environment and the Florida Department of 
Health both have stopped outbreaks of these drug-resistant 
diseases in recent years. But then again, what about hospitals 
in developing countries?
    For example, the brain drain has sent trained medical 
personnel in Africa in search of better working conditions and 
pay in the developed world. The lack of equipment and supplies 
that partly led to this brain drain would facilitate the rapid 
spread of drug-resistant diseases in these countries. What 
would be simple interventions, including removing temporary 
medical devices such as catheters or ventilators from patients 
as soon as possible, is less likely under current conditions in 
developing-world hospitals.
    Adding to this problem is the presence of expired and 
counterfeit drugs. Patients whose lives could be saved may not 
be because of inadequate medical care. Unfortunately, because 
so many countries do not maintain and report statistics on 
medical issues, we have little idea how serious the situation 
is today in many developing countries in Africa and elsewhere 
around the world.
    In our interconnected world, that means that infected 
people in the developing and developed countries pose a mutual 
threat. Last month a Nepalese man was detained at the Texas 
border while trying to make an illegal crossing from Mexico. 
Officials found that he was infected with an extensively drug-
resistant strain of tuberculosis and had carried this 
potentially deadly airborne disease through some 13 countries 
over 3 months, from his home of Nepal through South Asia, 
Brazil, Mexico, and finally into the United States. Who can say 
how many people he infected during this long journey.
    Conversely, 6 years ago, an American infected with 
multidrug-resistant tuberculosis traveled from our country to 
France, Greece, and Italy, before returning through the Czech 
Republic and Canada. Upon his return to the United States, he 
became the first person subjected to a Centers for Disease 
Control and Prevention isolation order since 1963.
    Clearly, both developed and developing nations must work 
together to prevent and treat these diseases and find a way to 
implement the new strategies in an era of constrained budgets 
and loosening control of authority in far too many countries. 
However, the administration's proposed budget for 2014 does 
call for a 19-percent cut in tuberculosis programming, and 
hopefully we might get some answers today and again on Thursday 
from Dr. Shah.
    Today's witness, a very accomplished doctor, heads an 
agency that is charged with examining the elements of disease 
and helping to develop the strategies for addressing the 
threats they pose not just to Americans, but to all mankind. We 
look forward to hearing Dr. Frieden and exploring with him the 
means by which the U.S. Government is working with developing 
countries to counter global threats.
    I would like to yield to Ms. Bass.
    Ms. Bass. Thank you. And, Mr. Chairman, as always, I want 
to thank you for convening today's hearing on drug-resistant 
diseases in developing countries.
    While we examine this very serious issue, I think it is 
worth noting that this is an issue with global dimensions that 
impacts all of us. While we sit in the halls of Congress, we 
are neither immune nor are we protected from what is a mere 
plane ride from this hearing room.
    Globalization has done much for allowing us to be more 
interconnected. The challenge before us today, however, is how 
do we understand and move to effectively address the smallest 
of things, microscopic organisms that have the ability to 
rapidly adapt and either avoid detection or resist efforts that 
would eliminate something that often has mortal consequences if 
left unaddressed.
    Dr. Frieden, I want to thank you for taking the time today 
to testify before the committee. I remember us talking about a 
very similar subject about a year ago, so I am very glad that 
you are here today. We all know that you have dedicated your 
life to addressing the great public health challenges of our 
day. You have been on the cutting edge of public health 
interventions and have undoubtedly saved millions of lives in 
the U.S. and around the world. For an extraordinary depth of 
work and experience, we owe you our thanks and look forward to 
your testimony.
    Without objection, I would like to submit for the record a 
written statement by Ranking Member Engel. He has been a 
staunch champion on a number of global health priorities and in 
particular the spread of tuberculosis, both multidrug-resistant 
and extensively drug-resistant TB.
    It would be remiss for me not to acknowledge that in my 
hometown of Los Angeles there has been a recent outbreak of TB, 
and I understand it is close to 5,000 people that have been 
diagnosed, and there is a concern that there is not a 
sufficient supply of drug treatment to address this outbreak. 
Dr. Frieden, perhaps in your remarks you can update us all on 
the situation, how the CDC is working with local officials. I 
am sure Los Angeles is not the only city that is dealing with 
this.
    But I will note that in the U.S. alone there are over 
10,000 cases of TB infection annually. In a country like India, 
four times our population size, there are approximately 2.3 
million cases each year and close to \1/2\ million people can 
die from it. The Wall Street Journal reports that India has the 
largest number of people infected with drug-resistant strains.
    In 2010, the Center for Global Development wrote a paper 
entitled ``The Race Against Drug Resistance,'' and in that 
paper the authors address the health and economic consequences 
of global drug resistance, the drivers of drug resistance, and 
the current global response to the problem. They concluded with 
four recommendations that I would like to read for the 
committee's consideration but also to get your feedback on. 
Recommendation one, improve surveillance by collecting and 
sharing resistance information across network of laboratories. 
Two, secure the drug supply chain to ensure quality products 
and practices. Three, strengthen national drug regulatory 
authorities in developing countries. And four, catalyze 
research and innovation to speed the development of resistance-
fighting technologies.
    The challenge before us is multifaceted and will require a 
comprehensive approach. Understanding the drivers of drug 
resistance and addressing them is critical, including 
strengthening health systems to include well trained and 
equitably distributed health workers who can properly 
administer treatments, eliminating substandard and counterfeit 
drugs. And I would in particular like if you could comment 
about the role that counterfeit drugs might play in this.
    We need to have well-structured surveillance and reporting 
systems that are in track to monitor outbreaks and infections 
and a strong focus on research development. I would add that 
public and private sectors must also play their part to ensure 
financial resources and regulatory standards are in place for 
the challenges of today. In Africa, for example, you don't have 
to look very far to find stories that report on totally drug-
resistant TB or emerging concerns of increased drug-resistant 
strains of HIV and malaria. These are troubling trends as our 
Nation continues to fund programs that we hope will end these 
crisis in our lifetime. We have heard President Obama and 
former Secretary of State Clinton speak of an AIDS-free 
generation, while at the same time you read a BBC article with 
the headline, ``Drug-Resistant HIV on Increase in Sub-Saharan 
Africa.''
    The World Health Organization reports that India, China, 
the Russian Federation, and South Africa are home to almost 60 
percent of the world's cases of multidrug-resistant TB. I would 
love to know your opinion, number one, if you agree with that 
or if you have a sense of why that is when we consider that, 
combined, India and China are home to over one-third of the 
global population of 2.6 billion people.
    This problem won't go away on its own and we continue to 
see people becoming infected with any number of diseases, and 
as our world continues to become smaller as a result of 
globalization we will continue to be confronted with the 
challenges of how to adequately deal with drug resistance that 
may or may not be on our doorstep today, but might be tomorrow.
    Thank you very much. I yield my time.
    Mr. Smith. Thank you, Ms. Bass.
    Mr. Meadows.
    Mr. Meadows. Thank you, Mr. Chairman.
    This is a timely hearing on an important issue. And, Dr. 
Frieden, I appreciate your willingness to be here as well and I 
look forward to your testimony.
    Obviously drug-resistant diseases are a serious problem 
everywhere. You know, our own healthcare providers are 
struggling to stay on top of this issue on a daily basis, and, 
you know, I firmly believe that to address this problem we must 
first determine the scale of the problem, and, you know, we 
need to make sure and ensure that we have the data necessary 
both here and in the developing world to properly define the 
problem.
    These drug-resistant diseases, you know, they don't 
recognize a political boundary. You know, in a globalized world 
that we live in a threat anywhere is a threat here, and so, 
therefore, we are bound to work on this problem wherever it 
presents itself and that obviously creates challenges, as you 
know. We know that developing countries may struggle with 
sanitary practices, the use of nonprescribed antibiotics, 
limited access to care, you know, and so on. And so I look 
forward to hearing how we can address those challenges and 
improve our knowledge of these severe threats.
    And with that, Mr. Chairman, I yield back.
    Mr. Smith. Dr. Bera.
    Mr. Bera. Chairman Smith, thank you. And again thank you 
for calling this hearing. It is extremely timely. And today I 
will be a doctor as opposed to a Congressman because that is 
really how I look at this issue, from the perspective of being 
a doctor. You know, as the former chief medical officer for 
Sacramento County we dealt with issues of drug-resistant 
tuberculosis, but 5 or 6 years ago we had second and third line 
medications that we could use judiciously and still deal with 
these cases when we are called into consultation in the 
hospital.
    What keeps me awake at night and what I worry about is the 
emergence of extremely drug-resistant cases of tuberculosis 
that we are starting to see pop up in Africa and other nations 
around the globe, and that is of critical concern not only to 
those countries abroad in Africa, but clearly to our hospitals 
and our patients here domestically. It is a real issue and it 
is one that we have to take very seriously.
    You know, I have seen it firsthand, having travelled to 
South Africa a few years ago with a group of doctors to 
evaluate how they were caring for the HIV epidemic there. You 
are seeing the devastating effects of these cases and the 
limited resources in the arsenal.
    The other thing that keeps me awake at night, and I saw it 
firsthand this past weekend when I was back home and rounding 
with a group of doctors at Mercy San Juan Hospital, seeing what 
was happening there. If I am not mistaken, the nurse 
administrator who was rounding with us suggested that close to 
50 percent of the patients that they are admitting now have a 
history of MRSA, or methicillin-resistant staph aureus. So 
there is a real concern of the efficacy of antibiotics that we 
are using and starting to run out of those tools in our arsenal 
as physicians.
    That leads me to another body of literature that really is 
emerging. As we incent our pharmaceutical companies to come up 
with the fourth generation of antibiotics, we really have to 
extend the life of these medications. And I have been a doctor 
for over 20 years and for years we could use penicillin and so 
forth. But now, as we get into our first, second, third 
generation of cephalosporins and antibiotics, the lifespan of 
these drugs are increasingly shorter and shorter. And part of 
that is the ease of access of antibiotics in third world 
countries, the ability to just buy them over the counter, and 
there is no guarantee that they are being used in an 
appropriate manner.
    So we have to work with industry to make sure, as we come 
up with the next generation of antibiotics, we are very 
judicious in how they are used, not only here domestically, but 
also abroad in other countries. And I would be interested in 
hearing your testimony on all of these issues, what we can do 
proactively here in Congress, as well as our medical community, 
to address that next generation of tuberculosis resistant, but 
then also how we work with industry as we develop the fourth 
generation of antibiotics and make sure we can extend the lives 
of these medications.
    And with that, Mr. Chairman, again, thank you for this 
hearing, and I yield back.
    Mr. Smith. Thank you, Dr. Bera.
    Mr. Weber.
    Mr. Weber. I will yield back.
    Mr. Smith. Okay. Thank you. Thank you.
    I would like now to extend a very special welcome to Dr. 
Frieden. Tom Frieden, medical doctor, M.P.H., who has been the 
Director of the Centers for Disease Control and Prevention 
since June 2009, has controlled both infectious and chronic 
diseases in this country and globally. From 1992 to 1996, he 
led New York City's program that controlled tuberculosis and 
reduced multidrug-resistant cases by 80 percent. Dr. Frieden 
then worked in India for 5 years, helping to build a 
tuberculosis control program that has saved nearly 3 million 
lives.
    As commissioner of the New York City Health Department from 
2002 to 2009, Dr. Frieden led programs that reduced illness and 
death and increased life expectancy substantially, including 
programs that reduced adult and teen smoking dramatically and 
eliminated artificial transfats from restaurants, and the 
department eliminated racial/ethnic disparities in colon cancer 
screening and began the country's largest community-based 
electronic health records project.
    As CDC Director, Dr. Frieden has intensified CDC's 24/7 
work to save lives and protect people, including through more 
effective response to outbreaks and other health threats at the 
local, State, Federal, and global levels. New programs have 
prevented infections from food and healthcare, helped Americans 
quit smoking, reduce childhood obesity, and save lives of teens 
and others from car crashes, and extended lifesaving treatment 
and disease prevention in more than 50 countries.
    A graduate of Columbia University's College of Physicians 
and Surgeons and School of Public Health, Dr. Frieden completed 
infectious disease training at Yale University and CDC's 
Epidemic Intelligence Service. The recipient of numerous awards 
and honors, Dr. Frieden speaks Spanish and has published more 
than 200 scientific articles, and we welcome him back.
    And the floor is yours, Doctor.

 STATEMENT OF TOM FRIEDEN, M.D., DIRECTOR, CENTERS FOR DISEASE 
                     CONTROL AND PREVENTION

    Dr. Frieden. Thank you so very much, Chairman Smith, 
Ranging Member Bass, and the other members of the committee, 
both for your support for global health issues and for this 
opportunity to speak with you today about such important 
threats that we face and the important work that the CDC does 
in this country and around the world to protect Americans 24/7.
    CDC's work is critical to addressing antimicrobial 
resistance and other global threats. What I would like to do 
here is briefly outline what the problem is, what we are doing 
about it, and what more needs to be done in three broad 
sections. Obviously, any one of those three could take a lot of 
time, so I will just give you some of the highlights. And I 
would really agree with all of what was said in the 
introductory comments from the chair, the ranking member, and 
the panel. This is a critical problem for us. If there is one 
basic concept, it is that we are inevitably interconnected as a 
world, and whether we like it or not, whether drugs are used 
correctly all over the world affects what happens to people in 
our communities.
    I think we are facing essentially a perfect storm of 
vulnerability. There are four trends that are combining to make 
us in some ways at greater risk than we have ever been in the 
past. The first is the emergence and spread of new microbes, 
things like SARS and H7N9 influenza, which I can speak about 
later if you would like.
    The second is globalization of travel, where people just a 
plane ride away can bring new organisms and resistant organisms 
from one part of the world to another, and also globalization 
of our food and medical supply. We are increasingly 
interconnected.
    The third and the main topic of this hearing is the 
inexorable rise of drug resistance. We now face an increasing 
rate of resistance in many different types of organisms. To 
mention just three, we have tuberculosis strains--and 
tuberculosis is an area that I worked in for many years--that 
are resistant to virtually all antibiotics. We have strains of 
Gram-negative organisms, a group, a problem referred to as CRE, 
or carbapenem-resistant enterobacteriaceae, basically very 
dangerous bacteria that are now resistant to most or even all 
antibiotics and are spreading in our country. And third, 
malaria. We are now beginning to see resistance to the last 
best drug we have treated on an outpatient basis, the 
artemisinin drugs and that class of drugs.
    There are about 12 million Americans a year who go visit 
malarious areas, areas where they are at risk for getting 
malaria. If these resistant strains spread, the risk to people 
in this country will be substantial, in addition to the number 
of deaths and the amount of suffering and economic hardship 
that that will cause around the world.
    The fourth risk is the potential of people, either 
intentionally or unintentionally, to create dangerous organisms 
and then to release those into the environment, either 
intentionally or unintentionally. Unfortunately, that has 
become easier as we have had technological advances.
    Poor quality treatment, whether of tuberculosis or of 
pneumonia in the hospital, anywhere in the world, in Asia or 
Africa, can and in fact has become a nightmare in communities 
in the U.S. Today in many communities, most likely each of the 
communities that you represent in this country, there is 
someone in a nursing home or a hospital who is fighting for 
their life against an infection that doctors have limited or no 
tools to treat. And as we saw, for example, in Colorado, where 
there was an outbreak recently, the indexed patient had just 
come from Asia and undoubtedly had brought that organism with 
them through no fault of the individual and unavoidably.
    Given the four big challenges that we face, I think there 
are two broad areas that give me a great deal of hope for being 
able to tackle them in the future. One is, frankly, political 
and one is technological. On the political side, I think we 
have more commitment to addressing this in more countries than 
we have ever had before. The SARS outbreak cost the world more 
that $30 billion. H7N9 Avian influenza in less than a month has 
cost China more than $2 billion. So I think countries get that, 
in addition to the human suffering, there are strong economic 
incentives to address health threats more effectively.
    In addition, we have global commitments through things like 
the International Health Regulations which require countries of 
the world to find, report, and stop disease threats, and we are 
getting reporting from an increasing number of countries. We 
are nowhere near where we need to be, but we have the political 
framework to provide the support and assistance so that the 
world can be safer because each of the countries around us is 
safer and each of the countries in the world is safer.
    And also, in terms of the commitment, we have success 
stories, and I will go into some of them, but we have seen that 
when we work with China or Thailand or Brazil or many, many 
other countries and help them see what needs to be done, they 
invest their own resources, their own substantial talent, their 
own capacities in doing that, so that we end up with a true 
partnership to reduce health risks both for their country and 
for the whole world.
    The second broad reason for optimism is the advances in 
both laboratory work and informatics. They are breathtaking. We 
are able to do things in the laboratory now that we could not 
have even dreamed of even just a few years ago. When I started 
at the CDC as an Epidemic Intelligence Service officer, we were 
just beginning to do genetic sequencing of tiny parts of the 
genome and to use that to figure out how tuberculosis and other 
organisms were spreading and to stop them sooner. It took a 
large room, months of work, a lot of very difficult comparison 
by hand sometimes of different patterns. Now much more 
information can be obtained in just 3 or 4 hours.
    In the President's budget for fiscal 2014, there is an 
initiative called Advanced Molecular Detection. This initiative 
would allow us to go to this next generation of tools, find 
outbreaks that we are missing now, find them sooner, stop them 
more effectively, and figure out how they are spreading so we 
can prevent more of them. This is our single highest priority 
for the 2014 budget at CDC. And in addition, there are really 
exciting bioinformatics developments where we can look at huge 
amounts of data and begin to make sense of it. So I think we 
have real reasons for optimism.
    In terms of what CDC is doing today, Ambassador Carson, the 
recently retired former Ambassador to Africa, said to me CDC is 
the 911 for the world, and we are happy to play that role, but 
we are even happier that we are now teaching countries to do 
that for themselves. And we are doing that in critical ways and 
with important platforms, and I want to thank the chairman, 
ranking member, and all members of the committee for your 
steadfast support for the PEPFAR program over the years. PEPFAR 
is really changing the world. There are more than 5.3 million 
people alive today who would be dead or dying otherwise. Last 
year alone a quarter of a million babies were born without HIV 
because of PEPFAR.
    And in order to do what we have done with PEPFAR, with the 
leadership of the State Department and the Global AIDS 
coordinator, in order to have those results, we have also used 
PEPFAR as a platform. We have come in under budget and ahead of 
schedule, but we have also used PEPFAR as a platform to 
strengthen laboratories for HIV and for other conditions, to 
strengthen diagnosis, to strengthen maternal and child health. 
And what we have seen with that, for example, is strengthening 
through PEPFAR, and also through the Global Disease Detection 
Program, which is a CDC program that is a platform to find and 
stop outbreaks. We have seen strengthening of laboratories, 
which are crucial, of epidemiologists or disease detectives who 
are essential to finding and stopping problems and of 
prevention measures.
    And just to mention a few of them, through the laboratory 
work, we now have created an African Society for Laboratory 
Medicine. Hundreds and soon thousands of laboratories 
throughout Africa will be certified so doctors and patients can 
rely on accurate results. Do they have an infection or not? Is 
it resistant or not? Is treatment working or not? Right now, 
without good laboratories, you can't answer those questions in 
far too much of the world.
    We are also expanding influenza surveillance throughout 
Asia and Africa so that we can get a better handle on where it 
is emerging, how it is happening. We know that a risk anywhere 
can be a risk everywhere, and though we have worked with 50 
countries on influenza surveillance, we were taken off-guard by 
H1N1 which emerged in Mexico. We have expected new influenza 
strains to emerge in China and Southeast Asia, as H7 is now, 
but H1 took us by surprise. And that emphasizes a key point, 
which is that a blind spot anywhere is a risk to all of us. But 
our laboratory work at CDC has strengthened work throughout the 
world so that there is much more accurate diagnosis.
    I will give you one example of this that CDC is doing with 
Uganda right now. Our CDC lab in Fort Collins, Colorado, came 
up with a new way to diagnose plague. Plague is often fatal, 
but with a simple $1 dipstick test, we are determining whether 
patients have plague.
    CDC is working with local traditional healers. We are 
working with the medical care system, and CDC is also working 
to see what treatment is best for plague. As a result, in just 
the past few months, we have diagnosed people who would likely 
have died otherwise and treated them before they have spread 
plague to others, and we are transferring this technology to 
Uganda so that they don't need for us to do it in the future, 
as we have done with Ebola as an example. We have taught them 
how to control it, how to diagnose it, so instead of the large 
outbreaks that we saw a decade ago, we are seeing isolated 
cases or smaller outbreaks now.
    The second key area is epidemiology, disease detectives, 
and this is so crucial to what we do, figuring out where 
disease is spreading, what the threats are, how to stop them, 
and whether our efforts are working. Our flagship program in 
epidemiology at the CDC is the Epidemic Intelligence Service. 
What we have done with more than 30 countries is help them 
start similar programs, called Field Epidemiology Training 
Programs. In the next year or 2, we will graduate the 3,000th 
disease detective. It is a 2-year, intensively mentored 
program. Eighty percent of the graduates stay in their home 
country, often in leadership positions, finding and stopping 
health threats. We also do epidemiologic investigations, and we 
start on average one of these a day in this country and on 
average, with our partners, one a day around the world to 
identify and stop a new threat.
    And third is prevention, and we do this in important ways, 
including vaccination. After all, if you vaccinate and prevent 
an infection from happening, it won't be resistant, and we are 
seeing that with, for example, pneumococcal infections now, 
with vaccination resistances less of a concern in that one 
organism.
    And of course we are closer than ever to the finish line in 
polio eradication, and the work of Rotary International and so 
many partners with CDC as the spearheading partner for this 
country has brought us to this point from 1988, when there were 
more than 350,000 children affected by polio in that year 
alone, to last year, when there were 222, the lowest number 
ever in the history of humanity as far as we know. We are also 
active in quarantine, identifying passengers who are ill and 
helping to reduce risks of people who come here from other 
countries.
    That is some of what we at CDC are doing. In terms of what 
more is needed, I have to say, frankly, that we are not keeping 
pace with the threats. Microbes evolve and emerge rapidly, and 
we need to keep pace with that evolution. What we are faced 
with is a need to accelerate progress in three specific areas.
    The first is detection. We need to fund and implement the 
Advanced Molecular Detection program. I brought for you a 
remarkable thing. This is a chip. It is one company. It fits 
very easily to carry. There are about five different companies 
that make something like this. But this chip in less than 4 
hours can sequence the entire genome of not just one, but many 
different microbes, and with advanced supercomputing, we can 
then take--there are actually more than 10 million individual 
wells on this chip. We can take the fragments of DNA, and with 
a supercomputer put them back together like a jigsaw puzzle 
with tens of thousands of pieces to figure out where the 
connections are, whether it is resistant, how it is spreading, 
and whether it is becoming more virulent. We are using this 
technology now to track H7N9, and this is the kind of thing 
that we need to invest in more to make an even bigger 
difference going forward. We have too many blind spots.
    Second, we need to improve our ability to respond to 
infectious disease and other threats. At CDC, we have an 
Emergency Operations Center, and if any of you are ever passing 
through Atlanta, please come by and spend an hour or 2 with us 
to see what we do there. We track what is happening around the 
world. We have an information system. We have a communication 
system. We respond rapidly. Ideally every country in the world 
should have some system like that. They will be safer and we 
will be safer.
    And third, we need to increase our ability to prevent, 
through better vaccines, through antibiotic stewardship, 
through better supply chain control in terms of antibiotics.
    So I will be happy to get into specific issues that you 
have raised. I don't want to take too much time with my 
introductory statement. But I do want to conclude with one 
simple thought, which is that a safer United States and a safer 
world is within reach if we invest in it, if we work with 
partners, if we take advantage of the unique opportunities that 
both the commitment of countries around the world has and this 
very exciting technology that we have to bring to bear on 
longstanding threats to our health. Thank you so much for your 
interest.
    Mr. Smith. Thank you so very much, Doctor.
    [The prepared statement of Dr. Frieden follows:]
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
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    Mr. Smith. And without objection, your full written 
statement will be made a part of the record, as well as that of 
Ranking Member Eliot Engel.
    Let me just ask you a couple of opening questions. 
Artemisinins, the power of these very important drugs to help 
cure people with malaria, may be thrown a huge curveball in, as 
I said earlier, in Cambodia, Burma, and particularly along the 
Thai border. And my question is, you know, there are 104 
malaria-endemic countries. Obviously, and you know it, because 
you have been a part of this, we went from a $100 million in 
the year 2000 to $1.8 billion worldwide in 2012, certainly 
below what the target was if we wanted to really look to 
eradicate this horrible disease.
    But how concerned are you and CDC about this problem? I 
know WHO talks about containment and trying to ensure that this 
does not spread to other places, particularly Africa, where it 
would be even more catastrophic. If you could spend some time 
on that, I would appreciate it.
    Dr. Frieden. Thank you. Thank you very much. And thank for 
your support for the President's Malaria Initiative. I have 
seen, as you have, this program in action in Africa and 
elsewhere and it is breathtaking. I have gone into communities 
that previously had extensive amounts of malaria. CDC has 
documented that in some of these communities, one out of every 
four medical visits of children was for malaria. One out of 
every two units of blood used for transfusion was for malaria. 
And in communities where they have implemented good control 
measures, we have seen essentially zero cases of malaria with 
good control and zero deaths. So we know that tremendous 
progress is possible.
    We are quite concerned about artemisinin resistance. We 
have seen areas, as you say, in Cambodia and elsewhere where as 
many as 30 percent of patients have evidence that their 
particular strain of malaria is responding much less well to 
the artemisinins. This is our last hope for good malaria 
control. We have to preserve this drug.
    I think you can think of drug resistance and prevention of 
drug resistance as something that we owe the world, we owe our 
children, that these antibiotics that we have been bequeathed 
by people who worked so hard to come up with them are preserved 
and can be used to protect lives for many years going forward.
    What we think is possible is, first, to understand better 
what has happened and, second, to contain as well as possible, 
through a comprehensive approach to vector control, that is 
stopping the mosquito, treating effectively, diagnosing and 
treating well. And I think overall with malaria, we are quite 
reassured by the overall amount of progress that is happening.
    The challenge with malaria is the challenge of persistence. 
We have seen big progress with malaria before, we let off our 
guard, and it came roaring back. That is exactly what we have 
to avoid. We have to intensify our work in Southeast Asia to 
understand and contain artemisinin resistance. At the same time 
we have to scale up the core malaria control interventions in 
Asia and Africa, especially so that we can reduce the number of 
deaths and the burden of illness.
    There is still a lot we know that we are not doing and we 
need to scale up that net use and high quality diagnosis and 
treatment. There is still certain things that we don't know 
that we need to understand better about the malaria parasite, 
about the best tools to control it.
    Mr. Smith. And isn't it true that about half of those who 
should have bed nets have it, but we are running into the 
problem of the bed nets now losing their efficacy to keep the 
mosquitos out? So we need a replacement effort as well.
    Dr. Frieden. CDC scientists have looked at this carefully. 
The life of a bed net is not an easy one. They get embers put 
on them from the stove, they are worn out. And so having the 
first set of nets out was great and knocked down child 
mortality enormously. We have documented at CDC overall 
reductions, not malaria specific, but overall reductions in 
child deaths of 25 percent just from the malaria control 
program. But exactly as you say, Mr. Chairman, the nets now 
need to be replaced, and that requires resources.
    Mr. Smith. You know, in terms of drugs that are actually in 
the pipeline, you know, we know that newer orders of new types 
of antibiotics are few and in between. On tuberculosis, without 
objection, we are including testimony from Dr. Adrian Thomas 
from Johnson & Johnson. And he points out that Janssen is 
bringing forward a new medicine specifically indicated to treat 
a drug-resistant form of tuberculosis. It is called Sirturo. It 
seems to have gone to the next stage, although it is not used 
yet.
    My question on that drug specifically and other drugs that 
are or not in the pipeline, particularly as it relates to 
malaria and multiresistant tuberculosis.
    Dr. Frieden. I think a key concept is that the development 
of new antimicrobials, new antibiotics is a necessary but not a 
sufficient condition. Now, for those two conditions 
particularly, we are very encouraged. It is the first new anti-
tuberculosis drugs in decades. We think at this point it should 
be reserved for people for whom other drugs are not available. 
The CDC has convened national experts to look at what is the 
optimal way of using this new drug. We will need to have some 
clinical trials and the FDA moved very quickly to approve it so 
that patients could get it and their lives could be saved. 
There are some other drugs for tuberculosis that are in the 
pipeline that are somewhat encouraging, but what we know is, 
unless we improve our treatment system, we will lose those 
drugs as well.
    In terms of malaria, the situation is perhaps a little less 
encouraging because virtually everything in the pipeline is 
either an artemisinin-related product, a synthetic artemisinin, 
or something that has the same resistance mechanisms as the 
artemisinins appear to have. So if we lose the artemisinins, we 
may lose the new drugs before we even get them.
    I think this comes back to one of the core concepts of 
antimicrobial resistance. Resistance develops because of poor 
quality programs. It is very straightforward. If you have a 
good quality program, you will not get lots of drug resistance. 
And in tuberculosis, which I worked in for many years, one of 
the core concepts is that a poor quality program can create 
multidrug resistance faster than a good program can treat it, 
no matter how many resources you have. And it is critically 
important to stop resistance from emerging and then to stop it 
from spreading.
    We documented in New York City in the early 1990s that as 
many as half of all of the multidrug-resistant tuberculosis 
patients had actually caught it in the hospital. So hospitals 
can become an amplification point for drug resistance. That is 
why in our work in this country and our recommendations to 
other countries we have advocated a program called Detect and 
Protect. Detect and Protect. It is a simple concept: Find the 
patients that have the resistant organisms, protect them from 
harm with it, and protect other patients from getting it from 
them. And one of the things that we are encouraged by is the 
amount of progress in things like methicillin-resistant staph 
aureus where since 2005 we have documented a more than 50 
percent reduction in the serious infections with that highly 
resistant organism.
    This is not a problem for which we have no solution. We 
know what to do. It is a question of doing it. We also need 
some new knowledge, but what we can do now is a much better job 
at reducing the risk of detecting it, so we find the patients 
who have it and are protecting others from them and protecting 
them from the organism.
    Mr. Smith. Dr. Frieden, you made a very strong appeal to 
Congress to include in its budget what is in the Fiscal Year 
2014 President's budget for the Advanced Molecular Detection 
initiative. As you point out, it combines two powerful 
technologies, molecular sequencing and bioinformatics. Could 
you perhaps elaborate on exactly how that works, and if you 
could also--and then I yield to my colleagues for their 
questions--speak to the area of labs, which you made reference 
to. How much connectivity is there with CDC and those labs? Are 
they at a basic level?
    When I travel, I always ask about the labs myself. As a 
matter of fact, we had hearing in the last Congress with CURE 
International and the magnificent work they are doing with the 
infection-based hydrocephalic condition. And they have cured 
over 5,000 children in Uganda alone with a simple intervention 
that does not require any stents, it doesn't require, you know, 
the kind of follow-up that we often would need here. But it is 
infection based, they believe, and I watched one of the 
operations myself. The lab you mentioned in Uganda, I am not 
sure if that lends itself to the kind of detection that they 
need to do on this, but the labs. Where are they? Particularly 
in Africa, but elsewhere in the world, how do we grow those 
labs, as well as their sophistication and their connectivity to 
you?
    Dr. Frieden. Thank you very much. The Advanced Molecular 
Detection initiative would give our top-quality disease 
detectives the cutting-edge tools to find problems and stop 
them sooner. We have terrific scientists at CDC. We have a 
mandate within this country and abroad to detect and stop 
problems. But our hands are in some ways tied because we can't 
look into the microbe's genome in the way that technology 
actually allows us to today.
    To give you just one example of that. With H7N9 influenza, 
which we can talk about more a bit later, we are very concerned 
to see will it develop the capacity to spread easily from 
person to person. So far we are confident it hasn't. If it 
does, it has major implications for all of us and for every 
country.
    We think we could learn more if we could go into clinical 
specimens and sequence the entire genetic material in those 
specimens. What happens when you grow an organism is that one 
particular strain grows very well and you can analyze that in a 
laboratory, but that is not exactly what is happening in the 
patient's body. What is happening in the patient's body is that 
there are many different--an assortment of different sub-
strains or what are sometimes called quasi-species of that 
organism, and by sequencing from there you can figure out what 
is going to happen. You can skate to where the puck is going, 
not where the puck is.
    AMD (advanced molecular detection) would allow us to do 
that, not just for influenza but for other organisms as well. 
It is a critical tool in helping us not only avoid problems, 
but prevent them in the future.
    The laboratories, we are very encouraged by the progress 
around the world. I think there are two broad areas where we 
are going to see more progress. The one is what are called 
point-of-care tests, things that a doctor or nurse or other 
health worker can do at the patient's bedside or at the 
patient's hut side. Things that use a dipstick, as we are using 
in Uganda with plague now. So these are great technologies 
because they take not much time, they are highly accurate. It 
is how we are diagnosing HIV and malaria now in the field.
    The other are the high-tech things where we can go in and 
look at a specimen, and there are now technologies which can 
look at two dozen different organisms to say in this one 
specimen of blood or sputum, which of these organisms are 
present. We have already use this on an experimental basis, for 
example, to look at an outbreak that we couldn't figure out 
what was causing it, and to our surprise it was a yellow fever 
outbreak, and because of that, we were able to do control 
measures. So there is the ability to bring these new 
technologies to bear on laboratories throughout the world.
    The African Society of Laboratory Medicine, which PEPFAR 
helped to start, has made really progress by leaps and bounds. 
In fact, the Ethiopian Government has given them, the African 
Union has given them free space. Countries all over Africa are 
doing more with that. In Africa they are being very willing to 
do regionalization so that not every country needs to create 
everything. It is not efficient. They can work regionally very 
effectively. Our polio labs, our measles labs, our influenza 
labs, our foodborne labs are a global network where all of us 
are safer if every country can do a better job finding and 
tracking it.
    Mr. Smith. Before I yield to Ms. Bass, is there an 
inventory of all of those labs that could be made a part of the 
record and give us a better sense of--and also would be a place 
that when we do travel, we will visit.
    Dr. Frieden. We will certainly get you what we have in 
terms of an inventory. I will also mention that Congress 
requested that CDC do summaries of CDC's laboratory work last 
year and this year, so we have two reports on laboratory work 
that CDC does in this country and around the world, and we 
would be delighted to share those as well, as the global 
laboratory network information.
    Mr. Smith. Thank you so much.
    Ms. Bass.
    Ms. Bass. Thank you.
    Once again, thank you for your testimony. And I do look 
forward to, I was saying to the chairman, I would love to go to 
Atlanta and to see the CDC. So I hope to do that in the future.
    You know, I wanted to ask you to address two areas, and one 
is, especially, you know, you said that internationally you 
thought there were good news on the political framework, so a 
couple of international issues I would like for you to address 
as to how countries are dealing with the unregulated sale of 
antibiotics, I mean, you know, you can get them over the 
counter in a lot of different countries, and how you are 
relating to countries and trying to get them to stop that 
practice.
    The other thing is on counterfeit drugs and how prevalent 
do you think that is. You know, I have heard it is only 
anecdotal, though, but I have certainly heard that there is a 
lot of countries, countries in Africa and also many other 
countries around the world that are buying medications that 
they think are legitimate and they are not.
    Dr. Frieden. Both of those problems are big problems, and I 
don't think we have great news in terms of what is happening 
today to address them, but we do have a pretty clear pathway to 
get there.
    On the unregulated sale of antibiotics, fundamentally this 
is a question of strengthening governmental public sector 
capacity to do core things that we take for granted in this 
country. We take for granted in this country that you can't go 
to the local pharmacy and pick up the latest antibiotic because 
you think maybe you need it. There is control over the use of 
antibiotics.
    I think many countries are not in that world yet, and one 
of the things that we do at CDC and the FDA does as well is to 
work with partner governments, both the public sector and the 
private sector, to strengthen their capacity to do those core 
governmental capacities that they need to have and it will 
protect them and us. As an example, the Government of India has 
recently passed rules outlawing an inaccurate test for 
tuberculosis that was being used very widely in India and very 
misleadingly. So people were being told they didn't have TB 
when they did and that they did have TB when they didn't. They 
have also ruled that you can't get TB over the market.
    Well, it is wonderful that they have taken those steps to 
have those rules so that people would need a prescription and 
you would have an accurate test. The next step is get them 
implemented effectively, and that is something that with any 
country we are willing to partner to help them get it right 
because that helps them and it helps us.
    In terms----
    Ms. Bass. Could I ask you a little bit, just one question 
about that? How about Mexico? You know, living in Los Angeles, 
I am just 2 hours from the border and a lot of times people do 
go across the border to get antibiotics and bring them back. We 
also had a problem in Los Angeles, frankly, with people selling 
them over the counter at swap meets and different places. What 
is our relationship with Mexico?
    Dr. Frieden. We have a longstanding relationship with 
Mexico. We have, at CDC, binational programs, especially for 
some of the border areas. Mexico has a very robust public 
health system. In terms of antibiotic availability, I would 
have to find out and get back to you.
    Ms. Bass. Okay.
    Dr. Frieden. In terms of counterfeit drugs, I don't think 
we have a good sense of the scope of the problem. We know it is 
a risk. We are very concerned about counterfeit artemisinins 
which we have seen and we are very concerned about the 
continued sale of monotherapy with artemisinin. One of the 
great ways to protect antibiotics is to the give them in pairs 
or groups of three or four. This makes a huge difference 
because it reduces the risk that if you develop resistance it 
will spread. This is one of the key lessons from tuberculosis 
and from HIV, that by using multiple drugs together you can 
cure patients more effectively and prevent the emergence of 
drug resistance.
    So the sale of monotherapy artemisinin alone is just a 
terrible thing. It should never happen. And one of the things 
that we need to do more of is work with WHO, work with other 
international organizations, work with individual countries on 
reducing both counterfeit and irrational drug formulations on 
the market.
    Ms. Bass. So then do you think the counterfeiting of drugs 
is not that big of a problem? I mean, it is talked about huge, 
and I don't know if it is playing that big of a role in drug 
resistance.
    Dr. Frieden. I think what I was trying to say is I don't 
think we know how big of a problem it is.
    Ms. Bass. Oh, okay.
    Dr. Frieden. We know that there are many problems of which 
that is one, and the FDA has some new technologies that they 
are looking at which may help countries to identify counterfeit 
drugs more easily. A lot of this involves strengthening 
national regulatory authorities in other countries. That may 
sound like something, why would we want to do that? But we want 
to do that because we don't want people anywhere getting drugs 
that they shouldn't be getting or drugs that are ineffective 
when their resistance will soon be just a plane ride away from 
us in the U.S. We have already seen this happen with patients 
from Asia coming here and creating outbreaks of disease.
    The answer to this isn't to try to say we are going to keep 
all microbes out. We are a globalized world, whether it is in 
our food supply, whether it is in our medications, whether it 
is in the travelers from the U.S. who go abroad and come back 
or people who come here, and in the case of tuberculosis, may 
have been here for decades and then develop an infection or an 
active infection with tuberculosis.
    Ms. Bass. Thank you.
    Mr. Smith. Mr. Weber?
    Mr. Weber. Wow, where do I start?
    I think you might have answered it, Doctor. You held up the 
chip, and you said the chip was instrumental, I think, in the 
detection of H7N9? And then you mentioned it had, oh, I don't 
know how many pieces of information on it. Would you go back 
through that again, please?
    Dr. Frieden. Sure. And if you would like, I will also talk 
some about H7N9 at some point.
    Mr. Weber. Okay.
    Dr. Frieden. But this chip allows you to take either a 
culture that you have in a laboratory or a patient's specimen, 
blood or urine, and then to isolate the DNA and put it in these 
wells and then, through testing, figure out what DNA is in it, 
so what organism it is, whether the DNA encodes for resistance 
genes, whether, when we learn more, whether it is related to 
other organisms. So two people may have the same species 
infection, but they may be totally unrelated or they may have 
gotten it one from the other.
    That kind of information can come from this kind of 
technology, but we need to learn more about it, we need to 
invest in it, we need to study the genome of many of the 
organisms that are causing human illness.
    Mr. Weber. Does that give us the ability to look at that 
DNA and say some strings of DNA are more resistant to drugs 
than others?
    Dr. Frieden. Yes, it would allow you to say which of the 
strains are more dangerous. I should give the caveat that this 
is only effective if it is done along with a lot of our 
traditional tools of laboratory work and what we call shoe-
leather epidemiology, going out, asking people questions, 
figuring out who is sick, figuring out who is resistant, and 
who had contact where with who.
    Mr. Weber. Okay. So this gives the ability to predict, for 
lack of a better term, I think the phrase you used was to skate 
not to where the puck is, but is going to be.
    Dr. Frieden. That is what we hope it will do.
    Mr. Weber. Yeah. Wayne Gretzky he said over here.
    Dr. Frieden. That is right.
    Mr. Weber. Okay. I didn't know he was a doctor.
    So what does that look like? I mean, are you anticipating 
strains evolving? What do you mean by that?
    Dr. Frieden. So we could see within an individual patient 
with influenza, in our current way of doing it, we can only see 
one dominant strain. With the new technology, we would actually 
see many strains that are in their body and making them sick.
    Some of those strains may be drug-resistant. Some of them, 
in the case of H7, may have picked up the ability to spread 
person to person. We don't know that yet. That is something we 
will be tracking very, very closely as H7 progresses and as we 
learn more about it.
    Mr. Weber. And then you do what? You skate to where the 
medicine that he or she needs?
    Dr. Frieden. We might, for example, use a different drug to 
treat that patient. We might change the way we create the 
vaccine so that the parts of the vaccine that are active are 
active against a different strain of the virus or a different 
type of the virus. So it would help us to both find it and stop 
it and prevent it.
    Mr. Weber. So when you do that, when you have this data--
and I forget how many pieces you said was on there, hundreds of 
millions, I am sure--are you able to get that into a database 
that says, okay, we can share this and we know--at some point, 
somebody named the H7N9. And so at what point do you determine 
that a particular strain is wide and it gets a name? Who 
determines that, and when does that happen?
    Dr. Frieden. So, for influenza, we have really a wonderful 
global partnership. We work with more than 50 countries, we 
work with the World Health Organization. And after the SARS 
epidemic in China, the Chinese got very interested in improving 
their system. So we have worked very closely with them to set 
up systems to track influenza, to help them develop their 
laboratory abilities to be able to detect it and to do the 
genetic sequence of influenza.
    And, in fact, we helped them become a World Health 
Organization collaborating center on influenza. And that is 
important, because, as a collaborating center, they are 
required to post on the Internet the entire gene sequence of 
every new influenza organism that they sequence, and they are 
happy to do so.
    So, within days of receiving the first sample, the China 
CDC, which is the collaborating center there, had sequenced the 
genome in ways that we had helped them to do and then posted 
that on the Internet. We brought that sequence down and used 
the sequence to create a test to see if someone has this 
organism.
    We have already had about two dozen people in this country 
coming back from China with severe illness who we have tested 
in our laboratories. None of them have had this. We don't think 
any have had it yet, of the ones that are still pending. But, 
in addition, we have already begun through what is called 
reverse engineering to make a vaccine against H7 based on this 
information from the Internet.
    That is all great, but there is actually a next generation 
of genetic work that can be even more powerful and allow us to 
see in advance--we only saw this once it had made a bunch of 
people sick. It has now made over 100 people sick in China----
    Mr. Weber. Well, and that is my question. How do know over 
here in this country? How do you get that word out? At what 
point do you know that these people--do they have a common 
theme? They have been overseas, I guess.
    Dr. Frieden. So for the H7N9, if I can just address that 
for a moment, influenza is, of all of the infectious diseases, 
the one that can kill the most people. During the 1918 
pandemic, more than 50 million people around the world died. 
The death rate among people who got the virus in 1918 was 
around 1.7 percent.
    Now, in an average flu year in the U.S., average seasonal 
flu year, about 20 percent of people, 60 million Americans, get 
the flu. So if a virus could be that severe and infect that 
many people, it would be of enormous risk.
    Mr. Weber. Knock out 6,000 people, basically, if you went--
and more than that at 1.7 percent of 60 million.
    Dr. Frieden. So that is why flu we take so very seriously 
and we track it all around the world. In fact, the Southern 
Hemisphere tends to get flu before we do, and we use the 
pattern there to decide which strains of flu to put into the 
virus for the coming year, and they use for the next year what 
happens here. So it is really a global collaboration on 
influenza.
    H7N9 is a new scenario. We have never seen anything quite 
like this before in China. And there are aspects of it that are 
reassuring, there are aspects that are not reassuring, and 
there are things that we are specifically doing.
    I will tell you the most reassuring thing about the bird 
flu in China now, the H7, is that it is not spreading from one 
person to another efficiently. And we are quite confident in 
that. The Chinese Government has checked more than 2,000 
contacts of people with flu, and they have found only a very 
small handful of secondary cases, whereas with a usual flu we 
might expect to see as many as 20 or 30 percent of those people 
sick. So we are not seeing spread. And we are seeing most of 
the cases had contact with birds--ducks, pigeons, quail, or 
chickens.
    So what is reassuring is we are not seeing person-to-person 
spread. We are also seeing very good collaboration with the 
Chinese authorities. In fact, the head of our flu program is 
there now on a World Health Organization delegation and getting 
great collaboration. The Chinese Government has asked us to 
send them three of our top experts in flu to work with them for 
weeks and months to come so that they can do everything 
possible to get ahead of it. And for 10 years we have been 
increasing our preparedness for threats and working better 
across the U.S. Government. That is the good news.
    The not-so-reassuring news is that this particular strain 
of bird flu, H7, is severe. So, of the 100 people or so who 
have gotten it, about 20 have died, and many of the remaining 
are quite sick. We also don't see birds getting sick from it. 
Now, you might say that is a good thing, but it is not, because 
with H5N1, another bird flu that we have been tracking for 10 
years, with H5, the birds get sick and the country culls the 
flock and it stops spreading. Here the birds aren't sick, so 
you can't cull the flock. You don't have that marker.
    And H5, the other bird flu, spread all over the world in 
years. So it started in Asia and soon was all over the Middle 
East and Africa. And for H5, it took about 18 months between 
the time the first case came and we had 100 cases. H1 was 
recognized on April 1st of this year, and we already have 100 
cases.
    So there are things that we are very concerned about in 
what the genome looks like, and creating a vaccine is 
particularly challenging for these types of virus. But our plan 
for addressing the flu basically uses four pillars that the 
Department of Health and Human Services coordinates. The first 
is tracking so we know what is happening. The second is 
mitigation, figuring out how we can reduce damage if it comes 
by treating people and helping them survive flu, by good care 
in hospitals. Third is vaccine development. Vaccine development 
in influenza takes at least 6 months, and for H7 it is likely 
to require probably two doses and maybe an adjuvant because the 
human body doesn't respond well to this. And communication. We 
are very up front. We have a fundamental rule: Tell them what 
you know when you know it; tell them what you don't know and 
how you are trying to find out. And that is our approach to 
this.
    The bottom line with H7 is that, currently, it is not 
spreading person to person. If it does not gain that capacity, 
it will not cause a pandemic. But I cannot predict if it will 
and, if it does, if it is going to be tomorrow or in 10 years.
    Mr. Weber. Sure.
    Let me ask one final question, if I may, Mr. Chairman.
    In your remarks, you said there were four trends, and your 
fourth trend was the potential for folks to intentionally or 
unintentionally create dangerous organisms and release them, 
which got my attention, because in all this talk about, you 
know, biological warfare, for example, with all of these 
databases up on the Web you talked about, where they identify a 
strain, they are supposed to post it as a member of the WHO, do 
you guys, for national security reasons, work with the branch 
of government that would track something like that?
    And I don't know if you can really go into it. How do you 
identify that strain, if you will? And how do you know who is 
working on it?
    Dr. Frieden. So within this country, within the United 
States, CDC operates something that looks at what are called 
select agents, things that could be used for terrorist purposes 
or could be dangerous if they got out of the laboratory. There 
are currently about 354 laboratories in this country that work 
with one or another toxin or select agent.
    We are generally not a regulatory agency, unless you want 
to import or work with plague or something like it in your 
laboratory, in which case we will do the regulation. And for 
each of these laboratories, we do on-site visits and we oversee 
them. And we ensure that both the workers there don't get 
infected, because if they got infected, they could bring it 
outside and they could be very sick, and we do everything 
possible to minimize the risk of spread.
    Mr. Weber. Well, I am not too concerned about the 
laboratories that are here. I was concerned about your example 
or, for example, other foreign countries posted their stuff 
online. If they find something that is so bad that there is 
really hardly a cure for it, what would keep them from just 
sending it over to our country? That is really my question.
    Dr. Frieden. Yep. The risk of biological warfare is real.
    Mr. Weber. Do you all track that?
    Dr. Frieden. We do. And we also retain under our 
jurisdiction the strategic national stockpile. It is 
countermeasures for a natural or manmade disaster that we can 
deploy to anywhere in the U.S. within 12 hours.
    Mr. Weber. So if you see a country that is hostile to 
America--of course, they probably aren't going to post that on 
the Web. That is the catch-22. If they come up with something 
like that, there is no good way for us to have a preventative 
vaccine in place without foreknowledge.
    Dr. Frieden. Well, we look at all the potential risks. So 
we have scientists at CDC who are essentially the world's 
experts in just about all of the threats that could be faced.
    We know, for example, that smallpox is something that we 
have been very concerned about someone reintroducing in the 
world. CDC, working with World Health Organization, eradicated 
smallpox from the world, but we have been concerned that 
someone might bring it back as a terrorist agent. We have in 
the stockpile enough vaccine to vaccinate the country. So we 
have essentially taken that risk off the table.
    Mr. Weber. Okay.
    Dr. Frieden. Not all risks are that amenable to our 
intervention, but we both track and think of how to prepare.
    And I would mention that the advanced molecular detection 
allows us to do very specific fingerprinting of strains which 
would help us in identifying the source of it. So that it is 
something that has additional benefits, as well.
    Mr. Weber. Okay. Thank you.
    Thank you, Mr. Chairman. I yield back.
    Mr. Smith. Thank you very much, Mr. Weber.
    Mr. Bera?
    Mr. Bera. Thank you, Mr. Chairman.
    And my apologies, Dr. Frieden, if you have been asked this 
question. But in my opening statement, I talked a little bit 
about how we come up with the next generation of antibiotics 
and certainly extend the life of those antibiotics.
    Part of the challenge that we face is, as our domestic 
pharmaceutical companies and global pharmaceutical companies 
look at making those investments and the amount of research 
that goes into developing that next generation and then the 
return on that investment, many of these companies are making 
those cost-benefit analyses and realizing, you know, the costs 
of prohibitive. So, clearly, the Federal Government has a role 
in making sure we are providing adequate resources and funding, 
creating that partnership between industry and academia to do 
this research and develop the next generation.
    But the critical question here is, as we are making those 
investments, we certainly want to extend the life of these 
therapeutics. And we are seeing--I was reading my home medical 
journal, the Annals of Internal Medicine, in this latest issue, 
and they were touching on the increasing incidents of CRE and 
the impact that is having and potentially will have in the 
future.
    What are some thoughts that you might have as we come up 
with this next generation to both protect and extend the life 
of these discoveries here domestically? But then also, we talk 
about the ease of obtaining antibiotics overseas in third world 
countries. What are some creative things that we can do here in 
Congress, working with industry, to, again, extend the life?
    Dr. Frieden. I think everything you say is a critical 
issue. We need to figure out how to preserve the antibiotics we 
have now and ensure that, as new antibiotics come on line, 
which we anticipate and hope they will, we don't lose them as 
quickly as we have lost some of the current ones.
    The amount of antibiotic usage in the U.S. is actually 
astonishing. CDC just published data on this within the past 
week, I believe. There are more than a quarter of a billion, 
``B,'' quarter of a billion courses of antibiotics prescribed 
in this country each year, about 8 courses of antibiotics for 
every 10 people in the country. And in some parts of the 
country, it is 12 for every 10 people.
    So I think we really have to work on antibiotic 
stewardship, making sure that when people need antibiotics, 
they get them, and when they don't need them, they don't get 
them. And CDC has sponsored some antibiotic stewardship 
programs which have been shown to save money for facilities. 
They require an investment; you have to have staff doing them. 
But they pay off. And this is something that is really quite 
important.
    In terms of the pipeline of how to get new antibiotics, the 
NIH is critical in that regard, and the FDA as well. It is 
figuring out ways to help companies bring products to the 
market sooner and at lower cost so that we can address this 
gap, because we don't have a lot of great antibiotics in the 
pipeline.
    In terms of preserving antibiotics, I talked briefly before 
about the new antibiotic for tuberculosis, which we are trying 
to do just that with, saying, let's just reserve this for the 
patients for whom there are no other options while we figure 
out the best mechanism for it.
    As you know as a doctor, Dr. Bera, if you use antibiotics 
correctly, you won't get drug resistance. A lot of the things 
that we need to do are fairly simple and straightforward: 
Getting healthcare workers to wash their hands, removing 
urinary catheters and intravenous lines very promptly and only 
using them when essential, getting patients off ventilators as 
rapidly as possible, reducing healthcare-associated infection.
    And CDC's healthcare-associated infection program does that 
in this country. Other countries, particularly low- and middle-
income countries, are not doing much in that area. And that is 
an area we would like to expand work on, but we are unable to 
for lack of resources.
    Mr. Bera. You have touched on a couple areas. I am 
astonished at the number of courses of antibiotics. I realized 
there was a lot being prescribed; I didn't realize it was that 
high.
    Are there best practices that we can make sure physicians 
around the country are utilizing that have been shown to be 
effective? So for years we have been talking about appropriate 
antibiotic prescriptions and prescribing habits. Are there best 
practices that you have seen and effective models?
    Dr. Frieden. Yes, we have seen antibiotic stewardship 
models that really make a difference. We have a program at CDC 
called Get Smart About Antibiotics. And we think it is 
important to involve both the clinicians and the community. 
Because the clinicians will say to us, you know, the patient 
came in and they demanded antibiotics, and they said if I don't 
give them to them, they are going to go to the guy down the 
street.
    Mr. Bera. Right.
    Dr. Frieden. So I think it is important to get more 
awareness that antibiotics--no medicine is without risk. So 
things should absolutely be taken when they are needed but not 
be taken when they are not needed. And I think that is the 
essence of the best practice.
    We have often seen that getting nondoctors involved in the 
system--pharmacists, nurses, allied health workers--can be very 
important.
    And the other thing that has been very effective is to 
track the prescribing trends of different doctors, not as a way 
of criticizing someone, but providing feedback, and if there 
are outliers, providing them that information and education so 
that they can do a better job.
    When I worked in tuberculosis control, we were able to 
standardize treatment for tuberculosis across an entire city, 
an entire country, using outreach workers to reach out to 
doctors, private doctors, in case the prescription wasn't 
appropriate or rational, and just provide them with education 
and information so we could improve the quality of care.
    Mr. Bera. Great.
    You know, just one last question. My colleague, Mr. Weber, 
touched on the threat of biological agents and so forth and the 
imminent threat here locally, or domestically. You know, in the 
full committee, we have certainly had a few hearings on Syria, 
a country that increasingly looks like it is going to fall and 
a country that we know possesses some of these biological 
agents.
    You know, as we prepare ourselves for, you know, all 
threats and so forth, is there anything that you would like to 
see from this body in terms of helping the CDC make sure that 
we are fully prepared for----
    Dr. Frieden. Well, at CDC we work 24/7 protecting Americans 
from threats, whether they are natural or manmade, whether they 
are infectious or environmental, whether they are from this 
country or abroad.
    What we do, frankly, is dependent on the resources we are 
provided. So when we have fewer resources, that means the 
resources that we provide to State and local entities to detect 
and respond to problems are less, that means the resources we 
have to work globally are less.
    Sequestration has had broad and serious impacts on CDC's 
ability to detect and respond to a wide variety of problems. We 
understand that we are in fiscally constrained times. We have 
done a lot to be more efficient, to make sure that as much of 
our money that we are entrusted goes out for direct program 
services. But we are concerned that our ability to respond is 
really at the breaking point in some of our programs.
    Mr. Bera. Right. Thank you.
    Mr. Smith. Thank you.
    Mr. Meadows?
    Mr. Meadows. Thank you, Mr. Chairman.
    And thank you for your illuminating testimony.
    And one of the areas that I want to broach is, Dr. Bera and 
I actually have had a lead letter together where we had Dr. 
Collins come in with NIH, National Institutes of Health. And he 
was sharing some of the groundbreaking, exciting research that 
they have been doing, particularly in influenza.
    And so what kind of correlation or partnership has there 
been with that group? And what can be learned from that 
partnership?
    Because as he was sharing, you know, right now we treat, 
and he described it, it is kind of like a mushroom. And, you 
know, every year you get a flu shot, and, you know, it is a 
different strain, and we are coming up with that, and that 
there is a hope that one day we will be able to, in the not-
too-distant future, just have one shot for that stem that, from 
a DNA perspective, helps us address that.
    And so are you working with them, and in what ways?
    Dr. Frieden. We work very closely with NIH, with FDA, with 
other parts of HHS. In fact, in the H7N9 response, we are 
having twice-weekly coordination calls to make sure we are 
perfectly aligned.
    What we are finding--really, what NIH is working on we 
really hope will work out.
    Mr. Meadows. Right.
    Dr. Frieden. They are doing the basic research to try to 
come up with a universal, long-lasting flu vaccine.
    Mr. Meadows. Right.
    Dr. Frieden. This would be phenomenal. Right now, our flu 
vaccine works okay. It doesn't work as well as most of our 
vaccines. You have to take it every year. Sometimes we have a 
mismatch, and it doesn't----
    Mr. Meadows. Right.
    Dr. Frieden [continuing]. Meet the strains. If you look at 
something like H7, it doesn't work particularly well. You have 
to give two doses and maybe an adjuvant.
    Mr. Meadows. Right.
    Dr. Frieden. So we have real challenges, and we ardently 
hope that they will succeed.
    But our job really is to take what is existing knowledge 
and turn it into practice. That is the CDC space----
    Mr. Meadows. Okay.
    Dr. Frieden [continuing]. Take what we know how to do and 
get it happening as broadly as possible to protect as many 
people as possible.
    And we are able through our laboratory, for example, to 
accelerate and improve some of the current vaccine development 
techniques. We are able through our laboratory to cut a month 
off vaccine production time through a new technology that we 
have developed.
    So it really is a partnership across the system.
    Mr. Meadows. All right. So you mentioned the FDA. And, 
obviously, there is this, where you are analyzing and seeing 
the issue and identifying the problem, so to speak. And then we 
have to figure out a way, how do we deal with the problem. And 
so there are a number of components there. One would be the 
FDA; the other would be pharmaceutical companies.
    What are the barriers that you face right now with either 
sharing that information or speeding up the process? You know, 
if you are identifying the issue, how do we make sure that as 
quickly as possible that we see the enemy and that we know how 
to fight it, with drugs or whatever? What are the barriers that 
you are seeing there?
    Dr. Frieden. I think within the Federal system, we are very 
well-aligned. I honestly might not have said that a few years 
ago, but that----
    Mr. Meadows. So that is part of the government that is 
working well, is what you are saying?
    Dr. Frieden. Yeah.
    Mr. Meadows. Okay.
    Dr. Frieden. Just to take food safety as an example, we 
have weekly reviews with both USDA and FDA on every potential 
cluster and investigate those that make sense.
    On influenza development, we are really very tightly 
aligned between FDA, USDA, NIH, and ourselves. So, for example, 
if we go forward to make vaccine for H7, even trial vaccine----
    Mr. Meadows. Right.
    Dr. Frieden [continuing]. It would be part of HHS that 
contracts for that, it would be NIH that does the clinical 
trials, it would be FDA that licenses it. So I think that is 
going well.
    There are at least two areas where we face real challenges. 
One of them is, as I have mentioned, our limitation in being 
able to do some of the advanced molecular work that would open 
doors and make things visible that are currently invisible to 
us.
    Mr. Meadows. Right.
    Dr. Frieden. The second are sometimes some of the 
incentives. The private sector is a crucial partner in this 
work, but for some of the work they don't have the incentive to 
do what might do the most good, either because a product 
wouldn't pay or because the market isn't necessarily there. If 
we don't have an H7 pandemic, there will be no market for the 
vaccine. So there are areas where the government needs to step 
in because there is no natural incentive for it.
    New antibiotics are an area where we are trying to get the 
incentives right, because it does cost so much money to develop 
a new antibiotic. How do we make sure that, if they do get one 
to market, it is preserved and they can get a return on their 
substantial investment to bring it to market?
    So I think those are two of the issues that we are looking 
at more.
    Mr. Meadows. All right. And so let's look at that 
prioritization, because I think you have come up and you have 
said, okay, you know, we have fiscal constraints, we have, you 
know, a priority on where we are in terms of our investment on 
these.
    How would you look at those areas and prioritize them? I 
mean, I have a number of friends that have worked for the CDC. 
I mean, they come up to the mountains of North Carolina to get 
away, and so I get to see them on a regular basis. And all of 
them are very dedicated, capable individuals.
    I still at times, though, see the CDC, what I believe, may 
have mission creep in terms of getting into areas that 
tangentially maybe have to do with disease. For example, I 
mean, I was real surprised to see some of the advertising done 
by the CDC with regards to gun control. You know, there was an 
issue there that came up, and I was just blown away that there 
would even be anything there.
    And so, how can you--or who is the best person to 
prioritize those things for us?
    Dr. Frieden. Well, first, I am not aware of any advertising 
CDC has done on gun violence. So if there is any example of 
that, I would like to see it.
    Mr. Meadows. I will get you a copy of it.
    Dr. Frieden. I think the bottom line for us is a return on 
investment, return on investment both in terms of health and in 
terms of dollars.
    So with influenza as an example, we are looking at what 
will be the return on investment from a better vaccine. Now, we 
hope we will come up with a universal vaccine. It might or 
might not happen. But we know that if we can increase----
    Mr. Meadows. Right.
    Dr. Frieden [continuing]. The use of existing tools, we can 
tamp down the impact of influenza.
    For many of the vaccines, we know that if we got to higher 
vaccination rates, we would have less disease in the future. In 
fact, vaccines are a great example of that. For every $1 we 
spend on vaccines, we get $3 back in healthcare savings and $10 
back in societal savings.
    So I think, for me, the key concept is the return on 
investment. It is not something we do because it makes us feel 
good or we think----
    Mr. Meadows. Oh, no, no. And I realize that. And I guess my 
question becomes, how do we share the issue of how concerning 
these issues are without creating panic and yet, at the same 
time--because, you know, funding becomes--you know, you only go 
to the doctor when you know you are sick. And a lot of these 
issues are here, that are out there, that, quite frankly, the 
average person on Main Street has no idea that the threat 
exists.
    So how do we share that information where we build, you 
know, public consensus and yet, at the same time, not create a 
fear, you know, where everybody is running around on Main 
Street with masks on their face?
    Dr. Frieden. So, right now, for H7 as an example, there is 
nothing for people to do differently. As a family member, as a 
parent, there is nothing that I am advising my family to do 
differently.
    Mr. Meadows. Because of the contagious nature that you 
talked about earlier.
    Dr. Frieden. That is right.
    Mr. Meadows. Okay.
    Dr. Frieden. For 10 years, we have told people, if you 
visit China, don't go to live markets. That was to protect you 
against SARS and avian influenza and other things. And that 
remains our advice, and that is----
    Mr. Meadows. Sure.
    Dr. Frieden [continuing]. Essentially the only thing 
different.
    For us at CDC, it is different. We have activated our 
emergency operations center. We are tracking it 24/7. We are 
sending teams out to look at it. We are working with State and 
local governments. We are working with neighboring countries. 
So there is a lot that we are doing.
    I think the issue of building consensus is a challenging 
one, and it really gets to the heart of this hearing, I think, 
which is, how do we ensure that there is a widespread 
recognition that in terms of global health threats we are 
inevitably interconnected, that a risk anywhere is a risk 
everywhere, that a blind spot anywhere puts us all at risk? And 
that is something that I think all of us can think together on, 
how to convey that most effectively.
    Mr. Meadows. So you think the Federal answer--and this is 
my last question, Mr. Chairman--you think the Federal answer to 
that would be to prioritize those, identify those areas, as we 
did with smallpox when there was a potential risk with smallpox 
after 9/11, and identify those areas that may not have a 
pharmaceutical payback, so to speak, and say that is where the 
Federal Government needs to get involved, and on the others 
leave it to the private sector?
    Dr. Frieden. Yes, in general. I would say that it is not an 
either/or. There are very important public-private partnerships 
where, say, take the example of the cell-based flu 
manufacturing capacity that the public sector invested in but 
Novartis also invested in.
    Mr. Meadows. Right.
    Dr. Frieden. So I think there are partnerships possible 
there.
    In terms of the gaps, we have talked about the advanced 
molecular detection. We have also talked about the global 
health security and the need to have that network around the 
world, because if any country is weak, we are all at higher 
risk. And, ultimately, things like vaccines can take diseases 
off the table but require more investment or, where we have the 
vaccine, investment to get it into people.
    Mr. Meadows. Okay.
    I thank you, Mr. Chairman, and I yield back.
    Mr. Smith. Thank you very much.
    Dr. Frieden, you have been very generous with your time. If 
I could just ask you a couple of final questions, and perhaps 
any other colleagues who would like to ask a final question as 
well.
    You mentioned drug-resistant gonorrhea. If you perhaps 
could speak to how prevalent that is, that we saw strains, 
``we'' being the government, detected in Asia, and now it has 
been observed around the world, including the United States.
    On MRSA, is that something that is multiplying globally, 
and at what rate, perhaps?
    I, on one trip to Korea, met with a number of people, but 
one of them was a priest who was doing work in Pyongyang to 
help multiresistant TB and XDR TB-affected patients, who are 
unbelievably sick, and yet he was allowed in. In that case, Kim 
Jong Il welcomed him because he was doing such a great 
humanitarian initiative.
    When you have a country like North Korea, or perhaps Iran 
or Eritrea, or some other country where human rights abusers 
are in power, like China and even Vietnam, they welcome, 
thankfully, the collaboration to try to mitigate and stop 
disease spread, but in a country like North Korea, that is not 
happening. Do you have any recommendations on what could be 
done, you know, to build that bridge? Because, obviously, I am 
sure CDC would love to be there helping to eradicate something 
like--or help people with drug-resistant tuberculosis.
    Let me also just ask you briefly if you can comment on the, 
maybe you might not want to, but the $236 million in last 
year's budget for Fiscal Year 2012 will be cut by $45 million 
in the President's budget for TB to $191 million. I mean, yes, 
these are hard times, but it seems to me that that money, 
minimally straight-lining it, if not increasing it, is--every 
dollar well-spent.
    And, finally, back in the early 1980s, during the child 
survival revolution, Jim Grant and all the others at UNICEF, 
and of course our Government was pushing hard for it, David 
Stockman came along as OMB Director and zeroed out in its 
second year the child survival emphasis on vaccines or 
rehydration therapy and the like. I offered the amendment to 
double it, to double down and say not only should we not end 
that money, we need to increase it.
    And I travelled to El Salvador and many other places when 
vaccination days were called. And pertussis, diptheria, and 
other killers of children, kids were vaccinated against it. 
Now, this is obviously several decades later, and I am 
wondering, are we hitting all the diseases? Are any of those 
diseases, like pertussis or diptheria, morphing into something 
that becomes drug-resistant?
    We thought we were on our way to eradication and universal 
immunization, but obviously they keep rearing their ugly heads. 
I mean, we need to redouble our efforts on the child survival 
effort as well.
    If you could speak to that.
    Dr. Frieden. Thank you so much.
    On drug-resistant gonorrhea, we have seen an increasing 
proportion of strains in this country and around the world that 
are resistant to cephalosporins. So, earlier, just a few months 
ago, we issued new treatment guidelines to use two drugs for 
patients, not one, because, again, using two will reduce that 
emergence.
    We know that it is a problem globally and we will have to 
address it globally. There is a lot of global transmission. And 
what we have seen is the need to have that kind of action. We 
have worked very actively with the World Health Organization to 
track it.
    In terms of MRSA, I think there is very limited evidence or 
knowledge about where it is globally. So that is one of the 
things that we would like to work with other countries on to 
further develop. But we do know that in this country we have 
been able to substantially reduce invasive MRSA through some 
commonsense, low-cost ways of reducing infections in hospitals.
    I agree with you completely that health is often a great 
way to foster collaboration. I mean, look at the partnership, 
steadfast partnership, over the past 10 years with China on 
influenza and other infectious diseases, regardless of what 
else may be happening. Or if you look at smallpox eradication, 
that was done when the Soviet Union still existed. There was a 
partnership between the CDC, the U.S., and the Soviet Union for 
smallpox eradication.
    So health can be a safe space. And the days of tranquility 
that you mentioned of James Grant and UNICEF were a very 
inspiring example of that, where people actually stopped the 
war to vaccinate kids.
    I can't comment on the budget on TB. I believe that is the 
USAID budget that you are referring to.
    In terms of the child survival revolution and what is 
happening now, vaccinations remain one of the great 
accomplishments of all time in humanity. Take measles alone. 
There are about 10 million children who would be dead who are 
alive today because of measles vaccinations. Low cost, it is 
highly effective.
    We know that there are limits to vaccines. For example, our 
pertussis vaccine doesn't work as well as we would like. Many 
countries are not using the vaccines that we know work. So 
rubella vaccines have to be used at a high rate or you actually 
can do more harm than good. So the vaccine work is very 
important.
    One thing that has been very encouraging is GAVI, the 
Global Alliance for Vaccines and Immunizations, which is 
funding and creating an incentive for companies to sell at a 
reasonable price vaccines around the world. And the vaccine 
manufacturers have been wonderful partners in this. The result 
of that is that new vaccines against rotavirus, something that 
CDC helped develop; against pneumococcal disease, which killed 
lots of kids last year; and against haemophilus are being 
introduced around the world.
    We still have much further to go to make sure that every 
child in the world can have the potential of receiving those 
vaccines. And there are some new vaccines that we are hoping to 
see developed in the coming years. But right now we have kind 
of a full plate getting these scaled up.
    We have worked in Haiti, for example, to help that country 
implement new vaccination programs at a higher rates for three 
of leading killers that they were never vaccinating against 
before post-earthquake, so rotavirus, pneumococcal, and 
haemophilus. Major killers, at least probably 10,000 deaths per 
year per pathogen. And those are getting introduced last year, 
this year, and next year in Haiti.
    So I think it is a great example of how much can be 
accomplished in global health. And I really thank the 
committee, the chairman for how much you have done in this 
area.
    At CDC, we also have searing memories of the zeroing out of 
the child survival revolution, because we were expanding 
vaccination. And lot of children could have had a fuller, 
longer life if that program hadn't been stopped.
    Mr. Smith. Doctor, is there anything you would like to say 
in conclusion?
    Dr. Frieden. Only to thank you again for your attention to 
these issues and to emphasize that, despite all the problems, 
despite all the threats, despite all of the risks, I remain 
fundamentally optimistic. We have commitment and we have tools, 
we have great people, we have will in this country and around 
the world. There is a broad consensus in this country and 
around the world of what needs to be done. And I am confident 
that we will make even more progress in the future.
    Mr. Smith. Thank you so very much for your great testimony 
but, more importantly, your leadership. It is making a huge 
difference and deeply appreciated by this committee. Thank you.
    Dr. Frieden. Thank you very much.
    Mr. Smith. The hearing is adjourned.
    [Whereupon, at 4:44 p.m., the subcommittee was adjourned.]
                                     

                                     

                            A P P E N D I X

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     Material Submitted for the Hearing RecordNotice deg.




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   Material submitted for the record by the Honorable Christopher H. 
 Smith, a Representative in Congress from the State of New Jersey, and 
 chairman, Subcommittee on Africa, Global Health, Global Human Rights, 
                    and International Organizations











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   Material submitted for the record by Tom Frieden, M.D., director, 
               Centers for Disease Control and Prevention

















                                 
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