[Senate Hearing 108-44]
[From the U.S. Government Publishing Office]
S. Hrg. 108-44
SEVERE ACUTE RESPIRATORY SYNDROME (SARS)
=======================================================================
HEARING
OF THE
COMMITTEE ON HEALTH, EDUCATION,
LABOR, AND PENSIONS
UNITED STATES SENATE
ONE HUNDRED EIGHTH CONGRESS
FIRST SESSION
ON
EXAMINING THE STATUS OF THE SEVERE ACUTE RESPIRATORY SYNDROME THREAT
__________
APRIL 29, 2003
__________
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COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
JUDD GREGG, New Hampshire, Chairman
BILL FRIST, Tennessee EDWARD M. KENNEDY, Massachusetts
MICHAEL B. ENZI, Wyoming CHRISTOPHER J. DODD, Connecticut
LAMAR ALEXANDER, Tennessee TOM HARKIN, Iowa
CHRISTOPHER S. BOND, Missouri BARBARA A. MIKULSKI, Maryland
MIKE DeWINE, Ohio JAMES M. JEFFORDS (I), Vermont
PAT ROBERTS, Kansas JEFF BINGAMAN, New Mexico
JEFF SESSIONS, Alabama PATTY MURRAY, Washington
JOHN ENSIGN, Nevada JACK REED, Rhode Island
LINDSEY O. GRAHAM, South Carolina JOHN EDWARDS, North Carolina
JOHN W. WARNER, Virginia HILLARY RODHAM CLINTON, New York
Sharon R. Soderstrom, Staff Director
J. Michael Myers, Minority Staff Director and Chief Counsel
(ii)
C O N T E N T S
__________
STATEMENTS
Tuesday, April 29, 2003
Page
Gregg, Hon. Judd, a U.S. Senator from the State of New Hampshire. 1
Gerberding, Julie, M.D., Director, Centers For Disease Control
and Prevention................................................. 3
Gully, Paul, M.D., Senior Director General, Population and Public
Health Branch, Health Canada; and James Young, M.D.,
Commissioner of Public Security, Ministry of Public Safety and
Security, Government of Ontario, Canada........................ 27
ADDITIONAL MATERIAL
Statements, articles, publications, letters, etc.:
Julie L. Gerberding, M.D..................................... 38
James G. Young, M.D.......................................... 41
Senator Johnson.............................................. 49
Samuel Wallace............................................... 50
(iii)
SEVERE ACUTE RESPIRATORY SYNDROME (SARS)
----------
TUESDAY, APRIL 29, 2003
U.S. Senate,
Committee on Health, Education, Labor, and Pensions,
Washington, DC.
The committee met, pursuant to notice, in Room SD-106,
Dirksen Senate Office Building, Senator Gregg (chairman of the
committee) presiding.
Present: Senators Gregg, Frist, Kennedy, Dodd, Mikulski,
Murray, and Reed.
Opening Statement of Senator Gregg
The Chairman. Why don't we get started? I will ask the
press to wrap up.
This is our second major hearing on the issue of the SARS
virus and its implications for the United States and our role
in trying to abate it as much as possible, certainly here in
the United States but also internationally.
Senator Kennedy will be joining us in a few minutes, as I
understand, but we wish to get started because we have a lot of
important witnesses who are actively involved in the fight, and
we want to make sure that they are not taken away from it any
longer than necessary.
It is important to get out as much public information as we
can on this issue so that the American public and to the extent
we have international viewers, they can appreciate the effort
that is going into trying to identify and contain this virus
and be sure that their government is doing what is necessary in
order to accomplish this with the tools that we have available
to us.
Unfortunately, it continues to be a rampant problem
especially in China. There is, as Dr. Gerberding has said
before, no vaccine and right now no antibiotics which appear to
be able to be used to limit its impact, and therefore it is
important that we identify quickly people who may have symptoms
of SARS, especially those coming into the United States. If we
identify those individuals, and people self-police themselves
as they come back from regions which may have high infection
rates, and if they have the sense that they have cold symptoms,
they call their medical provider--call them, hopefully, and not
go to them--and find out what the next step is. So it is
important that American citizens understand that that is their
obligation as good citizens to pursue that course of action.
Today we are going to hear from Dr. Gerberding, who is head
of CDC and is doing an extraordinary job for us on this issue
and many other issues. We are also going to hear from Dr.
Gully, from Health Canada, which is the national health
organization in Canada, and Dr. Young, who is with the province
of Ontario and is involved in the fight there.
I think the issues before us are many--how far down the
road are we here in the United States in being ready to handle
this threat. We have been lucky so far. The super-spreader who
hit Toronto may have easily landed in Boston or New York or Los
Angeles or even Manchester, NH.
We have just been fortunate in not having had the problems
that Canada has had, and the question is now that we have been
so fortunate, how can we make sure that we take advantage of
our good fortune and address the problem aggressively.
Clearly, China still has a huge problem and does not appear
to have its arms around that problem yet, in my opinion. But
other nations such as Vietnam and Canada appear to have taken
different tacks and have been reasonably successful, and we
look forward to hearing from those nations, Canada
specifically, today.
The border with Canada is, of course, the longest
undefended border in the world, and we are very proud of that,
but the issue now is do we need to defend ourselves relative to
the issue of SARS coming across the border, and if so, how do
we do that, and how do we do it in a constructive way that
assists not only our Nation and our people but also our
neighbors in Canada who are such important and good friends to
us.
So we look forward to the testimony today. A number of
other issues have been raised, and we will proceed to address
those as we move down the road of the hearing, but first, we
want to hear from Dr. Gerberding and get her thoughts and input
on how we should be proceeding, specifically where we are and
how we should be proceeding.
Before we begin I have a statement from Senator Dodd.
[The prepared statement of Senator Dodd follows:]
Prepared Statement of Senator Dodd
Mr. Chairman, thank you for convening this second hearing
on the continued spread of Severe Acute Respiratory Syndrome
(SARS). This is an important follow-up to our last hearing,
which took place two weeks ago. Since that time there have been
several new developments, some positive and some negative, and
I would like to understand from our witnesses how we should
interpret these developments. On the positive side, Vietnam has
been removed from the World Health Organization's (WHO) list of
countries with local transmissions of SARS. The WHO has also
reported that the disease appears to have peaked in Canada,
Hong Kong, and Singapore. And there still have been only a
limited number of cases, and no deaths, in the United States.
However, it is not all good news. The number of cases and
resulting deaths rises everyday in China, and it is still
unclear whether all cases are being reported.
With all of our advances in the field of medicine, it is
always shocking when an illness suddenly appears that we know
almost nothing about. In this country, we have been very
fortunate to have conquered so many of the diseases that have
threatened us in the past, that we may begin to feel almost
invincible. However, the development of an illness such as SARS
reminds us that we must remain vigilant to the threat of new
and emerging diseases. Especially in a world that is now so
interconnected, it is virtually impossible to stop disease at
our borders.
It is always the unknown that is most frightening, Mr.
Chairman, and unfortunately we know very little about SARS.
That is why I believe that today's hearing has the potential to
be quite useful as a forum to address some of the questions and
conjecture surrounding SARS. As I am sure all of our witnesses
here today would agree, we are best prepared to deal
effectively with an emerging threat only when we know exactly
what it is that we are confronting. Until we know the true
nature of SARS, we will not be able to effectively form an
appropriate response. It is my hope that today's hearing will
signify a step toward better understanding the threat posed by
SARS and how we might effectively respond to its emergence.
More than 300 people have already died as a result of SARS,
and thousands more are infected worldwide. International
flights have been cancelled, and businesses are recalling their
employees from overseas. Photographs in the news media show
ordinary Chinese citizens walking to work wearing surgical
masks a disturbing image in this uncertain time. All the while,
there is very little information about the danger that SARS
presents to our nation. The American public and I include
myself here is full of questions about how SARS might affect
us. Is the danger likely to grow? How can I protect myself and
my family? How do I recognize the disease? What should I do if
I begin to feel sick?
These questions may be an overreaction based on a lack of
information, which is exactly why this hearing is necessary. I
am hopeful that today's panelists can answer many of these
questions, and I thank them for taking the time to be here
today on such short notice.
Mr. Chairman, I would again like to thank you for convening
today's timely hearing. As legislators we have the
responsibility to help the American public better understand
emerging threats and the possible impact of these threats on
their health and well being. We also have the responsibility to
provide oversight of the development of an effective Federal
response to the same threats. It is my hope that today's
session will allow us to do both. I look forward to hearing
from our witnesses this afternoon.
The Chairman. Dr. Gerberding?
STATEMENT OF DR. JULIE GERBERDING, DIRECTOR, CENTERS FOR
DISEASE CONTROL AND PREVENTION, U.S. DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Dr. Gerberding. Chairman Gregg, I appreciate so much the
opportunity to be here to do this and the interest and
leadership that you and your committee have shown in this very
challenging epidemic that we are dealing with.
We are striving very hard at CDC to maintain transparency
about the status of the epidemic and the steps that we are
taking to combat it, and this is really an important
opportunity for us to update you and get your input but also to
make this visible to all the people in the country who are
interested and have a stake in how it is going. So I would just
really thank you.
I also thank Health Canada and my colleagues who have been
working side-by-side with us as we have come to develop
international strategies for managing SARS and also my
colleagues from Ontario who are here today to testify as well.
The concept of collaboration is a word that we use often,
but I think the spirit and the actualization of this particular
outbreak response is exemplary of what true international
collaboration can be; it also illustrates the consequences when
that kind of international collaboration fails.
What I thought I would do is give you a brief update on the
status of the SARS epidemic and then discuss for you the
current approach that we are taking in the United States as
well as what some of our long-term strategies may be as we
begin to transition from the beginning of this problem to the
ongoing concerns that we need to look forward to and anticipate
in the future.
If I can have the first graphic--this is an international
map. You have seen this kind of information before, but it
emphasizes the widespread distribution of SARS on a global
basis. Today WHO is reporting 5,050 cases in 28 countries, and
321 deaths have been reported. That gives a crude mortality
rate of about 6.3 percent internationally, but of course that
mortality rate is very variable from one country to another,
and it may in fact go up as the time lag between when cases are
detected and people either recover or die from illness and the
statistics catch up with the events internationally.
From a domestic perspective, today we are reporting 220
suspected cases. These are people who have traveled or who have
had direct contact with SARS patients and who are ill but do
not have the full-blown pneumonia. We are also reporting 52
probably cases. These are individuals who do have the
pneumonia. And today, shortly following this briefing, CDC will
be releasing a dispatch from our Morbidity and Mortality Weekly
Report that will provide for the first time for the U.S. case
definitions that include laboratory criteria of infection. So
we are adding to the concept of clinical status of the
patients, which would be mild illness, moderate illness for
suspect case definitions and then SARS, the severe illness with
pneumonia, another dimension which is laboratory-confirmed,
meaning one of the three testing criteria for laboratory
results has been positive or laboratory-negative, meaning those
tests are negative, and then finally, laboratory-indeterminate,
either because we have not done the test or the test results
are pending.
This will add a degree of precision, although at the
current time, the status of our test is not accurate enough, or
at least we do not know the accuracy of the test at this point
to indicate that if someone has a negative test, they do not
have SARS. We have more to learn about the interpretation. So
we are putting this out as an additional tool for classifying
individuals with the suspicion of SARS, but we are continuing
to cast a very broad net for our isolation precautions because
we do not want to overlook any potential infectious people who
could serve as a vector of transmission to others. So we would
be happy to make that dispatch available to you when it is
published and disseminated later today.
We have a current strategy in the United States that
emphasizes several key components. First and foremost is,
again, international collaboration, and we are extremely
fortunate and grateful for the efforts that WHO has made to
coordinate the overall global response to SARS. Their
leadership in the investigation as well as the laboratory
coordination is unprecedented and I think certainly accounts
for why we were able to learn so much so quickly once the WHO
alerted the international community to the evolving SARS
problem.
But domestically, our first priority is protecting
travelers, since travelers are the individuals who seem to be
at greatest risk of SARS right now on the international scale,
and our protection of travelers consists of information for
outbound travelers as well as information for inbound
travelers.
Outbound travelers are continuing to receive information in
the form of health alerts, travel alerts, which basically say
be aware that there is SARS in the country that you are
planning to visit, do not go to places where SARS is being
transmitted, and use common sense precautions to protect
yourself.
A higher level of precaution is a travel advisory, which
says there is concern for travelers acquiring this infection in
the country, and it is important that you not go there unless
you have absolute reason to be there--in other words,
nonessential travel to an area should be avoided.
Right now, mainland China, Hong Kong, Taiwan, and Singapore
are countries in which we have travel advisories. We had a
travel advisory in Vietnam as well, but it turns out that they
have been able to successfully contain the epidemic there,
there is not evidence of ongoing risk to travelers, so in the
last 24 hours, we as well as WHO took Vietnam off the list of
countries where nonessential travel should be avoided.
Our efforts on behalf of travelers include the mechanisms
for captains on airliners and other vessels to have the
requirement of reporting an ill passenger to a Customs official
as the flight is inbound and then, for CDC, quarantine
investigators or other Customs officials to intervene, board
the plane or the boat, and evaluate whether the ill passenger
is suspicious for SARS and could be posing a risk to other
passengers.
Finally, of course, is the ongoing distribution of these
health alerts. This is one that has been updated since my last
hearing here, and I can assure you that it is now in Spanish
and French as well as several other languages, and we are
making these health alerts available to airplane and vessel
passengers. In addition, these are being distributed at the 13
land crossings between Ontario and the United States, where we
have approximately 5 million travelers cross the Ontario-U.S.
border every month. So we have had enormous collaboration and
cooperation with the Canadian Government, with Health Canada,
and with the Ontario health officials. We have also benefited
from the interaction with the Department of Homeland Security
and the Customs inspectors, who have been totally supportive of
this major step up in our alerting process.
So international collaboration, protecting travelers, and
the third component of our current strategy is to detect cases
of SARS and isolate them as quickly as possible. And the public
health community and the clinician community in this country
have done an absolutely outstanding job of early detection but
also of implementing the kinds of airborne and other
precautions in the health care setting that will protect our
health care workers.
Our observation so far has been that in the countries where
SARS has really evolved into the community, the weakest link in
the chain is the health care system and the spread to health
care personnel. So we are putting huge effort into making sure
that we have the best possible protection in the health care
environment from the moment the suspected patient has the
initial contact with anyone in the system.
Isolation in our country for SARS cases has been almost
entirely voluntary. This is a typical pattern of maintaining
and managing infectious diseases in hospitals, but we also have
in our State and local health officials the authority to
require a patient with SARS to be isolated should that ever be
necessary.
Finally, the fourth important component of our strategy is
to protect the contacts of SARS patients. That includes in this
country a series of efforts. No. 1 is to identify the contacts,
and our health officials have done a great job of looking for
potentially-exposed people; second, putting those people in an
active monitoring program where they are contacted on a regular
basis to make sure they are not identified as having early
signs or symptoms of SARS; and then, if the do develop
anything, to alert the health care delivery system before they
get there so that those infection control precautions can be in
place.
One other important issue here for us is the fact that I
mentioned early on, that we are working extremely hard to be as
transparent about what is going on and are putting a strong
effort into communication. I wanted to give you some impression
of how active our communication system at CDC has really been.
We have triaged almost 5,000 press calls. Our hotline has
answered over 22,000 calls for information from the public and
about 2,300 emails. We have sent updates about the clinical
information to the 25,000 clinicians who have signed up for the
CDC clinician registry, and 67 clinical professional
organizations are taking our information and redistributing it
to their memberships, so we are reaching hundreds of thousands
of clinicians around the country.
Our website has been accessed by more than 6 million people
on SARS so far, and we have done a satellite broadcast
internationally in conjunction with WHO and clinicians in Asia
that reached more than 40,000 clinicians around the world.
We have sent 16 health alerts. We are now conducting
telebriefings with people in the Asian American community
because we recognize the ongoing concern about fear and
discrimination that they are having to deal with.
And last, our website increasingly has more and more
information that is translated into other languages so the
international community can benefit from the information.
This is not an exhaustive list, but I think it helps to
illustrate that we are making every effort to get information
out in all the ways that we have at our disposal to do that,
and we are always open to input or suggestions about how we can
do that better.
A couple of quick points on the success of that effort--we
have been working with collaborators at Harvard and getting
some information about how the public is really perceiving
SARS, and some preliminary information from this suggests that
about 93 percent of the public know about SARS or have heard of
it, and that is a good thing. It would be hard to miss it, but
occasionally people do not pay attention.
Eighty-nine percent of people said that if they became ill
with a flu-like illness, it would be very important to tell
their clinicians about recent travel. That is so important to
us to know that that message is getting through to the average
person in the community.
Ninety-four percent said that if they had SARS, they would
agree to be isolated, and about 92 percent said that if they
were exposed to someone with SARS and were asked to have
voluntary quarantine, they would agree to voluntary quarantine
for a period of 10 days.
So our public is informed, they are willing to cooperate
with public health measures, and I think that is a good thing,
because right now, all the steps that I have described to you
are primarily a public health strategy which is a tried and
true old-fashioned way of dealing with an epidemic; but until
we have a vaccine or we have antiviral treatment, this is the
best we can do right now, and we will make every use of these
tools, and if the problem evolves in this country, we are
prepared to take additional steps to focus on containment.
We are looking at containment as the primary goal. People
often ask what is the worst-case scenario. The worst-case
scenario is ongoing spread such as we anticipate with influenza
sometime in the future, and we do have a preparedness plan for
pandemic flu, and we are adopting that plan so that we can be
prepared for coronavirus or SARS if it did evolve in that
direction.
I think the best-case scenario is that the containment
efforts will uniformly be successful, and this will all go
away. Increasingly, that seems highly unlikely, as you
mentioned, given the situation in China and other countries
where there is ongoing transmission.
Finally, the most likely scenario, at least as it look from
our vantage point right now, is that we will have to work hard
at containment, but I think we have proven that containment can
be successful in getting a handle on the problem, and we hope
that this will prove to be a seasonal virus and we can buy some
time if the weather changes and transmission decreases--but of
course we cannot count on that, so we need to be prepared to
continue this effort until, again, we have the other tools.
I would just make reference to the Institute of Medicine's
recent report within the last few weeks on ``The Microbial
Threats to Health,'' which makes the major statement that these
emerging infectious disease problems are now part of our life
in the global community, and that the kinds of things we are
doing for SARS we can anticipate we are going to do again and
again as our universe becomes smaller in time and geography,
and we need to learn lessons from SARS and apply them more
broadly for future preparedness.
The last point along those lines is the two CDC strategic
plans for ``Protecting the Nation's Health in an Era of
Globalization'' and ``Preventing Emerging Infectious
Diseases,'' which speak to many of the issues that have served
us well in the current situation.
So I again just thank you so much for your support and
leadership and for holding this hearing so that we can provide
this perspective.
[The prepared statement of Dr. Gerberding may be found in
additional material.]
The Chairman. Thank you, Dr. Gerberding.
Those numbers which you cited, the polling numbers that
have been done at Harvard relative to people's receptivity to
being quarantined, to making sure they contact their provider
if there is some sort of flu situation, are extraordinarily
encouraging, and I think they reflect the great work that you
folks are doing at CDC in this transparency effort of getting
the message out, making sure people understand what we know and
how we know it and what we need to do from here. So I
congratulate you on that.
In that arena, however, you mentioned that you do not see
us containing it, essentially, in China, and as a result it is
continuing to grow as a problem. I am wondering if you can go
into that a little bit more. I notice that the Philippines now
has the issue, as well as Taiwan, China, and Hong Kong,
obviously. What do you see as the game plan for dealing with
those nations which were behind the curve and as a result
generated the problem to a large degree? Do you think they can
get a handle on this? Can they get their arms around it the way
Vietnam and Canada have, or can they not?
Dr. Gerberding. I do not know for sure. We are increasingly
confident that the information that we are getting from China
is reliable. We do not have teams in all areas of the country
yet, but the doors are certainly more open now than they were
in the past several months.
As part of the WHO effort, we have CDC people on the
ground, and we are getting information. The best picture of the
SARS epidemic in China right now would be characterized as
``variable.'' There are some regions like Beijing that are
having an extremely difficult time containing this, and other
cities where the problem does not seem to be widespread or
present at all. Obviously, that could change. There is a lot of
travel within China, so they would need to be able to exercise
the same kind of containment procedures that we are using in
other parts of the world.
I wish I had a crystal ball; I would try to project the
situation there. But I think there is very little suggestion
right now that it is going to go away any time soon in China.
The Hong Kong scenario is suggestive that they are making
strong progress in containment, but there are still
occasionally new cases being reported there. But we did see a
remarkable curtailment of transmission in Vietnam even though
it started there with a very serious outbreak in the hospital.
That situation, with fairly reliable data, seems to be coming
under control, and likewise in Thailand, where there was not
ongoing transmission.
It is very variable. You made reference to super-spreaders
or hyper-transmitters, and that is a term that is useful in
describing clusters of patients and why someone is especially
associated with a large number of exposed and infected people.
We do not really know if there is such a thing. It may be that
people who are ill are infectious because they have a lot of
virus, and when you take a combination of someone who is
infectious and a situation where there is inadequate protection
of the contacts, you end up with that cascade or a cluster that
sets off the chain of transmission. So we have a lot to learn
about why some people are transmitting and others are not and
why some people have severe illness and others do not.
The Chairman. How far away are we from being able to
produce a reliable test, that is, you can deliver in a timely
manner that gives you a pretty good reading as to whether or
not a person just has the flu or whether he or she has have
SARS? And isn't that critical to our capacity to contain it?
Dr. Gerberding. We are certainly at CDC putting a high
emphasis on that diagnostic testing. By the end of this week,
we are sending the first kits out to the State labs that have
the tests. We have two main categories of PCR tests which can
identify virus RNA in the respiratory tract or the blood of
some patients. We also have the antibody test which is
performing as a much better test for discriminating SARS from
other patients. Unfortunately, we cannot interpret it until 21
days after the person has become ill.
These tests are still under evaluation, but FDA is working
side-by-side with us to get them into a status where we can use
them for clinical care, and that is an imminent step that we
will be taking very soon.
We also have, as you know, posted the RNA genome on the
website, and I have documentation from numerous private sector
companies and biomedical or biotech companies who are
interested in working on diagnostic vaccines. So we are taking
the steps necessary to make the information and materials
available to the private sector so they can contribute to this
effort, and that, in the context of an international community
that is doing the same thing, putting our collaborators in
Canada. I think we are very close to a reliable diagnostic
test--weeks, not months or years--unlike the vaccine or the
treatment which is a long way away.
The Chairman. If you could just confirm again that we
believe this was not manmade and that it came from animals to
humans, that would be good; and second, to what extent are we
seeing the disease mutated or do we expect to see it mutate so
that even those diagnostics might become less than effective?
Dr. Gerberding. The virus itself is a single piece of RNA.
It is a single-stranded virus. It is actually probably the
largest RNA virus that we deal with in humans. And it is in a
family, the coronavirus family, that is notorious for
recombination, meaning exchange of pieces of the virus with
cousins, as well as making mistakes as it replicates.
We are so early in this epidemic that we have not
documented any association between changes in the virus and the
pattern of transmission or the severity of illness, but it
would not be surprising for this to occur with this particular
kind of virus, and that is something that we have to be
monitoring because it could very well at least interfere with
the PCR test and potentially with the antibody test as well.
So it is a concern. It will also have implications for
vaccine treatment. But we have not identified that as a problem
yet.
The Chairman. And we still do not feel that it was manmade;
we feel that it was transferred from an animal to humans?
Dr. Gerberding. The pattern and onset as we understand it
in China is really most consistent with a naturally-evolving
coronavirus. I do not have any evidence to suggest anything
intentional at all
The Chairman. And finally, the two prominent leaders on
this issue in Canada have joined us today, and I would be
interested in CDC's evaluation of where Canada stands and what
we can learn from Canada.
Dr. Gerberding. I look forward to being updated from our
nearest neighbors, but from our interaction--and we do have a
CDC employee at Health Canada, and Health Canada has a staff
member in our operations center at CDC, and we also have a team
in Ontario working in the health care system, so I think our
information is reliable--we understand that we need to be
cautiously optimistic about Canada. They have not had a new
case in I think 7 days, and there is not evidence of ongoing
community transmission there. That is why they are not on our
list of travel advisories. But we are doing the alerting at the
borders and for outbound passengers and if we are continuing in
this in trajectory, I think we will work very hard with our
collaborators in Canada to make sure the rest of the
international community appreciates that the disease is
contained there, at least right now.
The Chairman. So the Red Sox can go there and beat up on
the Blue Jays.
Dr. Gerberding. I am not going to get into sports issues.
The Chairman. Senator Kennedy?
Senator Kennedy. Thank you very much, Mr. Chairman, and I
thank you for holding this hearing again. It is enormously
important.
And I want to thank Dr. Gerberding and all those at the
CDC. I think it is important that Americans understand what a
center of excellence the Centers for Disease Control is and how
well it is being led. We are enormously appreciate of your
leadership, Dr. Gerberding.
It has been 3 weeks since you last testified. The disease
has spread to 27 countries, affected every continent, claimed
200 more lives, and sickened 2,000 more patients.
Although SARS remains a global threat, it has provoked an
extraordinary global response. Health agencies around the world
have responded forcefully to SARS. Scientists have labored day
and night with extraordinary results. They have deciphered the
complete DNA sequence of the virus. They are developing
sensitive new tests to spot infection and are testing ways to
cure the disease and develop the diagnostic test that Senator
Gregg referred to. Public health agencies have responded
effectively to prevent local outbreaks from becoming national
epidemics.
As has been pointed out, SARS is on the decline in Canada,
Singapore, and Hong Kong. In Vietnam, the wildfire of SARS has
been extinguished. Just one hour ago, the World Health
Organization announced that it is lifting its advisory against
travel to Toronto. The world owes an enormous debt to the
dedicated health professionals who have worked tirelessly to
protect our health from the threat of SARS.
From Boston to Los Angeles and Seattle to Miami, the story
is the same. Budgets have been cut to the bone, and there is no
excess capacity to meet new challenges like SARS. According to
Dr. Kevin Stevens, the director of the New Orleans Public
Health Department, ``We have very few resources, and if we
should have a SARS outbreak, we are very poorly prepared.''
Dr. Laurene Mascola of Los Angeles County Department of
Health Services said that, ``In California, about 2,000 people
die every month from unexplained pneumonia. We have dealt with
SARS to the detriment of other diseases.''
One of the most effective ways to fight the spread of SARS
is quarantine, yet many of the Nation's major health
departments would be hard-pressed to use even this basic tool
of disease containment. In Philadelphia, for example, there is
no city-owned hospital, and the health department has no funds
to set up a quarantine facility of its own. It would instead
have to rely on hard-pressed independent hospitals to house
SARS patients who need to be isolated.
Seattle has only limited facilities to isolate contagious
patients. That city is already facing the highest number of TB
cases it has seen in 30 years. With only two full-time
infectious disease physicians to serve over a million
inhabitants, the city would soon be overwhelmed by a major
epidemic.
In Boston, the health department is already stretched thin,
answering over 200 calls a day from people worried about SARS--
and there are no confirmed cases in the city.
In cities across America, there are gaps in our ability to
contain a SARS outbreak should one occur, and we need to
address the deficiencies, and we must address them now.
Congress has tried to reduce these deficiencies in recent
years, investing more in our defenses against bioterrorism, and
these investments are clearly paying dividends now in the fight
against SARS. But their effectiveness has been undermined by
cuts in funding for hospitals and health agencies at both the
Federal and the State levels.
A survey by the American Public Health Laboratory
Association found that 30 State health laboratories faced
budget cuts this year--only seven expected their budgets to
remain the same, and none expected more funds.
Our State laboratory in Massachusetts estimates that it
will need hundreds of thousands more dollars to test tissue
samples for SARS. With additional funds, they could determine
whether patients truly have SARS or a sniffle in a fraction of
the time it takes now; the quicker the decision, the more
likely we are to keep an outbreak from spreading.
This is the situation across the country. I have had my
staff call the major cities in the country and the ports of
entry, and I have just given you a taste of what is happening
out there.
We have had extraordinary success under your leadership of
CDC. We know the devastating impact that something like this
can have, let alone if it were a bioterrorism threat.
What do we say to the people in the local communities about
what kind of help and assistance they are going to receive in
terms of trying to deal with this kind of challenge locally?
What kind of hope can we give them?
Dr. Gerberding. First of all, let me just say that I am
aware of the difficulties that State and local health agencies
are having in this arena and others. As I try to say publicly
as often as possible, our public health system is suffering
from decades of neglect, and we cannot fix it with the one-shot
bolus of resources or even a sustained investment at the level
that we are making in terrorism without really thoughtfully
planning and focusing and prioritizing the capabilities to
respond to these new threats.
We are very grateful for your leadership and Chairman
Gregg's leadership, Senator Frist's leadership, and that of the
full committee, for your support of the improvements in public
health and public health infrastructure, and we have made
progress. I really would like to emphasize that we are
responding as well, I think, to SARS as we are because those
investments are paying off. But there is a lot more work to do,
and the appropriation that Congress made, the $16 million that
was included in the supplemental budget, we obviously need to
make sure that some of that resource goes to the States to help
out with the additional burden that this is placing, and we are
taking a lot of steps now to make sure that we can understand
and document the true needs as well as the true economic impact
of what they are trying to do.
It is a moving target right now, and it is difficult to
predict what they will need, but we need to take it seriously.
Senator Kennedy. I appreciate that, and it is not entirely
fair to ask you about the resources that ought to be necessary,
but having gone through the SARS period and having seen what
good preventive work means in terms of getting a handle on
this, we know that there is still a lot of danger out there.
But the progress that has been made is enormously important,
and people should understand that. But we also want to try to
make sure that we are going to benefit from this kind of
experience if we are going to be facing other kinds of threats,
whether it is dealing with smallpox, which is the
administration's program--we have been able to work out the
program now; that is costly in terms of implementation--plus
the potential danger from bioterrorism.
So this is an enormously important area of need, and at the
same time, we are facing the further cuts in terms of
hospitals--about $1.4 billion--at a time when we are returning
about $450 million that could help and assist them. We are
trying to prepare them for a surge capacity at a time when the
roofs are leaking.
I think we have got to try to make the investments that are
necessary in terms of protecting our people at the local and
community level. We see what a difference it makes when it is
done that way and when we have had strong leadership.
We thank you very much for all that you have done and all
that you continue to do.
My time is up, Mr. Chairman.
[The prepared statement of Senator Kennedy follows:]
Prepared Statement of Senator Kennedy
I welcome this followup hearing on SARS. And I commend Dr.
Gerberding and the men and women of the Centers for Disease
Control for their impressive efforts in addressing this deadly
virus. We are all enormously grateful for your leadership and
for the difference you have made in America, and across the
globe.
In the three weeks since Dr. Gerberding last testified, the
disease has spread to 27 countries, affected every continent,
claimed two hundred more lives, and sickened 2,000 more
patients.
Although SARS remains a global threat, it has provoked an
impressive global response. Health agencies around the world
have responded forcefully to SARS. Scientists have labored
day--and night--with extraordinary results. They have
deciphered the complete DNA sequence of the virus thought to
cause SARS. They are developing sensitive new tests to spot
infection and are testing ways to cure the disease.
Public health agencies have responded effectively to
prevent local outbreaks from becoming national epidemics. As a
result, SARS is on the decline in Canada, Singapore and Hong
Kong. In Vietnam, the wildfire of SARS has been extinguished.
Just one hour ago, the World Health Organization announced that
it is lifting its advisory against travel to Toronto. The world
owes an enormous debt to the dedicated health professionals who
have worked tirelessly to protect our health from the threat of
SARS.
The danger is not over, however. In China, the SARS
outbreak has intensified, and we must remain on guard in this
country to respond swiftly and effectively to any SARS
outbreak.
And this crisis exposes anew the limited capacity of our
own public health network. A brief survey of our nation's major
ports and air hubs conducted by my staff this week shows that
if CDC had not been able to contain the SARS outbreak in
America, our local public health agencies lack the resources to
protect the public from SARS and continue to safeguard
Americans from other deadly diseases.
The troops in this new war on disease are doctors and
nurses, and the front lines are hospitals and health agencies.
But unlike our military forces; those who fight battles against
disease are often not given the latest and best equipment.
Instead, they must do the best they can with outdated equipment
and too few personnel.
From Boston to Los Angeles, and from Seattle to Miami, the
story is the same. Budgets have been cut to the bone, and there
is no excess capacity to meet new challenges like SARS.
According to Dr. Kevin Stevens, the Director of the New Orleans
Public Health Department, ``We have very few resources and if
we should have a SARS outbreak, we are very poorly prepared.''
Dr. Laurene Mascola of the Los Angeles County Department of
Health Services said that ``In California, about 2000 people
die each month from unexplained pneumonia. We have dealt with
SARS to the detriment of other diseases''.
One of the most effective ways to fight the spread of SARS
is quarantine--yet many of the nation's major health
departments would be hard-pressed to use even this basic tool
of disease containment. In Philadelphia, for example, there is
no city-owned hospital and the health department has no funds
to set up a quarantine facility of its own It would instead
have to rely on hard-pressed independent hospitals to house
SARS patients who need to be isolated.
Seattle has only limited facilities to isolate contagious
patients--and that city is already facing the highest number of
TB cases it has seen in 30 years. With only two full-time
infectious disease physicians to serve over a million
inhabitants, the city would soon be overwhelmed by a major
epidemic. In Boston, the health department is already stretched
thin answering over 200 calls a day from people worried about
SARS--and there are no confirmed cases in the city.
In cities across America, there are gaps in our ability to
contain a SARS outbreak should one occur. We need to address
the deficiencies--and we must address them now.
Congress has tried to reduce these deficiencies in recent
years by investing more in our defenses against bioterrorism.
These investments are clearly paying dividends now in the fight
against SARS--but their effectiveness has been undermined by
cuts in funding for hospitals and health agencies at both the
federal and the state level.
A survey by the American Public Health Laboratory
Association found that 30 state health laboratories faced
budget cuts this year--only 7 expected their budgets to remain
the same, and none expected more funds.
These cutbacks come at a time when these state and local
health agencies are being asked to do more and more to protect
us against SARS and other diseases. Our state laboratory in
Massachusetts estimates that it will need hundreds of thousands
more dollars this year toy test tissue samples for SARS. With
additional funds; they could determine whether patients truly
have SARS or a sniffle in a fraction of the time it takes now.
The quicker the decision, the more likely we are to keep an
outbreak from spreading.
Even before now, health agencies and hospitals were already
reeling under the burden of implementing the nation's smallpox
inoculation plan. There is no reserve fund for health agencies
to dip into when they respond to a crisis. To meet new
responsibilities in one area, they must cut back in others.
53 percent of local public health agencies say smallpox and
bioterrorism planning are taking away from other public health
services. It's not easy to worry--about smallpox and have to
worry about SARS too.
The picture is no brighter for hospitals. Although they
have received $500 million for bioterrorism preparedness this
year, these funds are dwarfed by cuts in other areas. Graduate
medical education lost $750 million. Medicaid was slashed by
$1.3 billion. Recommended increases that were not funded took
$420 million from hospitals. The result--even with additional
funds from bioterrorism grants--is that hospitals lost $1.9
billion last year. And worse is vet to come this year.
We all have to hope that the SARS epidemic does not make us
pay too high a price for our failure to equip our hospitals and
health agencies adequately when we send them into battle.
That's why everyday--counts now. Dr. Gerberding is a
familiar and welcome presence in the committee, and we look
forward to her testimony and her recommendations for action.
We also welcome Dr. Young and Dr. Gully who will discuss
the response by Canada to the SARS outbreak in Toronto. The
World Health Organization this week announced that the worst of
the outbreak is now over in Canada, and I commend you both for
your success in dealing with this deadly epidemic.
Thank you for joining us today and we welcome your
testimony.
The Chairman. Thank you, Senator Kennedy.
We are going to limit the first round to 5 minutes; both
Senator Kennedy and I took about 5 minutes.
Senator Reed, did you want to ask some questions?
Senator Reed. Yes. Thank you, Mr. Chairman, and thank you,
Dr. Gerberding, for your testimony today and your leadership at
the CDC.
Basically, our strategy today is containment, and I think
consistent with that is monitoring. Could you elaborate on the
procedures you are taking to monitor particularly outside the
United States to get an advance notice of potential
developments?
Dr. Gerberding. When I mentioned monitoring earlier, I was
speaking about the monitoring of exposed people within this
country, and we have asked the State and local health officers
to implement systems whereby they can contact people who have
been exposed to SARS patients in the last 10 days and check in
with them to make sure that they are not developing the early
systems and helping to triage them to health care if they are.
Internationally, monitoring is more along the lines of
surveillance for cases that are occurring there, but we are
totally supportive of the WHO recommendations that passengers
be screened for illness at the time of departure so that there
is not exposure en route. And we are also, of course,
continuing the ongoing effort to alert returning passengers of
the need to get medical care if they develop symptoms within 10
days after their departure from a country where this is
ongoing.
Senator Reed. But you do not have a more comprehensive
surveillance plan, for example--these are just airline
passengers that you are talking about. What about people
leaving via ship or moving over land to different countries and
returning?
Dr. Gerberding. The health alerting mechanism for returning
passengers applies to the airline industry, it applies to the
vessels that come either directly or indirectly to the United
States, and in Canada, at the Ontario border, it also applies
to car passengers.
For direct flights coming into the United States, we have
very close to 100 percent contact. For indirect flights--for
example, if a passenger leaves China and goes to another
country before returning to the United States--we are getting
close to 98 percent, but we do occasionally miss flights in
that domain.
Senator Reed. So I presume, then, you feel that the
surveillance system in place is adequate to give you fair
warning as this disease continues in China, certainly?
Dr. Gerberding. I think the alerting of incoming passengers
is going very well, and it is working. We know that people are
responding to this information and getting medical care.
A broader issue is our capacity to detect these problems
when they start. And the first cases of SARS were in China in
November. We got a WHO alert on March 12. That is 5 months down
the road. That is the kind of system that we need to address in
collaboration with WHO as well as the ministers of health in
the global community. That is not acceptable, and this problem
got started because we did not have an early detection system
to tell us what it was.
Senator Reed. And do you have a plan to not only design
such a system, but to request whatever funding we must make
available for such a system?
Dr. Gerberding. We do have a plan for the system, and I
have to talk with you about the funding and support for it.
Some of the terrorism dollars from the appropriation have gone
into a program to create a better sentinel detection system
internationally. But I think we have a lot of work to do before
we really have a seamless system that we can rely on fast
enough and early enough to tell us that there is a new threat.
A related problem that I specifically struggle with at CDC
is that we cannot get specimens to the United States. We were
aware that there was a mysterious pneumonia brewing in China
and in Asia. We got our first specimen I think on March 13,
which was one from an American citizen in a hospital in Hanoi--
but it took us a really long time to get all of the patients'
specimens that we needed to begin to work on this virus because
the airlines were afraid to fly the specimens to the U.S. We
have no independent authority to go and get specimens, and that
is really a factor that has slowed us down in these
international response efforts time and time again. It happened
here with SARS. It happened with anthrax where we had anthrax
specimens in Chile, and we could not get them to the United
States, even though Department of State and DOD and everybody
were trying desperately to help us.
So that is another component of the early warning system
that we need to resolve.
Senator Reed. And that would require legislative remedy
that this committee should consider?
Dr. Gerberding. I am not sure. We have authorization as I
understand it to lease aircraft at CDC; that is how we managed
the stockpile plane. But there may be additional authorities
that are necessary, and I will certainly be happy to get back
to you with that specific information.
Senator Reed. Thank you.
Let me change the subject slightly. From your comments, it
seems that this might be the face of things to come, that with
globalization and with these inadequacies in at least
surveillance and early alert, we could see other viruses
following this. And as the chairman pointed out, this virus
appears to be mutating, which is the stock of all the science
fiction thrillers--the mutating virus that is detected too
late.
Does this give you concern, that we might see a series of
different viruses or illnesses sweeping across the country?
Dr. Gerberding. I do not want to be alarmist, but I think
history is already teaching us that that is the case. We have
seen the emergence of Nipa virus, we have seen Hanta virus, now
we see the SARS virus; we had the avian flu virus that
fortunately did not spread easily from person to person, so we
were able to attenuate that particular problem. But there is no
guarantee that the next flu strain to emerge is not going to be
as transmissible or more transmissible than SARS.
That is really the message of the Institute of Medicine,
that these kinds of emerging infectious diseases are a part of
our life, and we need to scale up and respond to this
proactively, because we are not going to be able to stop their
emergence.
Senator Reed. So deterrence is not working; we have got to
go into preemptive mode?
Dr. Gerberding. I think so.
Senator Reed. Thank you.
Thank you, Mr. Chairman.
The Chairman. Senator Mikulski?
Senator Mikulski. Mr. Chairman, I note that the Majority
Leader has arrived, and as a Senatorial courtesy, I would defer
to him.
The Chairman. If you want to proceed, he said he would
rather hear from you first.
Senator Mikulski. Thank you very much, Mr. Chairman, for
organizing this hearing, and thank you, Dr. Gerberding and all
the people at CDC who have been working so steadfast and
persistently on this.
SARS is a global menace and a local threat. Germs just do
not know borders. There are three possible cases in my own
State of Maryland, and Marylanders want me to ask what is the
Government doing to contain SARS, to find a cure for SARS, and
also to prevent it from spreading. We also need to be talking
about a communication strategy about what does the public need
to know about SARS, and what do they need to know about how to
protect themselves.
Another issue is that lessons can be learned from SARS
about how we can protect ourselves from other epidemics,
whether they are triggered from who knows where or whether they
come from a malevolent predator. So my question also goes to
the whole issue of public health infrastructure and what I call
``dual use'' to protect us from something like SARS but also
from something like smallpox.
Let me go to that, because Senator Kennedy raised the
issues, and I would like to raise them as well. Some years ago,
we found that the public health infrastructure was tattered, it
was worn and in some places, even nonexistent, with local
health departments not even having fax machines. The Majority
Leader led this committee and the Public Health Subcommittee,
and we worked on a bipartisan basis to upgrade it.
Then, with bioterrorism, we put $1 billion into the CDC
budget last year for State and local departments. Could you
tell me, number one, as you are struggling so valiantly with
SARS, what are the lessons to be learned to protect this
Nation; number two, what is the status of our public health
infrastructure--do we have the biosurveillance? Do we have the
monitoring? Was $1 billion enough, or was it a down payment so
that we could act again in this year's appropriations?
Dr. Gerberding. Thank you for your question and also for
all that you have done to get us started on rebuilding our
public health infrastructure.
There are a lot of lessons that I think SARS illustrates.
The first lesson is that emerging infections are a fact of
life, and we need to get used to that. I think it is also
teaching us that the whole public system has to be intact. We
are only as good as our weakest link, and if we have one failed
public health system or one failure to be able to take the
steps necessary to contain a problem like this, the whole
country could suffer.
The third lesson is the importance of the continuity of
public health with the health care delivery system. We have got
to have both capacities--a viable and vibrant and robust
medical care system with informed clinicians, but also beds and
surge space and training--and that has to be immediately linked
with the public health community.
For me personally, one of the most important lessons is
that we have to have public health research to identify what is
the best way to do all of this. We make it up as we go, and we
have long experience and some success stories to build on, but
looking ahead at the public health needs of the future, there
are a lot of unanswered questions, and we have got to know
faster how we can deal with these efforts and mitigate the
consequences of a problem like this.
Senator Mikulski. But, Doctor, are you satisfied that local
public health infrastructure, public health agencies, are
really fit for duty for this new area? In my own city of
Baltimore, thanks to the great help that came from the State of
Maryland, we have a vigorous biosurveillance program to be
ready for homeland security that is now serving us well in
SARS. Dr. Peter Beilenson, our local health department
official, was prime time thanks to your alerts and your
information, right back in the local community. Then, using our
biosurveillance techniques that were city-wide and even
metropolitan-wide, we could pick up those SARS cases, and Dr.
Beilenson himself went to the apartment building where one of
those cases was, and the information went out. Baltimore is
calm because we have confidence in Dr. Beilenson and our public
health network.
We are in the shadow of Johns Hopkins and the University of
Maryland; we are a wink away from the NIH--not everyone is. So
my question is particularly in these large metropolitan areas
that could be hit so hard, that are so high-risk, do you have
confidence that they are ready, or do we need to make a greater
public investment through you--meaning CDC--to really develop
these essentially combat-ready systems?
Dr. Gerberding. As you describe, Senator, the public health
system is tattered, and the investments that have been made so
far have helped a lot, and we are certainly much better off
today than we were even a year ago--but there are certainly
districts and local health communities that do not have the
kind of capacity that you have in Baltimore. In particular,
Baltimore has an outstanding biosurveillance network that is
directly linked to the health care delivery system, and that is
exceptional, and I would love to see a system like that
functional across the entire United States, if not the globe.
So we do have many more steps that can be taken, and I think
the investments do need to be sustained over time, because it
is not a one-shot fix.
Senator Mikulski. Thank you.
Mr. Chairman, does that mean my time is up?
The Chairman. Yes.
Senator Mikulski. OK. I would just like to thank you and,
really, all of the public health people who have been working
around the clock to do this at the Federal, State and local
levels. God bless you. I think you really are saving lives.
Dr. Gerberding. Thank you.
I would really like to thank you for making that comment
and actually, all of the people who have commented on CDC and
the public health community, because while I may be here
providing information, there are 400 people in Atlanta and many
internationally-deployed who are doing the hard work of
responding to this, and that does not even count all the folks
in the medical and public health communities--they are the true
heroes of this.
The Chairman. The Senate Majority Leader.
Senator Frist. Thank you, Mr. Chairman, and thanks for
holding the hearing today at an important time in an evolving
crisis, that 2 or 3 months ago, none of us would have fully
anticipated, although we all were aware that emerging
infectious diseases were on the horizon, would continue to
occur, and this is, as I have said before, one of many that we
are likely to see in the future. So the time that we spend with
it, the dissection of the response in the United States, in
Canada, in Taiwan, and in Vietnam, is something that is both
important to do and to dissect it in such a way that we can
learn. Thus, for the next emerging infection, we will be able
to respond quickly and appropriately. I am speaking
internationally as well as domestically.
Dr. Gerberding, thanks for your leadership. I do have the
opportunity to tell you that on a regular basis, and I thank
you for that.
I had a fascinating experience over the last 2 weeks and
had talked to Dr. Gerberding and a number of other people
before going to China, but about 2\1/2\ weeks ago made a very
conscious decision in part as a physician and in part as
someone who is familiar with infectious disease. In fact,I
spent most of my adult life fighting infectious disease in my
transplant patients before coming to the U.S. Senate. I made a
conscious decision to go to China, and to Taiwan and South
Korea as well as Japan, but especially Taiwan and China,
because it was unclear at that point in time whether accurate
reporting was underway from that country.
In fact, the consensus was that there was a coverup, a
coverup of data from a centralized Communist Party and
centralized government. And indeed what originated in Guangdong
Province in January had been covered up, had been covered up
aggressively, not only in the province there but almost more
inexcusably, in Beijing itself. For in Beijing, you do have the
potential of infrastructure and infrastructure support and
surveillance, probably more so in the provinces at large.
About 12 days ago, our delegation of eight United States
Senators arrived in Beijing, and President Hu Jintao and the
minister of health at that time knew that we were coming, and
up until about 3 days prior to that, they had simply not been
willing to release statistics.
Now we know that over 3,303 probable SARS cases--that is
the latest statistic as of this morning--and 148 people who
have died have been reported from the virus in China. But 12
days ago, those figures, instead of being 3,000 were, several
hundred, and instead of 148 reported deaths, were in the teens.
We did have the opportunity 8 or 9 days ago to talk
directly with the leadership of the Communist Party at the
highest level, the minister of health, and the acting minister
of health, and also President Hu Jintao.
We were very direct in our conversations with them, and
said that we were well aware that the leadership had been
withholding data. And their response was that was, ``We have
not been collecting the data,'' and that ``We have an
inadequate public health infrastructure''--which they do--``to
really collect that data.'' It was very clear that they were
not releasing data nationally within the country but also
globally as well.
It gave me a great deal of pride to see the World Health
Organization arrive--and all of us know the story--that as they
arrived, SARS patients were put into automobiles, put into
ambulances, and were actually taken out of hospitals so the
surveillance could not take place. This happened while we were
on our Asia trip.
Again I was very direct, speaking as a physician and as
someone interested in infectious diseases, but also as a
political figure here in the United States, that this cannot be
tolerated.
Let me say that the response of both the Communist Party as
well as President Hu Jintao was very positive. The Premier had
said 2 days before that he recognized that this was a problem.
President Hu Jintao said this is a disaster not only in China
but potentially in the entire world--and that was something
that they had not said before.
With that, people then asked where are we in terms of the
evolution in China, and Dr. Gerberding has people on the ground
there who have had the opportunity to meet at this point. I get
the feeling that things are progressing well in the sense that
what is being reported as probable cases and the deaths are
reasonably accurate. What is clear to me, having been in touch
on a daily basis with people in the health care community
there, including this morning and yesterday and every day, is
that we need more data. We are not really getting the data of
contacts. We are not getting the dates of onset of illness. And
I know that we are working hard in that regard.
Their response is simply: We do not have the public health
infrastructure. We can set the central policy at the top, but
by the time you get down to the provincial level itself, there
is no infrastructure there--there is nobody to collect the
data, there is nobody to report the data to--there is no
system.
I share that only because for me, this should give this
committee but especially our CDC and our Government something
that we should feel very good about in that we have begun, with
the assault on bioterrorism in this committee several years
ago, to develop, or further develop and support that
infrastructure in a very positive way.
My question, after that long introduction, stems from a
concern of global surveillance. With China, the public health
officials were generally not supported--nobody listened to
them, nobody at the provincial level. The head of the Communist
Party did not listen to them, the president of the country did
not listen to them--which shows the need for real leadership at
the top.
But Dr. Gerberding, how well are we doing in terms of
global communications? You may have already answered this
earlier, before I came in But what can we do as a committee to
facilitate, since these viruses know no boundaries, they cross
rivers, they cross oceans, they go in airplanes, they go into
people's nasal passages--what can we do to increase that global
surveillance to make sure that when the next virus hits, we
will not have to tolerate such withholding of data which allows
the virus to explode and to reach a point that is critical and
allows it to spread around the world?
Dr. Gerberding. Senator Frist, first of all, we really
appreciate the efforts that you made in China. I think there
was a strong association between your visit and the fact that
the doors became open, and we are now able to get the kind of
information that we have.
I would also say that your efforts follow on those of
Secretary Thompson, who made numerous efforts to intervene and
connect with health ministers in China. At the World Economic
Forum in January, I was present when Secretary Thompson tried
to ask questions about SARS. That was just 2 months into the
problem, and we were reassured there was not a problem, and
that it was chlamydia, and so forth. So it has been a very long
path to get to where we are, and I appreciate the problem of
infrastructure in China, but unfortunately, many parts of the
world lack global public health infrastructure, and I think we
have a lot of work ahead of us if we are going to be able to
get the kind of global surveillance system that you are talking
about.
However, we do have some pieces of it. WHO has a network,
and various countries have established networks of
communication, and I think our next step is first of all to
identify what we have that is working and fill in the gaps
where it is not working. Easier said than done, but just to
illustrate what can be done, in China, CDC does have a
satellite network for training that has been established in the
various provinces that allows us to put out information into
the Chinese public health and health care community. Now, that
is an enormously efficient tool for disseminating information.
We just have to get it connected in the opposite direction so
we can have the kind of surveillance and detection capacity
that we need to find something when it first starts.
We have plans, and I would be delighted to sit down with
you and with the Department folks in international health at
HHS to look at what the priorities really need to be right now
for filling in the gaps in the global surveillance system. It
is going to be a big task.
Senator Frist. In our meetings in China 8 days ago, I very
specifically offered to the Chinese leaders our support for any
technical assistance that the United States can provide in
containing the virus, and I am pleased that representatives
from across Asia are meeting today to endorse a series of
measures to both stop the spread of disease but also to reach
out and be willing to say, Yes, we can use that help as we go
forward.
Thank you for your leadership.
Dr. Gerberding. Thank you.
The Chairman. Senator Murray?
Senator Murray. Thank you very much, Mr. Chairman, for
holding this hearing, and Dr. Gerberding, for being here. You
have been really good about your time. I have had the
opportunity to talk with you about this issue several times as
a member of the Labor-HHS Appropriations Subcommittee, and I
know you are really working hard to make sure we have all the
information.
I especially want to thank our friends from Toronto, Canada
for being part of this today. I think we have a lot to learn
from them--and frankly, any of us could be Toronto, so it is
great for them to share their information and help us learn
what we need to know as well.
I just have a couple of questions, Mr. Chairman. I know you
want to get on to the other witnesses.
Dr. Gerberding, I continue to be concerned. I know we
provided $16 million in emergency supplemental to address the
SARS outbreak, but I am concerned whether that is sufficient
funding and whether CDC has shifted resources from other
infectious disease prevention efforts so we can focus on SARS,
and whether diseases like TB are being underfunded because we
have this focus now. If you could respond, I would appreciate
it.
Dr. Gerberding. When the SARS outbreak started, we were in
the midst of orange alert in this country because of the war in
Iraq and other issues then. So from the very onset, we defined
the goals of the mission but also defined the strategy as being
one characterized by parsimony, and that means trying to be
right-sized in the personnel and the amount of engagement in
SARS that we were committing particularly in the international
arena, since we had the expectation that we could be called
upon to deal with a second threat or something related to
terrorism.
Since that was the characterization of the response from
the beginning, I think we have been doing an efficient job of
managing our human resources as well as our dollars, but
clearly this is a large effort, and the $16 million
appropriation was really critical to our success.
We anticipate that some of the $16 million obviously needs
to go out to the State and local agencies that are directly
impacted by this as well, so it is not just there to support
the CDC infrastructure.
The impact on other programs at CDC has not been zero, but
we have mitigated, I think, any major impact by rotating people
in and out of the SARS effort, not taking somebody from another
center and keeping them engaged in this over the long haul. So
our management has been designed to allow a comprehensive set
of experts from across the agency--because it takes everybody,
not just the infectious disease people; it takes occupational
health people, it certainly takes a communications team that
activates our emergency communication system--but when people
get detailed to SARS, they are there on a time-limited effort,
and then they go back to their regular responsibilities so that
we can minimize the impact. But I certainly could not say that
there is no impact at all.
Senator Murray. And I think we have to be really careful
about that balance as we go through this.
The other question I have is really one of communication,
because as Dr. Frist has said, there are no boundaries on
disease. My home State of Washington has a great public health
prevention system and public health strategies in place, but
not all States do. How are you monitoring communication between
States, because if somebody gets infected in one State, in a
city right next to another one, it very quickly can progress
that way--and also internationally. Vancouver, B.C. is very
close to Bellingham, WA, and there are hundreds of examples
like that across both borders.
Are we working internationally with other governments as we
hear about those cases and communicating back and forth between
States, localities, and internationally?
Dr. Gerberding. In terms of the domestic situation, the
strategy for integrating information across State boundaries
has relied primarily on the weekly--or daily, sometimes--
conference calls that we have with a group of State health
officers, and Dr. Siedlecki is obviously a major leader in
that.
Senator Murray. Does everybody participate in that?
Dr. Gerberding. Most of the States participate most of the
time. At any given time, not all 50 are on a particular call.
But in addition, that information is posted on the Internet,
and we have health alerts that go out broadly throughout the
system whenever there is anything new. We also have a
connectivity with the public affairs officials in each State
that link back to CDC and with each other. So we are working
very hard to maintain that seamless integration.
Internationally, we have a CDC staff member at Health
Canada and a Health Canada staff person in our operations
center at CDC, so that has been a great help to us in having
free exchange of information back and forth. We are going to do
this every time because it has made so many problems disappear.
We have special groups of people looking specifically at
border issues, because there is the international boundary
where, for example, planes often fly to Vancouver before they
come to the U.S. and so forth, so those very specific cases of
the need for greater integration are handled on a situation-by-
situation basis. But we can always do more, and if you have
ideas or if there are gaps that come to your attention, we
definitely want to try to resolve that.
Senator Murray. Very good. I really appreciate that.
Thank you very much, Mr. Chairman.
The Chairman. Senator Dodd?
Senator Dodd. Thank you, Mr. Chairman, and thank you, Dr.
Gerberding once again for being here and for your testimony.
I have two quick health-related questions and then a couple
of broader questions if I can. First, I just want to get a
sense--I have read some reports that SARS actually appears to
have less potency when it comes to children than it does in
older people. And second, since we have talked, obviously a
short amount of time has elapsed, but to what extent is the
work or progress on a vaccine moving along?
Could you answer those two questions, please?
Dr. Gerberding. Yes. With respect to children, children are
not immune. I think we thought early on that this might be most
severe in the elderly, since the early cases and the deaths
were weighted in the direction of older people. But as we see
more of the international picture unfold, we are seeing severe
infection in all age groups. There is a small number of infants
born to pregnant women with SARS, and that has been cause for
concern in Hong Kong and probably in other areas as well.
Senator Dodd. Is it showing up in the infants?
Dr. Gerberding. So far, we do not have documentation that
infants have it or that they acquired it in utero, but they
were delivered by Cesarean section, and they are premature, and
they have respiratory difficulties, so they are being watched
very carefully to make sure that this was not a problem with in
utero infection.
So there is a lot to learn. I think that if we can get the
kind of information that Senator Frist mentioned from China
about dates of onset and ages and the clinical characteristics
of the 3,000 cases there, we are going to know a lot more about
the spectrum of illness and will be able to give you a better
answer to your question.
In terms of the vaccine, the short answer is we are not
going to have a vaccine for at least a year, but the steps are
well under way. Getting the virus sequenced was a major step.
NIH has inserted the coronavirus into a certified cell line,
which is an important step to getting a vaccine product
started. They are starting by simply killing the virus and
inoculating it in animals to see whether that protects against
re-exposure. The first-generation vaccine will probably be
based on something along those lines.
The optimism is that our technology should allow us to do
this very quickly and that there are vaccines for other
coronaviruses in animals and birds.
The pessimism is that those vaccines are not always 100
percent protective in animals and birds, and we do not know yet
enough about the immunology of the response to coronavirus
infection to know how likely it is that we will get a strong
protective response or that the protective response to one
strain will cross-protect against any evolution that occurs in
the virus over time.
So there is a lot of work to be done, but there has been
good progress, and I think certainly fast out of the starting
gate compared to many other infectious diseases.
Senator Dodd. Thank you very much.
Let me ask two quick questions if I can. I wanted to follow
up on Senator Murray's question. She asked about the
communication that goes on with the State health directors.
What are the requirements today? I have five suspected or
probable cases in Connecticut--and at some point I would like
to know the distinction between a ``probable'' and a
``suspected'' case--but are there requirements that those cases
be reported to you immediately? Do you know of all cases that
have been identified as probable or suspected at CDC?
Dr. Gerberding. We have high confidence in the reporting
from the States, particularly----
Senator Dodd. Is it required? Is it required?
Dr. Gerberding [continuing]. It is not required. CDC has no
authority to require reporting to CDC.
Senator Dodd. Could you have that? Would you like to have
that authority?
Dr. Gerberding. Well, we have a system that works, and that
is based on each States develops its own regulations and
statutes about what is reportable to the State, and because we
fund----
Dr. Gerberding [continuing]. Well, it is a little bit
different because we fund the States to report diseases to us,
so there is a carrot there, and we do not have to resort to the
stick. But it is true that overall, there is variability in the
reporting of many of the reportable conditions. This one,
because it is new and because we have these outstanding
relationships, I think we have a high degree of confidence that
we know about all the cases.
Senator Dodd. But it is troublesome in a way. I can see why
people were critical, and rightly so, of the Chinese,
particularly the province, not reporting for some time--
whatever their motivations may have been. I would be nervous if
someone at some point in some State, for whatever reason,
decided they did not want to report the cases. So I would give
that some thought if you would; I would be interested.
Second, after 9/11 here, obviously, we have all taken
different steps and actions to protect our homeland security.
Tell me what you are thinking now--what happens if we end up
with a Toronto in Hartford, CT, Baltimore, Seattle? What steps
have you already planned and thought about that you would take
in order to deal with that kind of problem in one of our major
cities--close schools--what are the steps that you have already
thought about that we would take in this country now as a
result of this experience?
Dr. Gerberding. We have a set of step-wise responses that
we would be able to scale up if the situation evolved to the
point that Toronto or worse experienced. The first step is to
initiate the appropriate level of quarantine--and I use the
word ``quarantine'' very precisely here; quarantine applies to
the exposed but unaffected people--so we would initiate
voluntary quarantine if necessary to separate the exposed
people from the rest of society so that if they were incubating
the disease, they would have little if any chance of passing it
on. And most likely the scenario would be that the health care
personnel are the most vulnerable group--that has been the
experience in virtually every country--so we could go from the
system we have now, where exposed people are monitored actively
by their State and local health officials to a system where
they are actually quarantined or set aside from others until
they are out of their incubation period, which is about 10
days.
Senator Dodd. Is there existing authority to do that?
Dr. Gerberding. We have a mosaic of authorities in States
for taking these kinds of steps, but yes, every State has the
authority to do that. How they do it is very variable, and one
of the things that has been going on since 9/11 is an
evaluation of what the public health laws are on a State-by-
State basis.
Georgetown and Johns Hopkins have initiated the Model
Public Health Law Program, and so far, all 50 States have done
an inventory of the adequacy of their public health laws to
deal with a situation like this. Thirty-nine States have
proposed statutory regulatory changes to their State
legislatures to improve their public law, and so far, I think
that about 22 States have actually changed statutes or
regulations to make sure they are up-to-speed.
Some States do not need to make changes because their
current laws are adequate, but we are working very hard to
bring everybody up to the same level--and keep in mind that if
the State authority fails for whatever reason, there is a
residual Federal quarantine authority, particularly if it
pertains to interstate commerce or borders with the
international community.
Senator Dodd. I have taken a lot of time, Mr. Chairman, and
I apologize.
We might want to think about something along the line--now
that we have all admitted, obviously, the mobility and
globalization issue that you have talked about, and Senator
Kennedy has and the chairman has--we might want to be thinking
about pulling all this together to some degree and looking for
a coordinated national approach much along the lines of the
homeland security issue here in terms of how our States
interface with the Federal organizations, the World Health
Organization, and others. I wonder if there could not be some
stepping back and looking at this thing in its totality in
light of this experience here, so that we might be better-
prepared structurally, heaven forbid we are confronted with a
far more serious situation than the one we presently seem to be
in.
So I want to suggest, Mr. Chairman, that we might want to
look at that.
The Chairman. Thank you, Senator Dodd. I agree 100 percent
with that assessment, and in fact I have asked our staff to
start looking at that. I think CDC has its hands full right
now, so that hopefully when we get this sorted out a bit, we
will have a chance to take a more comprehensive view and learn
from this exercise, which is what the next panel is about and
leads in naturally to the next panel.
So, Dr. Gerberding, I thank you very much for your time and
especially for the extraordinary effort--the superb effort, I
believe--that CDC is pursuing in protecting America's health.
Thank you.
Dr. Gerberding. Thank you very much.
The Chairman. We will ask our next panel to join us now.
We are fortunate to have the opportunity to hear from two
of the folks who are on the front lines of this issue in an
area which has, regrettably, been subject to a significant
impact, and that is, Canada, specifically, Toronto, and the
Province of Ontario.
We have with us Dr. Paul Gully, who is the senior director
general for the Population and Public Health Branch of Health
Canada, who is coming to us via videoconference; and also
joining us is Dr. James Young, the commissioner of public
security in the Ministry of Public Safety and Security for the
Government of Ontario.
We very much appreciate both of these gentlemen being
willing to testify. They did actually have to get some
dispensation from their government to testify before a
congressional committee in the United States, and we very much
appreciate their willingness to do that and the openness of the
Canadian Government in allowing this testimony to go forward,
Canada of course being a good friend and great neighbor.
Why don't we start with Dr. Gully, and then we will go to
Dr. Young?
Senator Kennedy. Could I, Mr. Chairman, just join in the
welcome as well?
Dr. Gully, just to join my chairman, the fact that you were
able to get the lifting by the World Health Organization is a
real reflection of your leadership as well, so we want to
recognize that and have the American people understand that we
are listening to some very expertise from both of our witnesses
here today, a very important message.
We are very grateful, and I join the chairman in thanking
you for taking the time, and your government, for sharing your
experience with us.
Thank you.
The Chairman. Thank you.
Dr. Gully?
STATEMENTS OF DR. PAUL GULLY, SENIOR DIRECTOR GENERAL,
POPULATION AND PUBLIC HEALTH BRANCH, HEALTH CANADA; AND DR.
JAMES YOUNG, COMMISSIONER OF PUBLIC SECURITY, MINISTRY OF
PUBLIC SAFETY AND SECURITY, GOVERNMENT OF ONTARIO, CANADA
Dr. Gully. Thank you very much, Mr. Chairman and Senators.
We really do appreciate the opportunity to present to you
this afternoon for Canada, and I certainly would like to
emphasize and concur with the assessment of the collaboration
between Canada and the U.S., our branch which is equivalent to
the CDC in Canada, and the efforts of Dr. Gerberding. I would
also agree with her in her cautious optimism.
I would just like to make a point. As I said, our
Population and Public Health Branch is similar to CDC and also
has a very similar legislative grounding as does CDC.
In terms of the context and our history with SARS in China,
we in Canada were aware of this through our public health
intelligence network. We were aware of what was going on in
November and again in February, and then what was happening in
Hong Kong in February as well as in China.
We also sent out information from that to our participants
across the country in February, and I'll make reference to that
again in just a minute.
The first Canadian case came to our attention on March 13.
The first case in Vancouver had in fact been identified on
March 6. This was an individual who came back from Hong Kong
and as a result of the prior warnings of what was happening,
this person experienced respiratory symptoms and, after coming
back from abroad, was put under respiratory isolation.
It was unfortunate that the first case in Ontario was a
woman who came back from Hong Kong, had stayed in the Metropole
Hotel, became ill, and died at home, and a member of her family
who acquired SARS came to an emergency room in a hospital and
spent a number of hours there and transmitted SARS, then, to
health care workers and other patients.
Unfortunately, because the person had not arrived back from
Asia, and in fact had not had any known connection, apparently,
the possibility of SARS or an atypical pneumonia problem from
Asia was not identified. I think it is a question of luck in
terms, therefore, of what happened there, and I think, as I
have said a number of times, it can easily happen elsewhere
once it gets into a community.
From that individual to that hospital and other hospitals
then came the genesis of the problem in the greater Toronto
area, and Dr. Young can tell you further about that.
At the present time, we have 146 probable cases in Canada.
At the moment, we have just 39 hospitalized cases--all the
others have left hospitals--and indeed, a number of those are
getting better, and they are staying in the hospital until they
are completely recovered.
We have unfortunately had 21 deaths, which is probably a
reflection of the transmission to hospital patients and their
family members, and those hospital patients have tended to be
older, and therefore, in the vast number of those cases, those
deaths have occurred in elderly people.
So the transmission, as I said, occurred to health care
workers and patients in 92 of those probable cases; home
contact with health care workers and patients in 43, so close
contact in the home situation; and then, two specific community
settings, again traceable back to the original hospital--one
transmission in a workplace, a worker who worked in a very
close environment with a colleague transmitted to that
individual, and then a religious group, a large religious
gathering of the order to 250 to as many as 500 people,
transmission to a small number, I believe 4 cases.
What is interesting is that even in a large group of
people, there was not a great deal of transmission. It was a
group meeting that seemed to have a lot of close contact in the
way that they interacted, but it only gave rise to a very small
number of people, those people who we believe were in really
close contact with their fellow believers.
The last health care worker case occurred in Canada around
April 20, and I will come back to that a bit later in terms of
the investigation. The last case occurring in a community
setting was April 7, and the last imported case, April 1.
So I think that there are grounds for that cautious
optimism.
I just want to say one or two points about investigation,
because this issue of case definitions has been a challenge
because of a case definition including contact with a known
case. But we have developed another case definition of a person
under investigation geo-linked, i.e., linked to a general area.
And that will present a challenge to us in terms of especially
those people who arrive, for example, in the U.S. who have been
in Toronto, have a fever, have some respiratory symptoms, to
interpret, if they had no known contact with a case or a
specific setting, whether they are a SARS case or not. And I
again will refer to that a bit later.
But again, we are referring to probable cases in the
numbers I have referred you to, those who have definite
disease.
In terms of laboratory diagnosis, we have carried out
thousands of tests on now thousands of people--we say thousands
of people because we have in fact tested as probable suspects
also those who have traveled with neither and also, then,
banked specimens. And we have some interesting results.
Certainly in the probable cases, we only have about 40 percent
of those who were in fact positive for the coronavirus. And we
have positive cases in those people who have travel history but
no symptoms. It is a mystery. It is undoubtedly a challenge in
terms of interpreting the epidemiology and interpreting the lab
test for the coronavirus, and we certainly look forward to
collaborating internationally in answering those questions.
We have sent out kits for testing to laboratories, but we
are saying that that is essentially at the moment a research
tool, because as Dr. Gerberding said, a positive test may be
indicative of something, a negative test is not.
We have imposed these actions early on in terms of public
health management, isolation, or isolation/quarantine of
probable cases and their contacts. Infection control has been a
huge issue, as Dr. Young will be able explain to you, in terms
of the hospitals. We have modified traditional infection
control procedures, and in fact we are having the benefit of
three people from CDC with specific expertise who are enabling
Health Canada to work with Ontario to investigate the
circumstances around health care worker transmission which
appears to have occurred even though those individuals have
implemented the appropriate infection control guidelines. So
that is being investigated right now, and again it is a
challenge.
We have in terms of Health Canada responsibility for
Federal workers ranging from our staff, quarantine offices, for
example, but also Customs agents, and giving advice to them has
been very important.
We have also given advice on clinical management and
treatments, and we are watching this very closely because our
Special Access Program enabling physicians to have access to
unlicensed drugs--I believe that is the same in the U.S.
through the APA--that Special Access Program has just issued a
notice essentially saying to physicians that because there is
really no evidence that ribavirin, which is the antiviral which
is being used most widely, little--actually no--evidence that
that is effective, and we have had numerous reports of adverse
drug reactions from this drug that, although we, the Special
Access Program, will not refuse a physician further access to
ribavirin, they will have to make a very, very strong case in
the future.
In terms of other responses, travel advisories, as you have
done in the United States, and we are indeed looking at those
travel advisories. Our activities at the borders are not
dissimilar to those in the U.S. in terms of inbound, and again,
airlines and ships have responsibility for reporting. We also
have yellow cards translated very early on into French,
English, and simplified Chinese, and now we are collecting
contact information on aircraft from the affected areas in Asia
so that we can keep those if necessary.
Outbound, because of the classification of Toronto as an
affected area, we have had another colored card, a cherry-
colored card, and posters at the Pearson Airport in Toronto. It
is a challenge; one has to think of how to get information to
approximately 38,000 people a day, and we are continuing to
refine that, and we will be enhancing that and we will be
working with the airlines to ask them to ask passengers about
what is in the cards.
We are also working in terms of getting information to
people who travel by rail, particularly those exiting the
country, and we are working closely with CDC in terms of the
issue of cruise ships.
We will be enhancing outbound screening. We have a number
of suggested procedures which we will be looking at, and that
is especially important in terms of the lifting of the travel
advisory from the World Health Organization. I believe they are
telling us that to ensure that we take the greater steps to
ensure that we don't export anymore cases, we do have to give
an assessment of how many cases we have exported. There may
have been two in our assessment, and those occurred at least 2
weeks ago now, which we believe is important.
The World Health Organization advisory has, as was
mentioned, been lifted, and lifted as of tomorrow. We lobbied
heavily the World Health Organization in terms of clarifying
the information that they used for the travel advisory, and we
are very appreciative of the close collaboration that has taken
place over the last few days on a number of videoconferences
and teleconferences which led to the advisory and also a visit
from Health Canada staff and the Minister of Health of Ontario
in Geneva.
Another issue for us now is how to maintain a sustainable
response, and I am sure Dr. Young will mention this. We hope we
have turned the corner in terms of the requirement for
quarantine and isolation. That has been a huge task of public
health authorities. The meeting which we are holding tomorrow
and the next day, which I will mention at the end, will be
looking at what we should perhaps do in the future in terms of
isolation, in terms of quarantine, and in terms of further
infection control. Infection control will be very important
because, as I have described, the challenge presented once it
gets into a hospital situation is a real challenge.
Early detection was mentioned earlier. Early detection by
physicians is extremely important, and getting information out
to them. So rapid isolation of a suspect case could be one of
the hallmarks of how we continue to control this, because we do
not think it is going away. We hope that certainly transmission
internally in Canada will go away, but we will continue to have
to deal with imported cases, I believe, even despite all the
border controls that we have.
The other sustainable response we need is in
communication--the transparency, the explanation of what is
happening, the reassurance of the public in terms of the fact
that we have methods to control, we have methods to contain and
control. And we hope that that message gets out
internationally, and we hope that the lifting of the WHO travel
advisory will aid that.
Another issue is the socioeconomic consequences and, even
before the WHO travel advisory, economic consequences for
Toronto and Ontario and Canada as a whole, because a number of
people outside this country do not appreciate the size of the
country and the fact that Toronto is a minuscule part of the
country albeit it has a sizable population.
In terms of travel, the economic downturn has been tangible
in Toronto--which again, Dr. Young may refer to. It is a
challenge for all levels of government in Canada in terms of
trying, again, to encourage people, say that Toronto is a safe
place to be, and encourage the Torontonians to be out and
about. There was a reference to baseball earlier on. The Blue
Jays are selling tickets for one dollar each tonight to get
people out and about in Toronto.
Finally, I would like again to emphasize the importance of
collaboration within Canada with our provincial territorial
partners, numerous Federal government departments, and with the
U.S., as has been mentioned, the liaison with CDC and Health
Canada and a staff person in Atlanta. We also now have a new
lay position who is embedded with the Health Canada Emergency
Operations Center.
Internationally, there is close collaboration with the
U.S., the United Kingdom, the Pan-American Health Organization,
and the WHO.
I agree with Dr. Gerberding in terms of the support and the
lead that the WHO has given us in terms of international
investigation and lab coordination.
Finally, we hare having an international meeting here
tomorrow and the next day. We are very pleased that Dr.
Gerberding will be able to spend at least some time with us, as
will Dr. David Heymann from the World Health Organization. We
are going to take stock, look at lessons learned, and move
forward in terms of border issues, in terms of future
epidemiology, infection control, public health management, and
in fact the laboratory work and science leading to a diagnostic
test and vaccine.
So again I really do appreciate on behalf of the Government
of Canada the invitation to present to you, and I look forward
to any questions that you may have.
The Chairman. Thank you very much, Dr. Gully. That was a
really excellent presentation, and not only comprehensive but I
think it settles out a lot of the issues in its substance and
reflectiveness of the management of the issues. So we
congratulate you on it and thank you for it.
Dr. Young?
Dr. Young. Thank you, Mr. Chairman.
I am pleased to be here today to discuss the important
issue of SARS and to tell you about the effective measures we
have taken to contain and control this new disease in Ontario.
I also wish to thank U.S. Consul General Antoinette Marwitc
and her staff for their strong support of Toronto during our
SARS outbreak.
The Centers for Disease Control is also playing a key role
in our scientific efforts and also in supporting our position
in regard to the WHO travel advisory against Toronto. I am
pleased to say that the WHO has accepted out facts and has
agreed to lift that travel advisory.
The problem for us in responding to SARS has centered on
the fact that we know so little about it. What is it? What are
its characteristics? How is it spreading? When are people
infectious? How do we test for it? And how do we control and
treat it?
In the case of Toronto and the Province of Ontario, we
faced these questions very early in the known history of SARS
and only knew that we were facing the challenge after the
disease was already spreading in a local hospital.
Our index case, as has been mentioned, was clear. A Toronto
resident contracted SARS in an elevator in the Metropole Hotel
in Hong Kong. That person happened to be returning to Toronto,
became ill and died. The 43-year-old son of that person went to
the hospital on March 16--and I would note that date because it
is only 4 days after the initial warning about SARS that was
mentioned--for treatment of what ultimately turned out to be
SARS. While in the emergency department and after being
admitted, this person was not in respiratory isolation. This
person in retrospect is believed to have been highly
infectious, and our cluster of cases takes off from this point.
This person and the next two persons who were infected
through contact in that emergency department all went on to
infect large numbers of other patients, health care workers,
and family members.
It took us time to recognize the initial hospital case and
to make the contacts from that case. Once that recognition was
made, we imposed strict and effective isolation measures. By
this time, however, because of the highly infectious nature of
our early cases, enough staff and patients were affected that
one hospital had to be closed to new admissions, emergency
cases, and transfers. We also started to alert the entire
health care system.
On March 25, we decided that a provincial health emergency
should be declared in order to mobilize the full resources of
the Province of Ontario. We decided to act quickly and boldly
to attempt to eradicate SARS from our community.
We started by restricting activity in all of the hospitals
in the province while we put in place stringent infection
control procedures in all hospitals in the province. These
included everyone, including staff, being checked for illness
before entering a hospital. Staff were required to gown, glove,
and mask in all patient areas of hospitals, and masks were
provided for all patients entering an emergency department.
Isolation was required for all respiratory patients in
emergency departments until their conditions were determined.
Initially, we also felt it necessary to stop all elective
surgery; we stopped all visitors and volunteers from coming to
hospitals, and we organized a new, very strict, system of
ambulance transfers between hospitals.
On the community side, we also took strong measures. Public
health vigorously tracked all contacts of SARS cases and
imposed a 10-day isolation or quarantine on all contacts. This
has meant the isolation or quarantine of more than 10,000
people for a 10-day period. If persons were found to be
ignoring isolation orders, legal remedies were used.
The public has also been encouraged not to go to work if
they show early symptoms of SARS, including headache, malaise,
or muscle ache, and not to go to work before they develop
fever.
Frequent hand-washing has also been encouraged, and we have
had press conferences each day at 3 o'clock in order to again
be as transparent as possible with the public, educate the
public and tell the public everything that we know about SARS.
This is done in order to foster a calm approach to the problem,
and these measures continue to this day.
Before our initial measures had time to take hold, a
transfer of one of the highly infectious patients occurred to a
nearby hospital. This patient again was highly infectious, and
this transfer resulted in more medical staff, their families
and other patients getting SARS. This hospital was also
restricted in its activities.
Our measures have proven effective. Both of the two most
affected hospitals have now been reopened, and they have been
through more than two incubation periods, 20 days, without any
further spread or new cases. All of our known SARS cases are in
SARS units in our hospitals, and there are currently 37
patients in hospitals with SARS. There is a small number of
SARS patients who are finishing their recovery at home.
March 16 was the critical date for Toronto and our SARS
outbreak. As well as the patients and staff becoming infected,
relatives of one patient who took their patriarch to the
hospital that night also became infected. They subsequently
visited doctors, a funeral home, and were involved in a
religious community. This series of unprotected contacts took
some time to trace and piece together and is referred to as the
``BLD cluster,'' named after the religious group. There were 31
cases within this group, and we ultimately isolated and
quarantined more than 500 people. There have been no new cases
from this group since April 9. It is important to note that our
so-called community cases all track back to the original index
case. We have had no sporadic or unexplained SARS in our
community.
Over the Easter weekend, we experienced a setback in our
efforts. We had some incidents of SARS developing in medical
staff working in SARS units. In one instance, a very difficult
and long intubation in a SARS unit infected, we believe, 15
staff who were in attendance for that medical procedure. We
immediately rewrote our isolation procedures for SARS units,
and we invited Health Canada and the CDC to work with us to
study this unfortunate event and to recommend the best ongoing
infection control standards for our SARS units. We believe that
these will become the standard for SARS treatment units around
the world, and we certainly appreciate the fact that the CDC
not only agreed to come, but is working diligently and well
with our people.
Finally, I will comment on where we are today. As of April
28, as I mentioned, we have 37 active SARS patients in our
hospitals--17 fewer than 1 week ago. We have 18 active SARS
patients at home finishing their recovery. We have had a total
of 142 probable cases of SARS but have very few cases each day
now. We have had 20 SARS patients die, but all but one of these
had significant other medical conditions, and most were
elderly.
There has been no spread of SARS through casual community
contact, and more than 20 days have passed since the last
transmission among close contacts outside the health care
setting. And I again emphasize there has been no spread of SARS
through casual contact at any time in Toronto.
We continue to work with the CDC on infection control for
our medical staff who are working in the SARS units and with
Health Canada. This, along with finding and isolating new
travel cases as they come into Ontario, is our current
challenge.
The streets of Toronto are safe from SARS. They are as safe
as the streets of London, Paris or Washington. In fact, a BBC
reporter told me last Saturday that he saw more masks and more
concern about SARS in London than he did in Toronto. That was
as we walked through the streets of Toronto, and people were
out and about on the weekend--and, as Dr. Gully mentioned,
there will be a full Sky Dome tonight out at the baseball game.
But the lesson for all of us is that it only takes one case
to start a new breakout, and therefore, we must be vigilant,
and we must remember that. We can best, as you asked, Mr.
Chair, defend the border by working together, by sharing our
experiences, by sharing scientific data, and by taking common
approaches.
Thank you for this opportunity to discus sour experience in
Ontario.
[The prepared statement of Dr. Young may be found in
additional material.]
The Chairman. Thank you, Dr. Young, and thank you also for
that excellent presentation--and I think it is a presentation
that can bring a fair amount of calm to the situation, and that
is important, because you reflect statistical facts which show
that the virus can be contained, and I guess that is my first
question to both doctors.
Do you feel you have a handle on it in Canada? As you said,
Dr. Young, there may be somebody else who comes in with the
disease, but do you feel as of this time that you have it under
control and have a handle on it?
Dr. Young. Let me speak to Ontario first, and perhaps Dr.
Gully can speak for the rest of Canada. We do feel that we have
a handle on the situation in Ontario. We acknowledge that we
are working in our SARS units with medical staff. This is an
age-old problem in infectious situations around the world in
any unit, and we believe and have reason to be optimistic that
our new measures are taking hold, but we are prepared to do
whatever is necessary and whatever is recommended by the study
group now in order to make our units as safe as is humanly
possible.
By going more than two cycles of this disease both in the
community and within the affected hospitals, we believe that we
have succeeded in getting it out of our health care system, and
as far as it went into our community--which I again remind
people is only by direct contact--it is out of the community,
and it is out of our general health care system.
But those remain the risks if a case comes in and it is not
controlled, but those are the risks for every jurisdiction
everywhere.
Dr. Gully?
Dr. Gully. I agree with Dr. Young that we do have it under
control. I also echo his words in terms of the fact that from
now on, we have to ensure that any new cases that arrive are
dealt with with the utmost care in close contact, but the
health care setting has not been the case in numerous
situations in the past with infectious diseases. The hospitals
have been the ones which are most vulnerable.
So I think it is important that even though it will be a
long time before we get a vaccine, maybe it is a question of
diagnostic test. As described by Dr. Gerberding, we have
traditional methods of public health--isolation in the
community, isolation and quarantine, and infection control--and
these have been applied--through a huge amount of work--but
have been applied and have worked.
The Chairman. Do you have a different approach toward
informing and trying to get the participation of people who are
coming into your country from China or other areas where there
is a higher degree of infection than we have? We are giving out
this yellow card, which was noted by Dr. Gerberding. Is that
your process? You mentioned that you have an information card,
but do you do a more aggressive screening than that in light of
your experience?
Dr. Gully. We still use the yellow card, but what we did do
is to put it back onto the airplanes, so that in fact on
flights from Hong Kong and from China and Taiwan, people on
those planes get the yellow card on the planes, and in
addition, we do collect contact information on those flights,
which is then collected when people disembark.
We have, in a similar way to you, officers meeting flights
to take individuals who are obviously sick and also expect the
airlines to cooperate in terms of informing us of sick people.
So we have in fact put it back into the system a bit more
in terms of on the planes, so that people have much longer to
digest the information and to perhaps ask questions even on the
flight and perhaps self-identify as being sick, so they can
then be dealt with when they disembark.
The Chairman.w are you handling people who are transiting
through a different country that does not have the issue?
Dr. Gully. That is a challenge. Certainly in terms of
individuals transiting through the U.S. we obviously are
relying on the process which we know the U.S. is undertaking.
We have taken the opinion that we have to put things in
place which are--that there is a cost and a benefit to these--
and we feel that because we have not had any reported cases
since April 1, what we have in place is working. And there have
certainly been calls for us to do a lot more, and we have to
decide what is doable, where we feel we should put in the most
effort, and we believe that we have done that.
In terms of outgoing, we may be making further enhancements
of that in particular because of the call from the World Health
Organization relating to exported cases.
The Chairman. What would you say are the three or four
things--or even five, if you have them--off the top of your
head that we in our country should learn from your experience?
You have developed protocols, as you said, that you expect to
be generally acceptable, but if you both could respond to that
question, I would appreciate it.
Dr. Gully. The protocols that we have set up with our
partners obviously in the province in the local health
departments have worked, and I think it was more the fact that
it was into the hospital situation in Toronto before we all
were aware of it. So I think that what you would do in terms of
public health management and infection control is what we would
do. I hope now that you do not get in the same situation that
we did in terms of not identifying a person who actually came
into the country with obvious symptoms and obvious disease.
Dr. Young may want to talk about the quarantine/isolation
experience which is directly related to Toronto.
The Chairman. Dr. Young?
Dr. Young. Yes, Mr. Chair. I would advocate several things,
and some of them you have heard of. Full, open and transparent
communication is number one, because it keeps the calm in the
community, and it keeps people doing what we ask them to do, so
that certainly is very important.
The actions that need to be taken when there is a problem--
we held the view at the time we declared the provincial
emergency that we had very little time to act and that we had
to act properly the first time. So the actions we took were
firm, they were bold, and in some cases they were described as
an overreaction. And I make no apology for overreacting; I
think they have to be when you are faced with this kind of
problem because you only get sometimes one chance to deal with
it.
You then need to mobilize in fact large parts of the
government, because a problem like this affects much more than
just public health; it involves the whole health care system,
doctors' offices, hospitals, and long-term facilities because
this disease is potentially fatal entering into a nursing home
or home for the aged or chronic care facility. It means other
government ministries, because it has such a broad, overarching
government effect on so many departments.
And then, you need to use, I believe, the things that have
worked for us--isolation, close contacts, but isolation has to
be again lots of people and more people isolated than you would
think necessary, and there is a big education in that; strict
infection control within hospitals; and then, reeducation of
the medical community--they have to approach SARS from the
point of view of every case that comes in with a respiratory
problem is SARS until proven otherwise, and a lot more
isolation until that is proven; and finally, trying to get the
community to understand that if there is a firm risk in the
community, people need to stay home when they are sick until
the issue is sorted out, because that allows people to be
isolated in relative terms so that you do not have hundreds of
contacts while somebody is out and sick with a fever.
The Chairman. That is an excellent set of recommendations,
and I am sure our folks will be following that closely, as the
protocols you have developed. I think it is good that you are
having this meeting--it is tomorrow or the next day?
Dr. Young. Tomorrow and the next day both.
The Chairman. Well, we would like to give you some tourism
and send a few staff folks up from this committee, if that is
appropriate, to observe and learn, because you obviously have a
lot to teach us on this.
Dr. Young. Very much so.
The Chairman. Just to reiterate, your last case that you
identified was a public event versus a nonhospital event and
was on April 9?
Dr. Young. April the 9th.
The Chairman. And the incubation period is 10 days?
Dr. Young. That is correct.
The Chairman. So you are fairly confident that as far as
public events are concerned, this is under control?
Dr. Young. That is correct. We are 20 days out today so
that we are confident that our community problems are hopefully
permanently behind us.
The Chairman. Well, we congratulate you, and again, Dr.
Gully and Dr. Young, I thank you very much for being willing to
take the time to participate in this hearing. It means a lot to
us here in the United States; I know it required some special
dispensation in Canada to be able to do this. We very much
appreciate this cooperation, and we look forward to continuing
it, and if we can be of help, you tell us; you have obviously
been of great help to us.
Thank you very much.
Dr. Young. Thank you, Mr. Chairman.
The Chairman. This hearing is adjourned.
[Additional material follows.]
ADDITIONAL MATERIAL
Prepared Statement of Julie L. Gerberding, M.D.
Good afternoon, Mr. Chairman and Members of the Committee. I am Dr.
Julie L. Gerberding, Director, Centers for Disease Control and
Prevention (CDC). Thank you for the invitation to participate today in
this timely hearing on a critical public health issue: severe acute
respiratory syndrome (SARS). I will update you on the status of the
spread of this emerging global microbial threat and on CDC's response
with the World Health Organization (WHO) and other domestic and
international partners.
As we have seen recently, infectious diseases are a continuing
threat to our nation's health. Although some diseases have been
conquered by modern advances, such as antibiotics and vaccines, new
ones are constantly emerging, such as Nipah virus, West Nile Virus,
vancomycin-resistant Staphylococcus aureus (VRSA), and hantavirus
pulmonary syndrome. SARS is the most recent reminder that we must
always be prepared for the unexpected. SARS also highlights that U.S.
health and global health are inextricably linked and that fulfilling
CDC's domestic mission to protect the health of the U.S. population
requires global awareness and collaboration with domestic and
international partners to prevent the emergence and spread of
infectious diseases.
EMERGENCE OF SARS
In February, the Chinese Ministry of Health notified WHO that 305
cases of acute respiratory syndrome of unknown etiology had occurred in
Guangdong province in southern China since November 2002. In February
2003, a man who had traveled in mainland China and Hong Kong became ill
with a respiratory illness and was hospitalized shortly after arriving
in Hanoi, Vietnam. Health-care providers at the hospital in Hanoi
subsequently developed a similar illness. During late February, an
outbreak of a similar respiratory illness was reported in Hong Kong
among workers at a hospital; this cluster of illnesses was linked to a
patient who had traveled previously to southern China. On March 12, WHO
issued a global alert about the outbreak and instituted worldwide
surveillance for this syndrome, characterized by fever and respiratory
symptoms.
Since late February, CDC has been supporting WHO in the
investigation of a multi-country outbreak of unexplained atypical
pneumonia now referred to as severe acute respiratory syndrome (SARS).
On Friday, March 14, CDC activated its Emergency Operations Center
(EOC) in response to reports of increasing numbers of cases of SARS in
several countries. On Saturday, March 15, CDC issued an interim
guidance for state and local health departments to initiate enhanced
domestic surveillance for SARS; a health alert to hospitals and
clinicians about SARS; and a travel advisory suggesting that persons
considering nonessential travel to Hong Kong, Guangdong, or Hanoi
consider postponing their travel. HHS Secretary Tommy Thompson and I
conducted a telebriefing to inform the media about SARS developments.
As of April 23, 2003, a total of 4,288 probable cases of SARS have
been reported to WHO from 25 countries including the United States, and
251 of these persons have died. In the United States, there have been
39 probable SARS cases reported from 18 states. Of U.S. probable cases,
27 have been hospitalized, and none have died. In addition, 206 suspect
cases of SARS have been reported and are being followed by state and
local health departments.
CDC RESPONSE TO SARS
CDC continues to work with WHO and other national and international
partners to investigate this ongoing emerging global microbial threat.
We appreciate the continued support of Congress, and of this Committee
in particular, in our efforts to enhance our nation's capacity to
detect and respond to emerging disease threats. The recent supplemental
appropriation of $16 million to address the SARS outbreak will aid our
identification and response efforts. SARS presents a major challenge,
but it also serves as an excellent illustration of the intense spirit
of collaboration among the global scientific community to combat a
global epidemic.
CDC is participating on teams assisting in the investigation in
Canada, mainland China, Hong Kong, Singapore, Taiwan, Thailand, and
Vietnam. In the United States, we are conducting active surveillance
and implementing preventive measures, working with numerous clinical
and public health partners at state and local levels. As part of the
WHO-led international response thus far, CDC has deployed over 40
scientists and other public health professionals internationally and
has assigned over 400 staff in Atlanta and around the United States to
work on the SARS investigation.
CDC has organized SARS work teams to manage various aspects of the
investigation, including providing domestic and international
assistance and developing evolving guidance documents. These work teams
have issued interim guidance regarding surveillance and reporting;
diagnosis; infection control; exposure management in health-care
settings, the workplace, and schools; biosafety and clean up; specimen
handling, collection, and shipment; travel advisories and health
alerts; and information for U.S. citizens living abroad and for
international adoptions. We have updated our travel advisories and
alerts for persons considering travel to affected areas of the world.
We have distributed more than 600,000 health alert notice cards to
airline passengers entering the United States from China, Hong Kong,
Singapore, and Vietnam, alerting them that they may have been exposed
to SARS, should monitor their health for 10 days, and if they develop
fever or respiratory symptoms, they should contact a physician. We have
begun distributing health alert notices to airline passengers entering
the United States from Toronto and at selected sites along the U.S.-
Canada border.
WHO is coordinating frequent, regular communication between CDC
laboratory scientists and scientists from laboratories in Asia, Europe,
and elsewhere to share findings, which they are posting on a secure
Internet site so that they can all learn from each other's work. They
are exchanging reagents and sharing specimens and tissues to conduct
additional testing.
On April 14, 2003, CDC announced that our laboratorians have
sequenced the genome for the coronavirus believed to be the cause of
SARS. Sequence information provided by collaborators at National
Microbiology Laboratory, Canada, University of California at San
Francisco, Erasmus University, Rotterdam and Bernhard-Nocht Institute,
Hamburg facilitated this sequencing effort. The sequence data confirm
that the SARS coronavirus is a previously unrecognized coronavirus. The
availability of the sequence data will have an immediate impact on
efforts to develop new and rapid diagnostic tests, antiviral agents and
vaccines. This sequence information will also facilitate studies to
explore the pathogenesis of this new coronavirus. We are also
developing and refining laboratory testing methods for this novel
coronavirus, which will allow us to more precisely characterize the
epidemiology and clinical spectrum of the epidemic. These discoveries
reflect significant and unprecedented achievements in science,
technology, and international collaboration.
In order to better understand the natural history of SARS, CDC is
investigating aspects of the epidemiologic and clinical manifestations
of the disease. In collaboration with our partners, we have implemented
or planned investigations to describe the spectrum of the illness, to
assess the natural history of the disease, to estimate the risks of
infection, and to identify risk factors for transmission. These
investigations are being conducted in concert with ongoing surveillance
and epidemiologic efforts.
Rapid and accurate communications are crucial to ensure a prompt
and coordinated response to any infectious disease outbreak. Thus,
strengthening communication among clinicians, emergency rooms,
infection control practitioners, hospitals, pharmaceutical companies,
and public health personnel has been of paramount importance to CDC for
some time. CDC has had multiple teleconferences with state health and
laboratory officials to provide them the latest information on SARS
spread, implementation of enhanced surveillance, and infection control
guidelines and to solicit their input in the development of these
measures and processes. WHO has sponsored, with CDC support, a clinical
video conference broadcast globally to discuss the latest findings of
the outbreak and prevention of transmission in healthcare settings. The
faculty was comprised of representatives from WHO, CDC, and several
affected countries who reported their experiences with SARS. The video
cast is now available on-line for download. Secretary Thompson and I,
as well as other senior scientists and leading experts at CDC, have
held numerous media telebriefings to provide updated information on
SARS cases, laboratory and surveillance findings, and prevention
measures. CDC is keeping its website current, with multiple postings
daily providing clinical guidelines, prevention recommendations, and
information for the public.
PREVENTION MEASURES
Currently, CDC is recommending that persons postpone non-essential
travel to mainland China, Hong Kong, Singapore, and Hanoi, Vietnam. We
are recommending that U.S. travelers to Toronto observe precautions to
safeguard their health, including avoiding settings where SARS is most
likely to be transmitted, such as Toronto health care facilities caring
for SARS patients. Persons planning travel to Toronto should be aware
of the current SARS outbreak, stay informed daily about SARS, and
follow recommended travel advisories and infection control guidance,
which are available on CDC's website at www.cdc.gov/ncid/sars.
Persons who have traveled to affected areas and experience fever or
respiratory symptoms suggestive of SARS should use recommended
infection control precautions and contact a physician. They should
inform their healthcare provider about their symptoms in advance so any
necessary arrangements can be made to prevent potential transmission to
others. Health care facilities and other institutional settings should
implement infection control guidelines that are available on CDC's
website.
We know that individuals with SARS can be very infectious during
the symptomatic phase of the illness. However, we do not know how long
the period of contagion lasts once they recover from the illness, and
we do not know whether or not they can spread the virus before they
experience symptoms. The information to date suggests that the period
of contagion may begin with the onset of the very earliest symptoms of
a viral infection, so our guidance is based on this assumption. SARS
patients who are either being cared for in the home or who have been
released from the hospital or other health care settings and are
residing at home should limit their activities to the home. They should
not go to work, school, or other public places until ten days after
their fever has resolved and respiratory symptoms are absent or
improving.
If a SARS patient is coughing or sneezing, he should use common-
sense precautions such as covering his mouth with a tissue, and, if
possible and medically appropriate, wearing a surgical mask to reduce
the possibility of droplet transmission to others in the household. It
is very important for SARS patients and those who come in contact with
them to use good hand hygiene: washing hands with soap and water or
using an alcohol-based hand rub frequently and after any contact with
body fluids.
For people who are living in a home with SARS patients, and who are
otherwise well, there is no reason to limit activities currently. The
experience in the United States has not demonstrated spread of SARS
from household contacts into the community. Contacts with SARS patients
must be alert to the earliest symptom of a respiratory illness,
including fatigue, headache or fever, and the beginnings of an upper
respiratory tract infection, and they should contact a medical provider
if they experience any symptoms.
EMERGING GLOBAL MICROBIAL THREATS
Since 1994, CDC has been engaged in a nationwide effort to
revitalize national capacity to protect the public from infectious
diseases. Progress continues to be made in the areas of disease
surveillance and outbreak response; applied research; prevention and
control; and infrastructure-building and training. However, SARS
provides striking evidence that a disease that emerges or reemerges
anywhere in the world can spread far and wide. It is not possible to
adequately protect the health of our nation without addressing
infectious disease problems that are occurring elsewhere in the world.
Last month, the Institute of Medicine (IOM) published a report
describing the spectrum of microbial threats to national and global
health, factors affecting their emergence or resurgence, and measures
needed to address them effectively. The report, Microbial Threats to
Health: Emergence, Detection, and Response, serves as a successor to
the 1992 landmark IOM report Emerging Infections: Microbial Threats to
Health in the United States, which provided a wake-up call on the risk
of infectious diseases to national security and the need to rebuild the
nation's public health infrastructure. The recommendations in the 1992
report have served as a framework for CDC's infectious disease programs
for the last decade, both with respect to its goals and targeted issues
and populations. Although much progress has been made, especially in
the areas of strengthened surveillance and laboratory capacity, much
remains to be done. The new report clearly indicates the need for
increased capacity of the United States to detect and respond to
national and global microbial threats, both naturally occurring and
intentionally inflicted, and provides recommendations for specific
public health actions to meet these needs. The emergence of SARS, a
previously unrecognized microbial threat, has provided a strong
reminder of the threat posed by emerging infectious diseases.
CONCLUSION
The SARS experience reinforces the need to strengthen global
surveillance, to have prompt reporting, and to have this reporting
linked to adequate and sophisticated diagnostic laboratory capacity. It
underscores the need for strong global public health systems, robust
health service infrastructures, and expertise that can be mobilized
quickly across national boundaries to mirror disease movements. As CDC
carries out its plans to strengthen the nation's public health
infrastructure, we will collaborate with state and local health
departments, academic centers and other federal agencies, health care
providers and health care networks, international organizations, and
other partners. We have made substantial progress to date in enhancing
the nation's capability to detect and respond to an infectious disease
outbreak; however, the emergence of SARS has reminded us yet again that
we must not become complacent. We must continue to strengthen the
public health systems and improve linkages with domestic and global
colleagues. Priorities include strengthened public health laboratory
capacity; increased surveillance and outbreak investigation capacity;
education and training for clinical and public health professionals at
the federal, state, and local levels; and communication of health
information and prevention strategies to the public. A strong and
flexible public health infrastructure is the best defense against any
disease outbreak.
Thank you very much for your attention. I will be happy to answer
any questions you may have.
Prepared Statement of James G. Young, M.D.
Mr. Chairman, and Members of the Committee: I am pleased to be here
today to discuss with you the important issue of Severe Acute
Respiratory Syndrome (SARS), and tell you about the effective measures
we have taken to contain and control this new disease in Ontario.
I also wish to thank U.S. Consul General Antoinette Marwitc and her
staff for their strong support of Toronto during our SARS outbreak.
The Centres for Disease Control is also playing a key role in our
efforts, and I will elaborate further on this in my remarks.
By way of introduction, I am a medical doctor who serves in a
number of capacities within the Ontario government. I am the Assistant
Deputy Minister of Public Safety and Security, the Chief Coroner for
Ontario and Commissioner of Public Security. The public security office
also coordinates Ontario's approach to terrorism, and manages emergency
situations within Ontario, including such things as SARS, 9/11, Y2K and
the Ice Storm of 1998.
The problem with responding to SARS has centered on the fact that
we know so little about it. What is it? What are its characteristics?
How is it spreading? When are people infectious? How do we test for it?
And how do we control and treat it?
In the case of Toronto and the province of Ontario, we faced these
questions very early in the known history of SARS and only knew that we
were facing the challenge after the disease was already spreading in a
local hospital.
Our index case is clear. A Toronto resident contracted SARS in an
elevator in the Metropole Hotel in Guangdong China. That person
returned to Toronto, became ill and died. The 43-year old son of that
person went to hospital on March 16th for treatment of what turned out
to be SARS, and while in the emergency department and after being
admitted was not in respiratory isolation. This person in retrospect is
believed to have been superinfective and our cluster of cases takes off
from this point. This person and the next two persons who were infected
through contact in that emergency department all went on to infect
large numbers of other patients, health care workers and family
members.
Initial information about SARS was only beginning to flow around
March 16th, and it took time to recognize the initial hospital case and
the other contacts from that case. Once that recognition was made, we
imposed strict and effective isolation measures.
By this time, however, because of the highly infectious nature of
our early cases, enough staff and patients were affected that the
hospital was closed to new admissions, emergency cases, and transfers.
We also started to alert the entire health care system.
On March 25th, we decided that a provincial health emergency should
be declared in order to mobilize the full resources of the province. We
decided to act quickly and boldly to attempt to eradicate SARS from our
community. We started by restricting activity in all of the hospitals
in the province while we put in place stringent infection control
procedures. Everyone, including all staff, were checked for illness
before entering a hospital. Staff were required to gown, glove, and
mask in patient areas of hospitals; masks were provided for all
patients entering an emergency department, and isolation was required
for respiratory patients until their conditions were determined.
Initially we also stopped all elective surgery, stopped any visitors or
volunteers from coming to hospitals, and organized a new very strict
system of ambulance transfers between hospitals.
On the community side we also took strong measures. Public Health
vigorously tracked contacts of SARS cases and imposed 10-day isolation
or quarantines for all contacts. If persons were found to be ignoring
isolation orders, legal remedies were used. The public has also been
encouraged not to go to work if they show early symptoms of SARS
including headache, malaise or muscle ache, and before they develop
fever. Frequent hand washing has been encouraged and a calm approach to
the problem advocated. These measures continue to this day.
Before our initial measures had time to take hold, a transfer of a
highly infectious patient occurred to a nearby hospital. This patient
was another superinfectious individual, and this transfer resulted in
more medical staff, their families and other patients getting SARS.
This hospital was also closed.
These measures have proven to be effective. Both hospitals have now
been through more than two incubation periods (20 days) without any
further spread or new cases and so both hospitals are in the process of
reopening. All our known SARS cases are in SARS units in our hospitals
or, if well enough, at home in isolation finishing recovery.
March 16th was the critical date for Toronto and our SARS outbreak.
As well as the patients and staff becoming infected, relatives of one
patient who took their patriarch to hospital that night also became
infected. They subsequently visited doctors, and a funeral home, and
were involved in a religions community. This series of unprotected
contacts took some time to trace and piece together, and is referred to
as the BLD Cluster (named after the religious group). There were 31
cases within this group, and we ultimately isolated more than 500
people. There have been no new cases from this group since April 9th.
It is very important to note that all of our so-called ``community''
cases track back to the original index case. We have had no sporadic or
unexplained SARS spread in our community.
Over the Easter weekend we experienced a setback in our efforts. We
had some incidents of SARS developing in medical staff working in SARS
units. In one instance a very difficult and very long intubation in a
SARS unit infected, we believe, 15 staff who were in attendance. We
immediately rewrote our procedures, and we have invited Health Canada
and the CDC to work with us to study this unfortunate event and
recommend the best ongoing infection control standards for our SARS
units. We appreciate the fact the CDC agreed to come and are working
diligently and well with our people.
The most recent major blow to our efforts was the World Health
Organization travel advisory issued against Toronto last week. WHO did
not visit Toronto or discuss our outbreak, or its management, directly
with us before taking this action; nor did they give us the required
warning before issuing it. We believe that this advisory was based on
old data and an incomplete understanding of our situation.
The WHO advisory unnecessarily and wrongly alarmed our own
population, has resulted in huge economic loss, and has already
demonstrated that it wastes valuable health resources in other
countries such as the US by causing authorities to think they might
have cases of SARS from Toronto when in fact there is no possible
epidemic link to our cases. The WHO is currently reviewing its advisory
and we urge that organization to immediately lift it based on
scientific facts
In fact, the CDC doctor currently working with us in Toronto has
described our efforts as exemplary. The CDC disagrees with the WHO
position and has correctly, in our view, talked about common sense
precautions in its travel alert. The director is planning a trip to
Toronto this week.
Finally, I will comment on where we are today.
We have SARS patients who are now well and back in the community.
As of April 28th, Ontario had:
37 active SARS patients are in hospitals--17 fewer than
one week ago
18 active SARS patients are at home finishing their
recovery
20 SARS patients have died, and all but one of these had
significant other medical conditions and most were elderly.
There has been no spread of SARS through casual community contact
more than 20 days have passed since the last transmission among close
contacts outside health care settings.
We continue to work with the CDC on infection control for our
medical staff who are working within SARS units. This, along with
finding and isolating new travel cases that arrive from outside
Ontario, is our current challenge.
The streets of Toronto are as safe from SARS as the streets of
London, Paris or Washington. In fact, a BBC reporter told me Saturday
he saw far more masks and concern in London than Toronto. However, the
lesson for all us that it only takes one case to start the new
breakout.
Thank you for this opportunity to discuss our experience in
Ontario. On behalf of the Ontario government, let me express our
appreciation for your interest and understanding.
SARS AND THE TORONTO EXPERIENCE
A report on what happened, why it happened, and the steps we need to
take to manage future outbreaks
When Severe Acute Respiratory Syndrome (SARS) first appeared on the
global scene, it took the world by surprise. Less than two months ago,
SARS was a virtually unknown disease: today it is a household name.
While more than 40 countries have reported SARS cases, a few countries
have been affected in an especially dramatic way. Canada is one of
them. The Toronto area has been particularly affected, largely due to a
series of unpresentable circumstances during the early days of this
disease, about which much is still unknown. But the Toronto situation
is not completely a matter of bad luck; a lack of communication and the
absence of political leadership were contributing factors. Now that the
number of SARS cases is on the wane, its evident that the Toronto
medical community handled the outbreak well (and continues to do so),
but it's equally evident that that perception did not always reach the
community at large or the rest of the world. It's essential that clear
protocols be put in place as soon as possible in order to prepare for
the next time. And there ,gill be a nest time. Future outbreaks of
infectious diseases and other medically related crisis, in Canada and
throughout the world, are a certainty.
HOW SARS CAME TO CANADA
Here is a brief history of the birth, christening and first few
months of the SARS outbreak.
Cases of atypical pneumonia are reported in Guangdong Province of
China in November and December 2002 and January 2003.
Rumors reach the ``WHO office in Beijing around February 10, 2003.
When Dr. L. Jianlun, who apparently brought the disease to the
Metropole Hotel in Hong Kong, dies in February, no one at the hospital
is infected and his history is not immediately shared with the local or
international medical community.
After cases are reported from Canada, China, Hong Kong Special
Administrative Region of China, Indonesia, Philippines, Singapore,
Thailand, and Vietnam, an international alert goes out from WHO in
Geneva on March 15, 2003.
What was previously described as an atypical pneumonia of unknown
cause that was initially localized to China becomes known as Severe
Acute Respiratory Syndrome (SARS).
Medical and public health officials worldwide are put on official
alert.
TORONTO, CANADA
A 78-year-old woman (Case A) from Toronto is unknowingly exposed to
SARS on February 21, apparently near or in the elevator at the
Metropole Hotel in Hong Kong.
With a history of heart disease and diabetes, when she dies at home
on March 5, it was reasonable for the coroner to attribute the death to
heart attack (what I was told by a public health doctor).
When her eldest son (Case B) is taken to the emergency department
of SG Hospital, a peripheral Toronto hospital, on March 7, it was
reasonable to assume that he was suffering from a local, community-
acquired pneumonia. He has no history of foreign travel. He is
diabetic. There is no history of contact with a SARS patient, in that
his mother died of a heart attack.
Owing to a chronic shortage of in-patient hospital beds. Case B
spends about 12 hours in a crowded, high-patient-volume emergency
department. As it is not vet routine to isolate and take respiratory
precautions yin cases of local community acquired pneumonia, none are
taken.
After transfer to the ICU, Case B is thought to have pulmonary
tuberculosis, which is not uncommon in the ethnic population served by
the hospital. He is transferred to an isolation area.
Case C, who acquired SARS from exposure in the emergency department
on March 7, comes back to hospital by ambulance on March 16. As a
result of exposure to Case C, two paramedics, a firefighter, four
emergency staff, one housekeeper and seven visitors who were in the
emergency department are infected. C's wife and three other family
members are also infected. When C was intubated, a face shield, mask.
Gown and gloves were utilized, suggesting performing the procedure
likely acquired SARS from contact with C's wife. The doctor transmits
the infection to one member of his family. The seven visitors in the
emergency spread the disease to live other people. In total, 15 cases
of SARS can be traced back to C.
Case D, who was also exposed in emerg on March 7, is re-admitted to
SG Hospital March 13 with a heart attack. He remains in the CCU with a
fever, which is not uncommon after heart attach, until March 16, when
because he requires kidney dialysis he is transferred to YC Hospital.
(SG Hospital does not do dialysis.) Before leaving, D infects 11 people
at SG Hospital.
On arrival at YC Hospital, D is not placed in isolation. D's wife
is subsequently admitted to hospital for surgery on March 21. D and his
wife likely spread the infection to nine staff and one patient at YC
Hospital.
Case E, who died on April 1, contracted SARS in Emergency on March
16 from C or his wife. Members of E's family spread SARS on March 28
and 29 to a church group of some 500 people and during the visitation
for E on April 3. Contacts of the group are traced and quarantined.
Thirty-one people are classified as suspect or probable SARS in the
Case E cluster.
In all of Ontario, suspect/probable SARS transmission can be traced
back to a health care facility.
There were no cases attributed to spread in the general community.
One person broke quarantine (with the cooperation of his wife, who
told public health he was at home) and attended his place of work.
While symptomatic he had contact with a co-worker in a small room,
resulting in the co-worker's becoming a probable case. The City of York
MOH subsequently put the entire workplace into quarantine.
LEADERSHIP
A. Political
There did not appear to be much political leadership during this
crisis. No one politician or community leader was perceived to be
actively involved and present on the streets. A number of politicians
organized press conferences at Chinese restaurants, to show that it was
safe to visit the area known as Chinatown. Or they were pictured
walking through hospitals wearing gowns. masks and other protective
equipment. While the intentions were noble, I believe that this further
drew attention to the Chinese community, who were not particularly
involved in the spread of the infection beyond the initial cluster. It
also focused attention on the hospitals, which were in some cases not
allowing patients to have visitors and in other cases closed to even
serious trauma and cardiac patients.
The Toronto mayor's teen of office is soon to end, and he is not
seeking re-election. Unfortunately, his once-excellent abilities as a
municipal politician have deteriorated; perhaps owing to the hepatitis
C he has been battling for several years, resulting recently in his
being unable successfully to represent Toronto.
Health is a shared jurisdiction between the provincial and federal
governments, but both the provincial and federal politicians have
largely distanced themselves from the crisis. The provincial premier of
Ontario might have called an election but for the SARS crisis and
opinion polls, which were not optimal. The Prime Minister of Canada is
near the completion of his final term of office. Both the premier and
the prime minister took golfing holidays daring the crisis. Both gave
the impression that they would not interfere with the health issues and
that they were powerless to deal, with the financial repercussions that
they estimated could be in the billions of dollars.
Neither the federal nor provincial health ministers assumed a
hands-on role. There is at least one example of information being
released by a government minister in a manner that potentially
compromised the confidentiality of an infected individual and
embarrassed a hospital, for no useful purpose. In another instance, a
political decision was made to release the name of a housing complex,
even though public health was certain that a case in another unit was a
suspected SARS and the incubation period was over.
The WHO recommended in late March that Canada step up screening
measures at airports to help prevent SARS from spreading. Vancouver did
take action, implementing a screening program involving mandatory
written questionnaires for passengers and reports from flight
attendants about ill passengers on incoming flights. But WHO felt that
Canada implemented only the minimum of the recommended airport
screening measures. In Toronto, signs about SARS were posted at the
airport and leaflets were available, but mane arriving and departing
passengers were not screened at all. It's not known how effective
infrared scanners are in detecting fever in travelers at airports--as
of April 30. Singapore had screened 75,000 people at its airport
without detecting a single case of SARS--but Toronto's lack of an
airport screening policy only served to fuel public concern that the
situation was not under control. The appearance that something was
being done might have gone a long way in lessening domestic as well as
foreign anxiety.
When the WHO issued a travel advisory for Toronto on April 23,
political figures appeared to be out of the loop. It was as if the
advisory was made public without any prior notice to the high levels of
government, which I expected should have been made as a courtesy.
A successful leader need not be the primary spokesperson. As we say
during the Iraq crisis, President George W. Bush and General Tommy
Franks were clearly the leaders, but each had a high ranking official
attend the regular briefings. Mr. Bush was seen to be involved publicly
with troops, civilians and internationally during the crisis. There
Novas no doubt as to who was in control.
Anxious people require a reliable, professional, straightforward
leader. They require reassurance that steps are being taken to protect
their health and safety.
We have confidence in leaders who stand front and center,
surrounded by outstanding professionals skilled in communicating
confidence that all the appropriate steps have been anticipated and the
crisis will thus be controlled. At the same time, it is paramount that
the leader have the courage to act against the advice of his experts
whenever necessary. Final decision making is more than simply
understanding the scientific complexities. It must take into account
the needs of the many as well as the political, economic and social
consequences.
B. Civil Service
There needs to be a clear delineation of the roles of the federal,
provincial and municipal governments. The decision-making
responsibilities of all levels need to be unambiguous. My perception
from watching television news conferences and reading the newspapers is
that various levels had different agendas, which from my perspective
did not necessarily serve the community as effectively as then might
have.
It was apparent that the municipal medical officers of health had
differing views on matters such as quarantine. This resulted in a
situation where there were differences in decision making in adjoining
municipalities. For example, had a business that was essentially closed
down as a result of quarantine been in Toronto proper as opposed to a
suburb, it would have remained open.
Managing a crisis via teleconference from another city is not
acceptable. While the provincial and federal governments may see
themselves as being progressively higher up the chain, it is the
municipal public health department that is responsible for individuals
at risk as well as those who have contracted the disease.
Levels that are one or more steps remote should not seek to control
aspects of the process. A consensus should determine when, what and how
often reporting back to them should occur. There is an absolute
necessity for higher levels of government to be in the loop--but not
predominantly by teleconference. Involvement might best be accomplished
by providing vital human resources to join the local team, not as
``spies'' but as contributors providing expertise that may not be part
of the local team. The exception might be when a toxic environment
exists, making it unwise for senior people to risk exposure.
One would think it should normally be possible to establish a sound
command post where representatives from all levels of government--and,
when appropriate, the community--could run the campaign. Fixed briefing
schedules should be possible in all but emergency situations where
conditions are rapidly changing. Even so, in that scenario, minute-to-
minute decisions would necessarily have to be made on site and not from
a remote location.
PUBLIC SECTOR--COMMUNICATIONS
A. From the Country's Senior Public Health Authority to the
International Community
Seemingly, information to the World Health Organization (WHO) from
Health Canada was such that WHO published an advisory that was not in
keeping with what Canadian and some international experts felt was
based on factual, scientific information. This possibly suggests a
communication problem between Health Canada and international bodies,
including WHO. If lines of communication have not been properly
established, they should be. If there are not clear criteria upon which
advisories are based, then there should be. Making travel
recommendations when not necessary and/or when actual risks have not
been delineated resulted in unnecessary anxiety and significant
commercial repercussions. After the SARS outbreak, occupancy rates in
downtown Toronto hotels were down by half, 54,000 room nights were
cancelled, one-third of hotel staff were laid off or had their hours
reduced, and four major conventions were cancelled, including the
American Association for Cancer Research, which alone caused losses of
upwards of $20 million. People wishing to visit Canada have been unable
to purchase health insurance. Decreases in travel and tourism have
affected other areas of Canada thousands of miles from Toronto, where
no cases of SARS have been reported have been affected. Although the
WHO travel advisory lasted only six days, from April 23 to April 29,
it's believed that the Toronto economy will be adversely affected for
up to two years.
B. Professional--from the Community to the Experts
Community health workers have a moral and legal responsibility to
report atypical or novel illness to the appropriate public health
authority. Public health authorities must investigate in a timely
manner and report to national and international agencies and bodies.
Failure to report at either level must be taken seriously.
Assurances that there be no government interference in the chain of
reporting, particularly internationally, must be strictly enforced.
Consideration must be given to creating criminal and/or civil
repercussions for noncompliance resulting in the unleashing of an
infectious disease locally or internationally. The international
community must agree to support reasonable, measures to prevent the
nurturing, harboring and dissemination--accidental or intentional--of
infectious disease.
C. Professional--from the experts to the community
Real-time global communication by email, tele/video conferencing,
television and print is more available to professionals worldwide than
ever before. The volume of communication in the Western world is such
that we are an over-communicated society. There is so much information
of variable quality and so little time to sort though it that we feel
as if we're suffocating as we gasp for knowledge.
In Toronto, the Ontario Medical Association disseminates
``important or timely'' information to members--essentially all
practicing physicians--by fax and/or email. There are, I suspect,
practitioners who do not have a fax in their office and likely the
majority have no email.
During the SARS crisis, I received emails from the two teaching
hospitals that I am affiliated with; the University of Toronto, where I
have a staff appointment; and the OMA. This is in addition to ProMed
Mail and to my checking Web sites of WHO, City of Toronto and York
Public Health Departments, the Ontario Ministry of Health and Long Term
Care, Health Canada, The U.S. Centers for Disease Control. The Globe
and Mail newspaper and the Canada Newswire for press releases.
I suggest that information to front-line health care workers; of an
urgent/important/timely nature come from a single reliable source to
avoid the waste of duplicated information. The composition of
professionals on the single-source committee needs to be established.
It should include a workable number of people with expertise to
interpret the basic science and to put it into a form useful to front-
line providers. There should be a clear protocol to determine content
of all releases.
Every physician and, when appropriate, every regulated health
professional must be assured of receiving necessary information. I
suspect that most clinical settings have a computer utilized for
billing purposes. Requiring mandatory on-line email capability may be
an option. Certainly this should be required of every hospital, acute
and chronic care facility and clinic.
The method of communication for urgent/important/timely information
must not be utilized for other purposes. For example, during the SARS
crisis, I received email from the OMA regarding election of officers
and other matters.
Information must contain necessary basic information but must be
more geared to providing practical advice, assistance and instruction
to front-line health practitioners. Recommendations should be as simple
and specific as possible.
An information/communications professional should be part of the
releasing source, and all information should be edited and cleared by
the specialist.
When information is based on partial knowledge or theories, this
must be made clear.
Care should be given with regard to recommendations that may be
difficult or impossible to follow. For example, a recommendation was
made to us that staff should wear N95 masks and gowns and that patients
should use hand sanitizer before entering the office, but materials and
supplies were not readily available to comply with the recommendation.
In communities where it is not possible to rely on fax or email,
alternative methods of communication need to be set up in advance, in
preparation for the nest crisis.
D. Professional--from the Experts to the Hospitals
In the Greater Toronto Area (GTA), there are some 22 hospital
corporations, each with a board of directors, CEO and medical staff.
There are also chronic care facilities, nursing homes, assisted living
facilities and other health care institutions.
Communication has to come from a central leadership to ensure that
there are uniform policies and procedures.
In this instance, there was confusion about what precautions
hospitals would take and in what time course. Early on, hospitals
outside the GTA were advised to take precautions that were likely not
necessary. In some hospitals, out- and in-patient services were
curtailed when there was no medical necessity to do so. Severe
restrictions were placed on physicians. Sanctions were put in place to
prevent physicians from working in more than one hospital. Some
physicians were not permitted to work in private outside of hospital
offices.
Conference calls between the 22 hospital CEOs, their senior staff
and various levels of government are not likely the ideal method of
communication.
A system needs to be established to link quickly all health care
facilities involved in a crisis and to allow for rapid, effective
communication to the central command. Hospitals require a senior
administrator on 24/7 calls to respond as required.
Where necessary, in the case of crisis, legislation should be in
place to allow a central authority to set hospital policy and
procedure.
E. From Professionals to the Public
Ideally, one credible person on the local level should carry out
communication to the public. This person should be perceived as the
chief medical officer. The person may have a communications expert
assist with, or be the primary speaker at press conferences.
The person should have medical credentials as well as an
understanding of the health, safety, and community, social, economic
and global issues. Ideally, the person should also have formal
communications training.
Where possible, communication should be in the form of or
supplemented by regular written media releases approved by a
communications professional.
While designating non-government professionals to ``expert'' or
``leadership'' roles is an excellent idea, these people must have
formal training or demonstrated ability in communication to the public.
In this instance, there were people involved who chose unfortunate
descriptive terms.
It is essential that accurate information be given to the media,
since the media rely on the data they receive from those who are
considered the experts or spokespersons. It is the nature of news that
dramatic information or events, even when incorrect, gets front-page
attention; a correction or retraction is much less noticed. For
example, there was a clear but incorrect message from perhaps the most
quoted local expert that the SARS virus could live on inanimate objects
for 24 hours. The information was said to have originated from the U.S.
Centers for Disease Control with the implication that it was credible,
when in fact it was not. Likewise, it was worldwide news when three
Canadian children suspected of having SARS were quarantined upon their
arrival in Australia, fueling widespread alarm. It was a much smaller
news story when the children were shown not to have SARS after all.
QUARANTINE
The use of quarantine was seen to be a draconian measure by some
health care professionals. There was, however, no other effective way
to control the spread of SARS.
As quarantine has largely been a procedure of the past, protocols
need to be revisited. The media referred to ``voluntary'' quarantine,
when in fact there was or should have nothing voluntary about it.
Quarantine is mandatory. The medical officer of health has powers to
detail people against their will. In that we respect rights and
freedoms, the issue of quarantine needs to be dealt with prior to the
next ``crisis.'' The use of monetary penalties, involuntary
confinement, police surveillance, electronic surveillance. etc., need
to be examined.
The rights of the state to screen people for disease either
unobtrusively or without consent requires guidelines and possible
legislation. The following issues must be debated:
Should the state in time of urgency/emergency have the right to
order non-invasive testing, such as estimation of body temperature, or
invasive testing, such as blood tests, other biological samples or x-
rays?
What rights should the state have to refuse entry to foreign
nationals who may be at risk of being infected or spreading infectious
disease? What criteria would be used to assess risk and classify
individuals? Currently people with a history of harmful or violent
behavior in association with a medical or psychiatric impairment
require a waiver to enter the United States. Likewise, people with
certain named diseases of public health significance (SARS is not on
the list) fall into the ``A'' or non-admissible classification.
In the case of a person at elevated risk of a disease of public
health significance who may or may not have symptoms, what right should
the state have to detain the person or prevent the person from leaving
the jurisdiction? Is there a right or duty to inform the jurisdiction
to which the person intends to go?
What if any screening programs or protocols should be legal or
mandatory at ports of entry?
What right does a common carrier have to screen or refuse passage
to a person at elevated risk with or without symptoms? There have been
reports of healthy Canadians, with no risk factors other than being a
resident of Toronto, having vacation cruises cancelled.
Voluntary confinement also requires examination. Voluntary
confinement is defined as going into isolation because of: 1. risk of
potential but not confined or likely contact with an infection, or 2.
manifesting non-specific symptoms with no specific history of contact.
At one point, when there was concern for the possibility of
community spread, people were advised to remain off work or school and
not to venture out in public if they had non-specific symptoms. Health
professionals were advised to recommend a voluntary confinement of 24
to 72 hours, during which time it was suggested the individual would
become sick enough that assessment in a secure facility (SARS
assessment clinic or emergency department) was indicated.
The very young, the elderly and people with underlying medical
conditions could be harmed by a period of voluntary confinement. There
have been no such reports to date, but considering the varied nature of
the early symptoms of SARS and the possibility of infection without
serious respiratory symptoms, voluntary confinement could have resulted
in serious repercussions.
CONFIDENTIALITY
Every effort must be made to protect the confidentiality of medical
information. However, when the health and safety of a workplace of the
community in general may be compromised, by maintaining
confidentiality, there must be guidelines to allow needed information
to be utilized in a responsible manner. If in order to determine which
employees may have reasonably had close contact with an index case and
thus be at risk to themselves and others, it may be necessary to break
confidentiality. This should only be done when reasonably necessary and
only by a regulated (licensed) health professional. It should be done
with the clear understanding that the information released is
confidential and that there would be a severe penalty for its further
release. The media should be legally- bound not to release information
that would normally be perceived as confidential in any form without
written permission. I think this should extend to potentially
identifying information. For example, it was not relevant that a nurse
from Mt. Sinai Hospital rode the subway and commuter train, when all
that needed to be said was that ``a woman'' made the journey.
HUMAN RESOURCES
Public Health (PH) Departments perceive themselves to be
underfunded and understaffed. PH staffs are not accustomed to working
extended hours, nor are they performing many of the functions required
in an ``urgency'' or ``emergency'' on a daily or even periodic basis.
Provision must be made to provide additional trained staff on an
immediate basis and to ensure that there are adequate staffing levels
for the necessary period of time.
Staff may be ``borrowed'' from neighboring jurisdictions, the
private sector or the military. Preventive preparation should include
details of the skill sets required for various urgencies and
emergencies and rosters of professional who meet those qualifications.
This will make calling up reserves a more seamless process. I am
uncertain what the Canadian military could offer and what reserves
exist in the public sector. Consideration should be given to
establishing an active trained reserve force. Staff will suffer the
effects of physical and emotional stress as part of the job. Provision
has to be made in advance to accommodate anticipated needs.
People on the front lines may, owing to the nature of the
catastrophe, be deemed contaminated, requiring voluntary confinement or
quarantine. This may put strains on their families. Some health care
professionals feel they are invincible and may go through periods of
denial. Counseling and support will be necessary--in the event of a
prolonged crisis.
INFORMATION TECHNOLOGY
Computer programs need to be developed for large-scale contact
tracing. Provision needs to be set up to monitor perhaps tens of
thousands of people over a course of weeks. In that there will be
overlapping municipal health units involved, provision needs to be
built in for sharing of information. People often do not reside in the
same jurisdiction where they work. Involvement with the private sector
could result in information transfer, for quarantine and tracking
purposes to public health. This would save resources and prevent
inputting errors.
SOCIAL SERVICES AND SUPPORT
Quarantined people may require food, water, thermometers,
medication, sanitary products, masks, gowns, etc. In addition to having
a reasonable stockpile of medical supplies, one has to take into
account all the other requirements that a confined person or family
would normally require.
In the Toronto episode, there were logistical problems in
delivering masks, gowns and other protective equipment to community
doctors and health facilities. In that the government had made major
purchases, many of these medical supplies were not commercially
available.
Quarantine can also cause financial losses for workers. It is
against everyone's interest for people in the workplace to spread
disease to others, but some workers may balk at being quarantined, as
they would lose pay. It is my strong recommendation that people be
assured that if they are sent home on voluntary confinement or on
quarantine by public health, they should not suffer financially.
Employees' base pay should be maintained as a leave with pay. If they
were impaired/disabled, they would then be entitled to whatever short-
term absence benefits the business normally had. It would be possible
to maintain pay as a loan with the employee applying for employment
insurance benefits and then paying back the loan once employment
insurance was received. This way, there would be no financial reason
for a sick person to attend work.
During the height of the SARS outbreak, the Red Cross and other
social agencies became overwhelmed, causing delays in the delivery of
necessities to quarantined people. Logistics experts should likely do
some contingency plans to more efficiently address these needs for the
next urgency. Volunteers should be recruited, trained and made part of
a reserve force. Likewise, hospitals and institutions require
volunteers to screen people at entry points.
Methods of transporting infectious or contaminated people on an
individual basis but in large numbers also need to be addressed. Are
ambulances the answer for the walking wounded?
We must also take into consideration the needs of minors, the
intellectually challenged and the psychiatrically impaired. One couple
who became seriously ill with SARS and who remain hospitalized have two
young children. When no relatives or social agencies, including
Children's Aid, were willing or had facility to care for two
quarantined children, pediatric hospital admission was the only option.
One child was subsequently ill but recovered. Both remain in hospital,
essentially because there is no other place for them at the present
time.
CONCLUSION
Toronto has borne Canada's largest burden in dealing with the
illness. But at the same time, it has successfully managed to keep the
disease from spreading across the country and across the continent. One
reason that Toronto appears to be a hot spot for SARS is that the
medical community has quickly become very competent at identifying the
illness in the first place, and Canada has been very forthcoming about
making public the numbers of suspected and probable cases.
Still, the outbreak has served to highlight the weak spots in the
system. SARS has been a wake-up call not only for Toronto but for the
world. Infectious diseases will always be with us, and with the speed
and volume of world travel, outbreaks can happen anywhere and spread
faster than ever before. There will be other man-made and natural
events that put great numbers of people at mortal risk. There was a
time when spread of infection in the community and subsequent death was
inevitable. We are not willing to accept that today. We expect a high
level of leadership and an immediate successful response in order to
prevent potential disaster. This makes it essential that we put systems
in place now to more fully prepare before the next crisis strikes.
Prepared Statement of Senator Johnson
Mr. Chairman, thank you for allowing me to submit my statement to
the record for today's hearing on Severe Acute Respiratory Syndrome or
SARS.
We live in a time when people can move freely around the globe with
ease and people can travel from America to virtually every corner of
the earth in a matter of hours. This convenience provides great
opportunities for international exploration by all of the world's
citizens and for partnerships to be developed between countries,
communities and societies.
But in this time of great mobility, we must be concerned about the
ability of newly emerging microbial threats to spread across oceans
swiftly and quietly. Flu epidemics of the past had the capacity to take
millions of lives and destroy communities all over the world. And
today, SARS is impacting the lives of thousands and threatening the
economic stability of our near neighbors in Toronto and our friends far
away in China.
Today we know that over 5000 people all over the world have
suspected or probable SARS. Hundreds have died at a rate of 6 percent.
We remain unaware of the period in which infected persons can transmit
the disease. We remain unsure of the various modes of transmission and
we are unaware of exactly why people in the U.S. appear healthier than
those who contract the disease in other nations.
There are a lot of unanswered questions, but I know that CDC and
the WHO are working hard, around the clock even, to find these answers
as quickly as possible and I want to commend Dr. Julie Gerberding and
CDC for their tireless work to conduct surveillance and provide public
health information across this country. CDC has also provided extensive
staff resources to the WHO which I know have been so important in
helping identify cases quickly across the globe and have made a real
difference in reducing the spread.
I also want to commend my colleagues in joining me to support the
supplemental appropriation
funds that have provided an additional $16 million dollars for the
CDC this year to combat this new infectious disease. I know that I and
other members of the appropriations committee would be interested to
learn how CDC intends to utilize these funds and whether Dr. Gerberding
considers this amount sufficient to address all disease control efforts
including the development of diagnostic tests, antviral drugs and
vaccines.
We are aware of at least 41 probable cases of SARS and many
suspected cases in the United States. Just last week, South Dakota
reported its first suspected case of SARS, a man recently returning
home from a trip to Hanoi. Luckily, he has returned home and I
understand is recovering. Fortunately, the State Health Department was
able to quickly identify this case and was able to take appropriate
measures to protect health workers and the broader community from its
spread. The challenge now for South Dakota and other states is to be
able to identify all cases in an appropriate and timely manner. I am
hearing from my state that they are in need of access to diagnostic
tools as quickly as possible in order to be prepared to protect the
public health. I hope CDC will continue to communicate with states
about progress being made on the development of diagnostic tools and
that CDC will work to disseminate these testing procedures as soon as
possible.
As I mentioned earlier, SARS has not hit our country as hard as
others. We should consider ourselves lucky that our citizens have not
felt the fear that the people of other nations have experienced. Some
Americans have however started to express concern. Some have bought
masks. Some have been hesitant in airports or doctors offices. And
others have stopped eating in Asian restaurants.
Actions similar to these may increase if we see more cases in
America, resulting in economic hardships in our own communities. And
with more cases, hesitancy can turn to fear, something that I know my
colleagues and the CDC want to prevent. I encourage CDC and all of my
colleagues in Congress to examine closely the experiences of other
countries hard hit by SARS, and how they have handled economic
hardships and broad fear by citizens and I hope we can work together to
develop strategic plans to handle such issues, should the outbreak in
the U.S. worsen. I look forward to working with my colleagues on this
important issue and I thank the chairman for the opportunity to submit
this testimony today.
Prepared Statement of Samuel Wallace
A wise man once said that those who do not learn from the lessons
of the past are doomed to make the same mistakes again. After World War
II, the entire world experienced an epidemic of the sexually
transmissible diseases: syphilis and gonorrhea. The two diseases were
categorized: ``incurable'' and efforts were made to quarantine those
who had the disease and some people were deliberately infected with the
disease as ``experiments in the interests of science.'' The epidemic
continued to spread not only in America, but also world-wide. And it
was not until those with those diseases were treated with the
Antibiotic Penicillin in sufficient dosages to cure those diseases that
the epidemic was finally quelled.
Prior to the 1960's, Viral Illnesses such as the common cold, viral
pneumonia, the measles and the mumps were treated and cured with
Antibiotics. (See Goodman and Gilman's Pharmacology 1955 to 1958, p.
1388: ``Tetracycline cures Viral Illnesses such as Viral Pneumonia''.
And in 1962 after Senator Kefauver Amended the FDA Act Requiring the
use of Safe and Effective Medicines which were usually Antibiotics. The
new law required the FDA to Tests for effectiveness representative of
batches of each Antibiotic produced by each manufacturer mandatory. At
that point the American Health Care System became so efficient that
President Kennedy was able to reduce taxes and at the same time
increase government revenues for the only time in American History. In
the late 1960's President Nixon, announced: War on Cancer and rejected
Elliot Richardson's nominee for Assistant Secretary of Health, Dr. John
H Knowles of Mass. General Hospital who was an expert on Public Health
and who had warned the country that the new trend of not using the
Antibiotics to treat the sick was resulting in more mortalities and
much higher medical costs particularly in the Public Health Sector. Had
he been appointed and allowed to implement his ideas, he would have
been able to save the country several trillion dollars in Health Care
Costs up to the present. Today, it is now generally held as dicta that
``the Antibiotics do not cure Viral Illnesses.'' Even though, I recall
that the late Dr. Peter Marshall Murray M.D., my Uncle, a Surgeon and
Officer in the AMA who could operate in any hospital in New York City
told me that he prescribed the Antibiotics to Cure Viral Illnesses in
1957. Which can still be verified by prescription records in New York
City, that fact indicates that it was common practice at the time.
ACQUIRED IMMUNE DEFICIENCY SYNDROME, (AIDS), like syphilis and
gonorrhea was initially classified as ``incurable'' and so had an
enormously high death rate. In recent years the most prevalent and
mildest form of that disease, HIV 1, which is identical to ``Cat
Leukemia'' found in medical and nursing students has begun to be cured
with an ordinary course of Penicillin or Tetracycline and apparently
many American doctors are curing both forms of the Disease with Empiric
Antibiotic Therapy just as the American Cancer Society indicates in its
Text: ``Clinical Oncology'' that it Oncologists now cure ``Neutropenic
Fever'' in Cancer Patients routinely with Empiric Antibiotic Therapy.
Which has reduced mortality for Neutropenic Fever by 95% in Cancer
patients whose immune systems are compromised due to various causes.
This is similar to the approach of over 51% of American Doctors who use
similar Antibiotic Therapy to treat Viral Respiratory Diseases such as
the common cold, influenza and viral pneumonia and perhaps Asthma.
Though such Antibiotic Therapy is condemned by the NIH and CDC and this
despite the fact that in 1955-1958 and onwards, the NIH co-authored
Goodman and Gilman's: ``The Pharmacological Basis of Therapeutics''
which on page 1388 indicated that the Antibiotic Tetracycline cured
such viral illnesses as Viral Pneumonia.
It appears that at the present time the death rate due to HIV AIDS
in America has steadily declined. However, it is not certain whether
this is due to the ``empiric antibiotic therapy'' similar to that used
to treat medical and nursing students who have ``cat leukemia''
acquired by dissecting cats , which is also used by 51% of American
Physicians to also treat Respiratory Viral Illnesses or whether it is
due to an increased morality among Americans generally. However, AIDS
has continued to increase at an alarming rate not only in Africa, but
also in Eastern Europe and in Asia, particularly in China and Thailand,
but not in Japan where doctors rely far more heavily on Antibiotic
Therapy or apparently the Philippines, perhaps for the same reason.
The countries of Eastern Europe and Russia , at one time had
excellent Public Health Systems. Those Public Health systems have been
largely abandoned, as have free medical education. Doctors there no
longer as a general rule prescribe Antibiotics for the sick. And
medical costs there have begun to soar and the health of most of their
people have begun to decline significantly, particularly in Russia.
India which once had one of the best Public Health Systems of any
developing country in the world to treat its poor was in the early 70's
induced by the IMF to privatize its entire Health System and as a
result with the exception of the Indian States of Bangor, Kerala and
Madras, there are no longer Public Health Systems in India available
for the poor. Last year, the President of the World Bank, Mr. Wolfson
held hearings on this issue and he and his panel recommended that India
adopt the Public Health Systems and its policies of the three Indian
states that still have free Public Health for the poor. As a result,
the Indian State of Kerala whose Public Health System relies heavily on
Antibiotics has a lower rate of Infant Mortality than the District of
Columbia where many doctors follow NIH guidelines with respect to
treating illnesses with Antibiotics. Tragically this is not true for
the remainder of India for reason just stated above.
Today, China like Russia has begun to abandon its rural Public
Health Systems which means as reported by some Reporters the rural poor
have begun to suffer greatly because they can no longer obtain the
curative Antibiotic Medicines for their Bacterial and Viral Illnesses
which were once provided by their Public Health workers, nurses and
practitioners who delivered Health Care to the poor living in rural
areas.
Right next door to the beautiful city of Hong Kong lies Guandong
where most of Hong Kong`s food animals are raised. It is a poor rural
area where poor peasants live in poverty in close proximity to poultry
and live stock without the benefits of good drinking water etc. And
where in the past once an occasional viral anomaly, such as the Hong
Kong flue briefly developed, such a virus was defeated by antibiotic
therapy in a relatively short period of time by Public Health Nurses
administering antibiotics to people living in the outlying rural areas.
But today in China the poor in neighboring rural areas can no longer
expect to obtain such care and either must overcome their disease by
endurance or else succumb to it.
Now, in China, as the Public Health System there has begun to
breakdown in rural China, the Chinese are now faced with a deadly new
Pneumonia-like Virus, SARS, which is even is deadly to Nurses and
Doctors who normally have access to the curative Antibiotic Medicines
and are normally less like to become Infected with such respiratory
viruses. And so SARS today is raging throughout China and it is not
even certain whether doctors there today are even prescribing the
appropriate Antibiotics in the affluent urban areas and hospitals.
Because so many even there appear to be infected with SARS.
So the lessons of the 1950's have been forgotten that if you wish
to stop an epidemic, you must cure the sick generally with the common
antibiotics such as penicillin or tetracycline which prevents the Virus
or Bacteria from continuing to spread from one sick person to another.
And here we are learning once more that If you do not, you may
experience a devastating epidemic. So far perhaps as many as 6,000
people are infected with SARS in China. And at least 500 people have
died from that deadly Virus. And this is because of the deadliness of
this new Pneumonia like virus and because the Chinese Public Health
System has begun to fail.
But here in the United States we have a Public Health System lead
by our CDC, NIH etc. that experiments with one fad after another in
treating Viral Illnesses, but consistently denies the Antibiotics cure
viral illnesses-even though 50% of American doctors prescribe the
Antibiotics in the treatment of Respiratory Viral Infections such as
Influenza and Viral Pneumonia.
In Puerto Rico where its doctors attend American Medical Schools a
report in the HCFA Journal by a Miss Pagan of Puerto Rico indicated
that the Puerto Rican Health Care System was 95% more efficient than
the mainland Public Health System . Which I know as a former Public
School teacher there was because the Puerto Rican Public Health System
relies heavily Antibiotics to treat Bacterial and Viral Illnesses.
It is because of CDC and NIH Policies no longer believes that
antibiotics cure viral illnesses as they once did that they condemn the
majority of American doctors who prescribed empirical antibiotic
therapy to treat Respiratory viral infection while ignoring that as
many as 15,000 Americans die of Influenza and thousands of Asthma
because they condemn the doctors use of the very same antibiotic
medicines that the NIH. once claimed or admitted cured viral illnesses.
1 /
Therefore, while the world is witnessing the beginnings of the
demise of Public Health Systems in Eastern Europe, Russia and now in
China and other parts of Asia, the United States experiences each year
15,000 deaths due to the Influenza Virus! Because the NIH and CDC lead
what is essentially a failed Public Health System here in the United
States due to their disastrous Public Health Policies condemning
doctors for prescribing Antibiotic Medicines that they once admitted
cured the sick. /
I personally know this is true because I lived for 5 years in
Brazil from 1969 to 1974, where Antibiotics could be purchased over the
counter in small quantities without a prescription. I therefore tested
the Antibiotics against a wide range of viral, bacterial and protozoa
illnesses. Which I testified about before the Subcommittee of Health of
the House Ways and Means Committee Dec. 4th, 1975 indicating that the
times of cure were reduced by 30 to 50% when a Nasal Decongestant Nose
Drops was combined with one or two grams of Penicillin per ounce of a
Nasal Decongestant such as Rimidol made by Squibb Industria Brazil of
Sao Paulo. Which should be applied as Nose Drops three or four times
per day.
Such therapy is nonspecific innate therapy where the antibiotics
activate the macrophage which in turn activates complement and
immediately begins the curative process. This is scientifically
demonstrated by observing that as soon as the Antibiotic Nose Drops are
applied any fever is immediately reduced to normal temperatures. This
therapy which is so safe that it can be given to infants in reduced
strength cures most forms of Viral Pneumonia in three days time and is
such a nonspecific form of Antibiotic Therapy that it was called:
``Penicillin diversum'' by the Japanese Pharmaceutical Industry in
Chemical Abstracts, April 15, 1985, Vol. 102, #15:
130454m:''Production of antitumor agent PD-3. (I) ...[88899-01-8]
was produced from cultures of [Penicillium diversum]...PD-3, The
antitumor antibiotic, ``...inhibited growth of Yoshida Sarcoma cells by
98%'' ...Institute of Physical and Chemical Research. Japan. Kokai,
Tokyo, Koho, Japan.
I personally discussed this formula in my testimony 1975 which is
quite similar to the Nasal Decongestant Rimidol made by Squibb in Sao
Paulo which is composed of Naphazoline Hcl in .1 of 1% sol. Combined
with 1 or 2 grams Penicillin k or ampicilin per ounce of Nasal
Decongestant Nose Drops in Congressional Testimony, Subcommittee of
Health of the House Ways and Means Committee, Dec. 4th, 1975, Testimony
Samuel B. Wallace where I emphasized that it could cure Viral
Respiratory Illnesses such as Influenzas and Viral Pneumonia in three
days time as well as bacterial infections such as cholera and Protozoa
Illnesses such as Malaria.
My Research with the Penicillin Nasal Decongestant Nose Drops
Rimidol indicates that that formula could cure a wide range of viral
respiratory illnesses such as SARS in approximately 3 days. And because
such treatment treats the entire blood and entire glandular system to
which the Lungs are attached it becomes impossible for the treated
patient to become a carrier of the disease since the disease is removed
from the entire system. And this route of administration is important
in China because it does not use the injection of needles which are
often reused and sometimes spread the infection. The cost of
manufacture of Penicillin and the Nasal Decongestant in China is
relatively low and to make such effective medicines available is far
cheaper than building new hospitals. Since the Japanese found that the
same formula was effective against Yoshida sarcoma or bone marrow
cancer in vitro 98% of the time-the highest rating for any Cancer
Agent. That means that it would also be effective against less virulent
virus infections, hence that named the same formula that I had tested
in Brazil from 1969 to 1974: ``Penicillin diversum'' So in any event,
the contemporary SARS epidemic does teach us that there is still a need
for good Public Health Systems as well as good common sense Public
Health Policy in the world that hopefully still use the low cost safe
and effective medicines in developing countries where so many poor
people are unable to afford even ordinary Health Costs.
The SARS Epidemic in China also teaches us that indifference to the
poor in Health Care matters does not necessarily allow the more
affluent areas to escape the consequences of such neglect of the poor.
And that in order to protect all good Health Care in some reseasonable
form must be available to all.
The economic issues are also important. The SARS epidemic has
already cost the nations of Asia billions of dollars in lost trade and
tourism. Which is a very high price for poor Public Health and Health
Policies and Procedures that ignore the value of the low cost safe and
effective Antibiotic Medicines for panaceas that do not work.
Particularly where such countries are faced with a Virus readily
treated and cured with Antibiotics yet powerful enough to even fell
nurses and doctors in their communities.
The governments and the Public Health Systems of Japan and
amazingly Viet Nam, a country much poorer than China and the
Philippines should be singled out for praise in using the best
Antibiotics available to them in the treatment of SARS which is a very
deadly virus, indeed. While the doctors in Hong Kong should be reminded
that they have a responsibility to treat and cure the sick. And not to
just posture and ignore the plight of their sick countrymen. And of
course there should be studies by universities in China directed toward
improving the plight of the poor including their Health, Nutrition,
Water and Sanitation in the rural areas of China which produce its
vital food supplies.
Another example, of poor Public Health Policy is subsidizing the
Pharmaceutical Industry by encouraging it to use ``Antiviral Agents''
which its manufacturers and numerous studies prove do not cure HIV
AIDS. Since the low cost safe and effective Antibiotic Medicines that
have proved effective in Curing HIV I and III Leukemia, cost only
pennies per patient. The cost of quelling the AIDS epidemic in
developing countries is much less than the costs of providing medicines
which do not cure at all. Experience has shown that such epidemics can
not be stopped until the disease is cured world wide as occurred in the
1950' when the epidemic of Syphilis and Gonorrhea was quelled when
finally the antibiotics were administered to patients and there were
cured. Therefore stopping the AIDS epidemic with ``Antiviral Agents''
and weak protease inhibitors is not a solution, but rather is a
government largess for the richest industry in America-the
Pharmaceutical Industry. Such a policy promoting the world wide use of
ineffective panaceas is like fighting fire by pouring oil on the
flames. Evidence that this is true is seen by the fact that Japan where
Antibiotics are used to Cure AIDS Japan has a very miniscule incidence
of AIDS because it is cured almost as soon as it is diagnosed.
1/ The Pharmacological Basis of Therapeutics, P. 1386,
Tetracycline's:
THERAPEUTIC USES (OF TETRACYCLINE) (PARENTHESIS ADDED)
``The Tetracyclines are firmly established as extremely valuable
therapeutic agents in the treatment of a variety of diseases caused by
microorganisms''. Among the infections for which tetracycline are of
proved value ``viral diseases''. These Antibiotics are also, of benefit
in primary viral pneumonia''
2/ a nonspecific form of Antibiotic Therapy that it is called:
``Penicillin diversum'' by the Japanese Pharmaceutical Industry in
Chemical Abstracts, April 15, 1985, Vol. 102, #15:
130454m:''Production of antitumor agent PD-3. (I) ...[88899-01-8]
was produced from cultures of [Penicillium diversum]...PD-3, The
antitumor antibiotic, ``inhibited growth of Yoshida Sarcoma cells by
98%'' ...Institute of Physical and Chemical Research. Japan. Kokai,
Tokyo, Koho, Japan.
3/ Penicillin diversum's 98% effectiveness in vitro is the highest
rating ever given to any Anticancer Agent in Vitro including Adriamycin
praised by the American Cancer Society which like Penicillium Diversum
is a Naphazoline Hcl compound to which is added Streptomycin rather
than Penicillin.
However, both Dr. Bonadonna and the late Dr. Hamao Umezawa both
indicated to me that Penicillin was more effective in treating Cancer
as did the Japanese Pharmaceutical Industry Immediately above
discussing [Penicillium Diversum] in Chemical Abstracts 1985.
I personally discussed a similar formula in my testimony 1975 which
is a Nasal Decongestant Rimidol made by Squibb in Sao Paulo composed of
Naphazoline Hcl in .1 of 1% sol. Combined with 1 or 2 grams Penicillin
k or ampicilin per ounce of Nasal Decongestant Nose Drops in
Congressional Testimony, Subcommittee of Health of the House Ways and
Means Committee, Dec. 4th, 1975, Testimony Samuel B. Wallace where I
emphasized that it could cure Viral Respiratory Illnesses such as
Influenzas and Viral Pneumonia in three days time as well as bacterial
infections such as cholera and Protozoa Illnesses such as Malaria.
My Research with the Penicillin Nasal Decongestant Nose Drops
Rimidol indicates that that formula could cure a wide range of viral
respiratory illnesses such as I project SARS in approximately 3 days.
And because such treatment treats the entire blood and entire glandular
system to which the Lungs are attached it becomes impossible for the
treated patient to become a carrier of the disease since the disease is
removed from the entire system. This route of administration is
important in China because it does not use the injection of needles
which are often reused and sometimes spread the infection. The cost of
manufacture of Penicillin and the Nasal Decongestant in China is
relatively low and to make such effective medicines available is far
cheaper than building new hospitals. Since the Japanese found that the
same formula was effective against Yoshida sarcoma or bone marrow
cancer in vitro 98% of the time-the highest rating for any Cancer
Agent. That means that it would also be effective against less virulent
virus infections, hence that named the same formula that I had tested
in Brazil from 1969 to 1974: ``Penicillin diversum''
4/ a Nasal Decongestant Rimidol made by Squibb in Sao Paulo
composed of Naphazoline Hcl in .1 of 1% sol. Combined with 1 or 2 grams
Penicillin k or ampicilin per ounce of Nasal Decongestant Nose Drops
was obliquely described in Goodman and Gilman's, The Pharmacological
Basis of Therapeutics 1955-1958, on pages 1346 and 1347beginning on
page 1346::
P. 1346:4. Penicillin for Inhalation Therapy. Penicillin is
employed in several forms and by various techniques for inhalation
therapy of bronchorespiratory tract infections....
P. 1347: Penicillin is inhaled through the Nose...similar
bronchodilator drugs can be incorporated in the penicillin solution for
use in patients requiring both antibiotic and antiasthmatic
therapy...the usual dosage is 199,999 units of penicillin applied three
times daily.
My testimony before the Subcommittee of Health, House Ways and
Means, Dec. 4, 1975:
Indicates almost the exact quantity of Penicillin to be applied to
patients with respiratory illnesses. Which is ten percent of that
recommended by the Physicians Desk Reference or one gram capsules of
penicillin for Pneumonia.
And in addition I indicated in the same Congressional Testimony of
Dec. 4th, 2003 that a Nasal Decongestant nose Drops such as Rimidol
combined with Penicillin reduces Viral, Bacterial and Protozoa Fevers
as soon as it is applied as Nose Drops. (I indicated within one day
because I did not feel confident that any one would believe me if I
indicated the precise true time which was within seconds of its
application as Nose Drops. This can be verified as I suggested
previously to the NiH in one day pilot tests against any type of fever.
Dr. Fauci indicated on the Ted Koppel television program that he
did not believe that a vaccine would be developed for SARS in less than
three years time. He did express some optimism about finding a new drug
that cured it because SARS is ``tissue sensitive.'' Thus, it is a virus
that like Yoshida Sarcoma and Viral Pneumonia can be readily tested in
Test tube against various medicines, including I suggest Rimidol (or
Naphazolene Hcl combined with Penicillin K.
And since it is both Safe and Effective and very quick to cure
Pneumonia as my Research in Brazil and subsequent testimony in 1975 as
well as the great research on the very deadly virus: Yoshida Sarcoma by
the Japanese Institute indicate, I suggest that it should be given
expedited
Consideration for testing against the SARS Virus in vitro and in
vivo. In order to save lives and in order to end this deadly Virus
before it becomes Endemic everywhere.
[Whereupon, at 3:58 p.m., the committee was adjourned.]