[House Hearing, 108 Congress]
[From the U.S. Government Publishing Office]
THE SARS THREAT: IS THE NATION'S PUBLIC HEALTH NETWORK PREPARED FOR A
POSSIBLE EPIDEMIC?
=======================================================================
HEARING
before the
COMMITTEE ON
GOVERNMENT REFORM
HOUSE OF REPRESENTATIVES
ONE HUNDRED EIGHTH CONGRESS
FIRST SESSION
__________
APRIL 9, 2003
__________
Serial No. 108-9
__________
Printed for the use of the Committee on Government Reform
Available via the World Wide Web: http://www.gpo.gov/congress/house
http://www.house.gov/reform
U. S. GOVERNMENT PRINTING OFFICE
87-067 WASHINGTON : 2003
____________________________________________________________________________
For Sale by the Superintendent of Documents, U.S. Government Printing Office
Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; (202) 512-1800
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COMMITTEE ON GOVERNMENT REFORM
TOM DAVIS, Virginia, Chairman
DAN BURTON, Indiana HENRY A. WAXMAN, California
CHRISTOPHER SHAYS, Connecticut TOM LANTOS, California
ILEANA ROS-LEHTINEN, Florida MAJOR R. OWENS, New York
JOHN M. McHUGH, New York EDOLPHUS TOWNS, New York
JOHN L. MICA, Florida PAUL E. KANJORSKI, Pennsylvania
MARK E. SOUDER, Indiana CAROLYN B. MALONEY, New York
STEVEN C. LaTOURETTE, Ohio ELIJAH E. CUMMINGS, Maryland
DOUG OSE, California DENNIS J. KUCINICH, Ohio
RON LEWIS, Kentucky DANNY K. DAVIS, Illinois
JO ANN DAVIS, Virginia JOHN F. TIERNEY, Massachusetts
TODD RUSSELL PLATTS, Pennsylvania WM. LACY CLAY, Missouri
CHRIS CANNON, Utah DIANE E. WATSON, California
ADAM H. PUTNAM, Florida STEPHEN F. LYNCH, Massachusetts
EDWARD L. SCHROCK, Virginia CHRIS VAN HOLLEN, Maryland
JOHN J. DUNCAN, Jr., Tennessee LINDA T. SANCHEZ, California
JOHN SULLIVAN, Oklahoma C.A. ``DUTCH'' RUPPERSBERGER,
NATHAN DEAL, Georgia Maryland
CANDICE S. MILLER, Michigan ELEANOR HOLMES NORTON, District of
TIM MURPHY, Pennsylvania Columbia
MICHAEL R. TURNER, Ohio JIM COOPER, Tennessee
JOHN R. CARTER, Texas CHRIS BELL, Texas
WILLIAM J. JANKLOW, South Dakota ------
MARSHA BLACKBURN, Tennessee BERNARD SANDERS, Vermont
(Independent)
Peter Sirh, Staff Director
Melissa Wojciak, Deputy Staff Director
Randy Kaplan, Senior Counsel/Parliamentarian
Teresa Austin, Chief Clerk
Philip M. Schiliro, Minority Staff Director
C O N T E N T S
----------
Page
Hearing held on April 9, 2003.................................... 1
Statement of:
Heinrich, Janet, Director, Public Health Issues, U.S. General
Accounting Office; Dr. Margaret Hamburg, vice president,
Biological Programs, the Nuclear Threat Initiative; and Dr.
David Goodfriend, director, Loudoun County Health
Department................................................. 64
Thompson, Tommy G., Secretary, Department of Health and Human
Services, accompanied by General Phil Russell (retired),
Commander, U.S.M.; and Steve Ostroff, Centers for Disease
Control.................................................... 12
Letters, statements, etc., submitted for the record by:
Clay, Hon. Wm. Lacy, a Representative in Congress from the
State of Missouri, prepared statement of................... 57
Davis, Chairman Tom, a Representative in Congress from the
State of Virginia, prepared statement of................... 3
Goodfriend, Dr. David, director, Loudoun County Health
Department, prepared statement of.......................... 95
Hamburg, Dr. Margaret, vice president, Biological Programs,
the Nuclear Threat Initiative, prepared statement of....... 85
Heinrich, Janet, Director, Public Health Issues, U.S. General
Accounting Office, prepared statement of................... 66
Maloney, Hon. Carolyn B., a Representative in Congress from
the State of New York:
Article from the New England Journal of Medicine......... 40
Prepared statement of.................................... 44
Shays, Hon. Christopher, a Representative in Congress from
the State of Connecticut, prepared statement of............ 10
Thompson, Tommy G., Secretary, Department of Health and Human
Services, prepared statement of............................ 16
Towns, Hon. Edolphus, a Representative in Congress from the
State of New York, prepared statement of................... 127
Waxman, Hon. Henry A., a Representative in Congress from the
State of California, prepared statement of................. 7
THE SARS THREAT: IS THE NATION'S PUBLIC HEALTH NETWORK PREPARED FOR A
POSSIBLE EPIDEMIC?
----------
WEDNESDAY, APRIL 9, 2003
House of Representatives,
Committee on Government Reform,
Washington, DC.
The committee met, pursuant to notice, at 10:45 a.m., in
room 2157, Rayburn House Office Building, Hon. Tom Davis of
Virginia (chairman of the committee) presiding.
Present: Representatives Tom Davis of Virginia, Shays,
Burton, Mrs. Davis of Virginia, Putnam, Duncan, Sullivan,
Murphy, Janklow, Blackburn, Waxman, Towns, Maloney, Cummings,
Clay, Watson, Lynch, Sanchez, Ruppersberger, and Norton.
Staff present: Peter Sirh, staff director; Melissa Wojciak,
deputy staff director; Keith Ausbrook, chief counsel; Ellen
Brown, legislative director and senior policy counsel; Jennifer
Safavian, chief counsel for oversight and investigations; John
Hunter, counsel; David Martin, director of communications;
Scott Kopple, deputy director of communications; Teresa Austin,
chief clerk; Joshua E. Gillespie, deputy clerk; Susie Schulte,
legislative assistant; Corinne Zaccagnini, chief information
officer; Brien Beattie, staff assistant; Phil Schiliro,
minority staff director; Phil Barnett, minority chief counsel;
Sarah Despres, minority counsel; Karen Lightfoot, minority
senior policy advisor/communications director; Josh Sharfstein,
minority professional staff member; Cecelia Morton, minority
office manager; Earley Green, minority chief clerk; and
Christopher Davis, minority staff assistant.
Chairman Tom Davis. A quorum being present, the Committee
on Government Reform will come to order.
I want to welcome everybody to today's oversight hearing on
our public health system's response capabilities at the
Federal, State, and local level to manage an emerging
infectious disease.
The global outbreak of Severe Acute Respiratory Syndrome
[SARS], provides a valid test to the Nation's preparedness to
handle any public health threat whether it's caused by
naturally occurring infectious outbreak or bioterrorist attack.
The Public Health Security and Bioterrorism Preparedness
and Response Act provided substantial new funding for States,
localities, and hospitals to boost preparedness to respond to
highly contagious disease.
The SARS threat is the first challenge to our Nation's
health network capabilities. It provides us with a chance to
evaluate existing procedures and safeguards. SARS has brought
fear and confusion to everyone's lives, particularly
international travelers, airline crews and health care workers.
Currently there is no known cure and the disease is easily
communicable. In a precautionary effort to prevent further
spread of the disease, President Bush signed an Executive order
on Friday, April 4, authorizing the use of quarantine if
necessary. The President's unprecedented actions prove how
serious the threat of SARS epidemic is to our country.
SARS is believed to have originated in China in the fall of
2002. It has since spread to 17 countries. As of today there
have been over 2,600 SARS cases reported worldwide, with 98
deaths.
In the United States the number of cases continues to rise.
Today this country has approximately 148 suspected cases in 30
different States, with the highest concentrations in New York
and California. Fortunately, no deaths have been reported.
We've actually seen two suspected cases of SARS nearby in
northern Virginia. I'm pleased that we'll hear testimony from
the director of the Loudoun County Health Department, who is
responsible for the treatment of a SARS patient in early
February.
It is important for our Nation's public health
infrastructure to recognize what lessons can be learned from
the SARS threat.
I have a fairly lengthy statement that I'd ask unanimous
consent go in the record, and we have a great selection of
witnesses to provide testimony this morning. Secretary Thompson
is going to provide the very latest information on this virus
and will discuss efforts being taken at the Federal level to
respond to SARS. He'll also describe preparedness coordination
efforts with State and local authorities.
Joining us on our second panel will be Janet Heinrich,
Director of Public Health Issues for GAO. She'll discuss the
GAO report released this week. The GAO report is timely and
very applicable to the SARS threat. Dr. Margaret Hamburg,
former commissioner of health for the city of New York,
recently co-chaired the Institute of Medicine Committee that
produced a noteworthy report on micro-biothreats to health.
And, finally, Dr. Goodfriend, director of the Loudoun County
Health Department will be sharing with us his experience in
their first suspected case of SARS.
I want to thank all of our witnesses for appearing before
the committee. As I said, everyone's statement will go in the
record. Secretary Thompson is limited here until 11:30, so we
want to move quickly to your testimony.
What I'm going to ask is that Mr. Waxman give a statement
for the minority, our vice chairman, Mr. Shays, give a
statement, and all other statements will be put in the record.
Is there objection to that?
[No response.]
Chairman Tom Davis. If not, Mr. Waxman?
[The prepared statement of Chairman Tom Davis follows:]
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Mr. Waxman. Thank you, Mr. Chairman. Thank you particularly
for holding this hearing today on SARS, which is a highly
contagious and potentially deadly new disease that has infected
more than 2,600 patients in 17 countries and claimed over 100
lives. Today in Hong Kong, just a single flight away from the
United States, the schools are closed, residents of a city
apartment building are living in vacation camps, which is a
euphemism for quarantine, and police are searching the streets
for people who are contacts with infected patients.
This emerging epidemic reminds us, as Dr. Fauci of the NIH
said to the committee last week, that nature is the most
dangerous bioterrorist. At a time when it is unclear how much
damage this epidemic will do in the United States, we have an
urgent need to answer many important questions. There are
questions of biology. How did SARS come about and what
infection agent is the cause? There are questions of secrecy.
Why did China fail to tell the truth about the epidemic in its
early stages? And what can we do to assure international
cooperation in the future? There are questions of medical care.
When will we have the drugs to treat the most seriously ill
SARS patients, and what are the prospects for a vaccine?
Today we will focus on a practical question. Is our
country's public health system prepared for SARS. We cannot
claim that there was no warning. We have many examples in the
past decade that were a wakeup call or should have been a
wakeup call on the breakdown of our Nation's public health
system and its vulnerability to new infections.
Over the last decade our Nation has taken some important
steps to combat emerging infections as we look back at the
history from the hantavirus to the epidemic of West Nile Virus
and the feared Bird Flu that led to the slaughter of chickens
in Hong Kong. All these warnings have been presented to us, and
over the last decade we have tried to respond to it. The
Centers for Disease Control and other agencies have bolstered
their disease surveillance around the world. With U.S. support
the World Health Organization has developed an international
system for identifying and responding to new diseases.
In 2002 Congress appropriated $1.1 billion for bioterrorism
preparedness at the State and local levels. The intent was that
this money would go to shore up our public health
infrastructure, and it is important that we do that. Despite
these efforts, however, significant weaknesses remain. In
October 2001, an investigation by my staff revealed critical
shortages in hospital surge capacity. In March of this year the
Institute of Medicine followed up its landmark 1992 report with
a warning that, while 13,000 to 15,000 public health
investigators and scientists are needed at the local level,
many barriers exist to prevent public health agencies from
hiring qualified staff. The IOM recommended the Nation take
dramatic steps to improve surveillance, enhance response, and
reduce antibiotic resistance. And just this week GAO found that
many health officials lack guidance from the Federal Government
on what they need to do to be prepared.
It is not hard to understand why we have neglected core
public health functions. There is very little political appeal
to the nuts and bolts of epidemiology, laboratory capacity,
communications systems, planning, and assuring adequate
hospital capacity. By comparison, it is much easier to attract
attention and funding to magic bullet technology solutions.
By any measure our investment in State and local public
health efforts pales next to what we are contemplating spending
on drugs, antidotes, and vaccines for bioterrorist agents. I'm
not saying we should not spend money for those vaccines and
other agents. Of course we should. But as the SARS epidemic
makes abundantly clear, a critical aspect of our response is
the ability of the public health system to recognize disease
and to contain it. That's why I believe Congress must do more
than investigate SARS; we must take concrete steps to shore up
our public health infrastructure as soon as we can, then we
must sustain this commitment for the long term.
As a starting place, Congress should adequately fund the
smallpox vaccination effort so that critical resources are not
diverted from core public health functions. We should also make
sure that the public health threats are addressed adequately in
the bioshield proposal. I commend Chairman Davis for the
interest he expressed in this issue at last Friday's hearings.
I am pleased that we are holding this bipartisan hearing
today and that Secretary Thompson is with us. I also note that
we have a very distinguished second panel of witnesses, and I
very much look forward to their testimony.
Chairman Tom Davis. Thank you very much.
[The prepared statement of Hon. Henry A. Waxman follows:]
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Chairman Tom Davis. Secretary Thompson, Mr. Shays has
agreed to put his statement in the record so we can get right
to you.
[The prepared statement of Hon. Christopher Shays follows:]
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Chairman Tom Davis. Would you stand please and be sworn as
is customary of this committee.
[Witnesses sworn.]
Chairman Tom Davis. Thank you. Secretary Thompson, thank
you so much for being with us today.
STATEMENT OF TOMMY G. THOMPSON, SECRETARY, DEPARTMENT OF HEALTH
AND HUMAN SERVICES, ACCOMPANIED BY GENERAL PHIL RUSSELL
(RETIRED), COMMANDER, U.S.M.; AND STEVE OSTROFF, CENTERS FOR
DISEASE CONTROL
Secretary Thompson. Thank you very much, Mr. Chairman, and
thank you so very much for holding this hearing. Congressman
Waxman, Congressman Shays, and Congressman Burton, all the rest
of the Members of this distinguished panel, thank you for
giving me this opportunity. I'm especially appreciative of my
good friend Governor Bill Janklow being on this committee, so I
know I'm in good shape, good stead.
Chairman Tom Davis. Wait until the questions. Janklow is
tough on the questions. [Laughter.]
Secretary Thompson. Members of this committee, thank you so
very much for inviting me. I also would like to introduce
retired General Phil Russell, who is the Commander of USM, and
also Dr. Steve Ostroff from the CDC. I'm going to have to leave
at 11:30 because I'm meeting with all the vaccine manufacturers
on SARS back in the office. I had set up this meeting. They're
coming in and I feel I have to go back at that particular time.
I appreciate this opportunity of giving the statement, but Dr.
Steve Ostroff is going to stay and answer any questions if
there still are questions after I leave. My colleagues and I
are committed to doing everything we possibly can to protect
the health of all Americans. Right now responding to the SARS
outbreak is one of our top priorities.
I also would like to just invite each and every member of
this committee to stop over to the Department at your
convenience to see our brand new communication war room in
which we detect and from which we are able to monitor diseases
and storms across the world, and I would appreciate if you
would stop over. I'm confident that if you come over it would
allay a lot of your fears. Congressman Shays has been over to
see it, and I think he will confirm that it is state-of-the-
art. It's probably the most technologically advanced command
center in the world. I would appreciate if you would all come
over and see it.
But right now responding to the SARS outbreak is one of our
top priorities. More than 250 researchers and staff from the
Centers for Disease Control and prevention are working around
the clock in laboratories and on location in several affected
nations to understand this new disease, devise appropriate
protections, and work with State and local health departments
in their efforts to do the same.
Scientists from the National Institutes of Health are
working with their colleagues at CDC, as well as the World
Health Organization in order to develop diagnostic tests and
explore a broad range of ideas for treatment and the possible
development of vaccines.
It was the researchers at CDC, ladies and gentlemen, who
identified the virus that we think causes SARS, a coronavirus.
A lot of other laboratories around the world thought it was a
paramixovirus and made that determination. It was our doctors
at CDC that said, ``No, it doesn't look like a paramixovirus,
it looks more like the coronavirus.'' So I think we are very
much in debt to the wonderful doctors that we have working for
the Department and for the Nation.
It obviously identifies the virus as critical to the
development of antivirals as well as vaccines. As you probably
know, Mr. Chairman, it looks like SARS began in the Guangdong
Province in China last fall, probably in November of last year.
From there it apparently spread to one floor of a hotel in Hong
Kong by a physician from Guangdong who was also a professor who
became infected while he was treating people at Guangdong
Province who himself became ill and subsequently died caring
for the patients. He stayed on the ninth floor of the Maripole
Hotel in Kowloon Province in Hong Kong. He happened to stay in
room 911, which got us very suspicious, and we were able to
find out and followup, and we are fairly confident that there's
no human involvement, no bioterrorism attack whatsoever in
regards to the SARS epidemic.
We are trying to improve our understanding the condition of
this man, ladies and gentlemen, and the residents of the hotel
floor. It was amazing that the seven individuals that he
infected on that floor are the individuals that went out and
transmitted the disease to Bangkok, to Hanoi, to Singapore, and
to Toronto, and four out of the seven individuals that were
infected from that one doctor who also died also subsequently
died, so it was very much what we would have called a super
transmitter was this doctor that transmitted to the individuals
on the 9th floor of the Maripole Hotel, the residents of this
hotel floor.
In order to learn more about how this disease was spread,
unfortunately the infection was carried to other countries by
these travelers who stayed on that floor at the same time.
Worldwide, thousands of people have already been infected, and
103 have died, approximately 4 percent, at 3.9 percent of those
infected are individuals that have fatally died from this
disease. To put it in proper perspective, during the worldwide
Pandemic Flu Epidemic of 1918 it was about 3.5 to 3.8 percent
of the people died, which of course caused somewhere between 25
and 40 million people to die and about 518,000 in America.
As of yesterday there were 154 suspected cases in the
United States. We can be thankful that all of them are still
alive. Of those 154, definitive diagnostic information is
currently only available from five of the cases, as
demonstrated by two different laboratory tests. Four have
evidence of coronavirus antibodies, indicating that they were
indeed exposed to this novel virus. One had a positive culture
of the virus of the 154, 53 have been hospitalized at some
point, but only 1 of the individuals out of 154 required a
ventilator. Thirty-one have tested positive for pneumonia.
So let me stress that these are suspected cases. Once we
have a good test, many of them may turn out not to have SARS at
all. We expanded our definition so we would make sure that we
got all those individual potential cases so that we could start
controlling and making sure they would not infect other people.
So out of the 154, we do not have definite tests on all of
them, so there may be more than likely--probability is quite
high--that it will be much less than 154 when we finally get
up. We had one additional case as of yesterday.
Other countries have not been as fortunate. According to
the World Health Organization, the worldwide SARS total not
counting the United States is 2,523 cases as of midnight last
evening. We'll have an update at 3 p.m., when the World Health
Organization reports in.
The early symptoms of SARS are a fever of more than 100.4
degrees, a headache, muscle ache, and a cough. People with
severe cases may have difficulty breathing. CDC has asked
people who have these symptoms to consult a health care
provider for a diagnosis. The incubation period from exposure
to symptoms is probably somewhere between 2 and 7 days, though
a few reports suggest up to 10 days. That's why we have
indicated that people who have the indications, the symptoms of
it, we ask them to stay isolated for 10 days.
SARS seems to be transmitted by coughing droplets, by
sneezing, and by personal contact. American health care
providers have been very good about protecting themselves while
interacting with patients that they suspect are suffering from
SARS. They've also provided excellent supportive care.
As we speak, CDC and NIH are developing three diagnostic
tests which we will soon be able to send to State laboratories
as soon as they are ready and FDA approved. Two antibody
systems require two samples of serum, one taken as early as
possible and the other about 3 weeks later. When comparing
these two samples from a given patient, it is possible to tell
who has been exposed to this virus. We are also developing a
polymerase chain reaction [PCR] test, for use as a diagnostic
test--all developed at CDC in Atlanta.
Rapid and accurate communications are absolutely crucial to
ensuring a prompt and a coordinated response to any infectious
disease outbreak. For this reason, strengthening communication
among clinicians, emergency rooms, infection control
practitioners and hospitals, pharmaceutical companies, and
public health personnel have been of the utmost paramount
importance to CDC for some time. And in the past 3 weeks CDC
has held multiple teleconferences with State health officials
to give them the latest information on SARS spread as well as
the implementation of enhanced surveillance and infection
control guidelines.
CDC has also appreciated receiving their input in the
development of these measures and processes. In addition,
ladies and gentlemen, we have issued travel advisories to
people returning from China, Hong Kong, Singapore and Vietnam.
There are about 70 flights coming in from the affected
countries. We hand out these particular pamphlets to each
passenger as they come off the airplane and be able to give
them information, telling them what they should do, how they
should conduct themselves and how they should control this
disease if they come down with it. It's very good. We've
expanded our surveillance from 8 ports to 22 ports as of today.
In addition, we would issue these travel advisories to people
returning from China, Hong Kong, Singapore, and Vietnam. We've
distributed now more than 200,000 of these health alert notice
cards to airline passengers entering the United States from
these areas. What these do is alert passengers that they may
have been exposed to SARS. Mr. Chairman, these cards advise
people to monitor health for 10 days and to consult a doctor if
they develop fever or respiratory symptoms.
So far, Mr. Chairman, the lessons that we can draw from
SARS is that surveillance is absolutely critical and that
surveillance works. Early detections of a pattern of symptoms
have been able to give scientists critical time to start
investigating this disease. In addition, we know that we have
much more to learn about this virus and this disease so that we
can develop the tools that we need to prevent, treat, and
contain it. We continue to work around the clock and to learn
more about every aspect of SARS.
I want to assure you, Mr. Chairman and members of the
committee, that this is not business as usual. We will not rest
until we understand how to detect, treat, and prevent this
disease.
I look forward to your questions and thank you once again,
Mr. Chairman, for giving me this opportunity to appear in front
of you.
Chairman Tom Davis. Secretary Thompson, thank you very
much.
[The prepared statement of Secretary Thompson follows:]
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Chairman Tom Davis. That was a pretty complete statement. I
have just a brief question or two before I yield to Mr. Waxman
and try to give everyone a question.
To ensure the safety of our health care workers who might
have come in contact with the SARS patient, we can issue
bulletins and everything else, but as you get out into places
like Loudoun County and some of the rural areas, people who
have traveled, you know, who knows who they have come in
contact with. Are first responders such as paramedics provided
with protective gear? What other precautionary measures can we
use and get the word out that they may be handling a potential
SARS patient?
Secretary Thompson. Congressman Davis, we are hooked up to
90 percent of the health departments right now through the CDC
and through the command center, which I hope you come over and
see, at the Department. Every Friday we give out a report, the
MMWR, talking about current diseases, infectious diseases and
so on. The last two reports have been totally on SARS, how you
protect yourself. We ask people to wear masks, the health care
workers to wear masks, as well as goggles, because we're not
sure but there may be the potential they can get in--the
infection can get in through the eyes, as well. We also, of
course, have every health worker wearing gloves. We also are
putting out advisories how people can take care of people that
may be infected in the home with the potential of SARS, about
washing and about controlling any kind of diseases whatsoever,
and that the individual that is a suspect for SARS should be
wearing a mask. We got this information out throughout the
country.
We are also putting out a video for all the airplanes
coming in. We're filming that today. It's going to be put out.
That's going to be shown to all passengers on planes coming in
from the affected countries.
Chairman Tom Davis. And that's really the critical part, to
stop the importation of this----
Secretary Thompson. That is correct.
Chairman Tom Davis [continuing]. From other countries
coming in at this point.
Secretary Thompson. That's why we put out the advisory
about travel conditions to other countries, and that's why
we're handing these out for all those individual passengers
coming back from affected countries, and that's why we're
putting out so much information to health care workers
throughout the country.
Chairman Tom Davis. Thank you very much.
Mr. Waxman.
Mr. Waxman. Thank you, Mr. Chairman.
Mr. Secretary, I'm concerned that we passed the
bioterrorist bill and that's supposed to help the local, State,
and local governments be able to deal with any emergency.
They're using funds for a potential smallpox epidemic, but
they're not adequately funded for that. But while they're
spending money doing that, which comes to $200 a vaccine per
person for first responders, I worry whether we're
shortchanging the infrastructure to deal with a SARS epidemic.
And I'd like to know what is the administration doing to assure
that State and local governments do not have to sacrifice
preparation for public health emergencies like SARS in order to
prepare for a possible smallpox attack.
I might take note that the IOM, Institute of Medicine, GAO,
and the HHS Inspector General all have found major gaps in
public health readiness at the State and local levels.
Secretary Thompson. Thank you very much for the question.
Let me first off thank you for your support on improving the
infrastructure of the local State public health systems. You
and I both know that we have avoided too long investing the
dollars necessary to have a real, complete, comprehensive local
State public health system. Now, thanks to you, thanks to all
Members of Congress, on a bipartisan basis last year you
appropriated $1.1 billion, which we sent out faster, I believe,
than any department has ever sent out the dollars to local and
State health departments.
I am sad to be able to report to you that only 20 percent
of that money has now been actually drawn down out of the
Federal treasuries, and the States have that opportunity to do
so. California, for instance, has only drawn down approximately
59 percent, which is much higher, but undrawn still is about 41
percent of the dollars that they can draw out.
Mr. Waxman. So is your contention----
Secretary Thompson. Could I just----
Mr. Waxman [continuing]. That there's enough money for the
State and local government to handle all of the possible health
emergencies?
Secretary Thompson. If you let me finish, I can explain it,
Congressman.
Mr. Waxman. Certainly.
Secretary Thompson. Second, we have an additional $1.5
billion that we can send out right now, and we're going to be
sending 20 percent of that $1.5 billion out right now, and we
are telling--the advisory is going out that States should use
some of this money to pay for their smallpox.
The third thing is in the budget resolutions going through
there's $60 million approximately set aside--I think it was $55
million, to be exact, set aside for smallpox on top of that 20
percent, plus there's $16 million set aside for SARS in the
budget resolution.
If there was going to be any addition, I would think that
maybe we want to bump up that SARS to $25 million, but that is
a decision that you and other Members--but right now I would
encourage you and other Members to contact your State Governors
to start drawing down more of this money that we have, because
we are in the process of sending out an additional $1.5 billion
this year. And this is still fiscal year 2002 funds.
Mr. Waxman. Mr. Secretary, I appreciate your sincerity in
trying to make sure that we don't have gaps in our public
health infrastructure and I know you're doing what you can, but
I worry that we're not doing enough. When we hear from the
Institute of Medicine, the General Accounting Office, and
others who say there are major gaps and that we are spending
money to deal with the smallpox possible epidemic, as we
appropriately should----
Secretary Thompson. Yes.
Mr. Waxman [continuing]. And then they come back and tell
us that they don't think that we're prepared if there is a
surge in need for hospitals to deal with an emergency like a
SARS epidemic, that there is a capacity to deal with it, that
there are enough inspectors to go out and find out whether--can
find the people that need to be found.
I just would point out to you that the reports we're
getting are that we're not doing enough. Do you feel that we
are doing everything we should be doing?
Secretary Thompson. No. I'll never say that, Congressman.
But I'm telling you right now there's money available right now
for States to draw down. As far as hospitals, last year we sent
out $135 million, this year it is going to be $518 million for
surge capacity, for improvements. And we could always use more,
but this is a tremendous improvement. We have an additional
$1.5 billion, including the 518 for hospitals to send out this
year, for fiscal year 2003, and only 20 percent of the money
that we sent out last year has actually been drawn down.
Now, the States could have allocated it and are building
for the infrastructure and haven't actually drawn down, but
there's money in the pipeline and there's more going out. Plus,
out of the $1.5 billion, 20 percent--part of that 20 percent
can be used for smallpox.
Mr. Waxman. Let me ask you what----
Secretary Thompson. So I'm just saying, Congressman,
there's money in the pipeline. We're working hard. And I would
invite you to come over to the command center and see it, and I
think we could allay a lot of your fears about all the things
we're doing.
Mr. Waxman. Let me ask you one last question. Last week the
President added SARS to the list of quarantinable communicable
diseases. Under what circumstances would you invoke your
authority to order a quarantine?
Secretary Thompson. That Executive order has not been
amended since 1983. This is the first time there was any
addition to the Executive order. It came about because a woman
came back from Asia and she landed in California, she came down
sick on the plane. We asked her to go in and get an X-ray and
be examined by our doctors. She refused. She got on a train to
go to New Mexico and we couldn't stop her. So we made the
suggestion, went up through CDC, through my office, to the
President asking him to expand the Executive order so we could
do that. We would use our Executive order and I would use it in
that kind of a question. We had a situation like that this past
couple days in New York, and the State of New York used the
authority and had this individual isolated. We don't use the
word ``quarantine.'' It's ``isolation.''
Mr. Waxman. Thank you.
Chairman Tom Davis. Mr. Shays.
Mr. Shays. Thank you, Secretary Thompson, for being here.
I've used SARS as kind of a wake-up call, you know, a very
real, live-fire exercise. This is, I believe, highly contagious
and we don't have a cure.
Secretary Thompson. That's correct.
Mr. Shays. I want to first know, in the incubation stage
can you spread the disease?
Secretary Thompson. Pardon?
Mr. Shays. In the incubation stage, can you spread the
disease?
Secretary Thompson. We're almost certain that it can.
Mr. Shays. I would like to know, when you talk about
surveillance as being the most important issue, which I think
is, as well, let me just ask you this specific question because
I don't have the comfort level that we do have the surveillance
yet. If I just took my hospitals in my district--Greenwich,
Stanford, Norwalk, two in Bridgeport, one in Danbury--are you
saying right now that you know every day what they are
experiencing, whether they have any outbreaks or not having
outbreaks, or has it not gotten that sophisticated yet?
Secretary Thompson. We know every day that the hospitals
report in their occupancy of the beds. Hospitals report in to
CDC on their particular cases, but----
Mr. Shays. Every hospital?
Secretary Thompson. I believe it is every hospital.
Dr. Ostroff. Well, in particular in Connecticut, you know,
most appropriately----
Mr. Shays. Your mic is not on, sir. Sorry.
Dr. Ostroff. Most appropriately, that information goes to
the State health department, and in Connecticut there is an
excellent system whereby the State monitors all of the
hospitals within the State of Connecticut for unusual illness.
Mr. Shays. On a real-time basis of what?
Dr. Ostroff. On a real-time basis. Correct. They are one
of--the State of Connecticut is one of our emerging infections
programs recipients, so that's the type----
Mr. Shays. Right. I know the claim----
Dr. Ostroff [continuing]. Of activity they're doing.
Mr. Shays. I'm sorry. I have only 5 minutes. I know the
claim; I'm just a little concerned that in reality that's not
happening. So how would you know? Do you have to get your
information from the State?
Dr. Ostroff. We do get our information from the State. We
have a highly collaborative working relationship with them, and
if there was an unusual event within the State of Connecticut,
we feel quite confident that they would contact us.
Mr. Shays. The problem is ``unusual,'' it may only be
unusual if you compare from a lot of different places and then
you see that maybe a pattern is happening, and so I want to
know very specifically if there is an outbreak of some kind but
rather small in Stanford so they don't think it's necessarily a
big deal, but there may be something in Bridgeport--I'm just
taking my own communities--would that be instantly or daily
transmitted to--I mean, would the State be informed and would
you be informed, as well, out of courtesy or legal requirement?
Dr. Ostroff. There isn't a legal requirement that the
States report to the Centers for Disease Control and Prevention
those types of outbreaks. They would do it as a courtesy.
Again, this is a very highly collaborative interaction and
relationship that we have with them.
Mr. Shays. Why wouldn't we want it legally required? Why
wouldn't we want to legally require it? I mean, why would we
even want to leave a doubt, because this whole system it
strikes me is only going to work if you can contain it and box
it in and you know about it soon enough. So is that something
that is being considered?
Secretary Thompson. I think we should consider it,
Congressman.
Mr. Shays. You don't have any Executive order to demand it?
Secretary Thompson. No, we do not.
Mr. Shays. OK. And that's important to know.
Secretary Thompson. But we really have great collaboration
and cooperation, and especially since we got the new dollars.
We are hooked up through the Health Alert Network with 90
percent of the health departments, and we have regular
communication with them, and----
Mr. Shays. I guess the Stakes----
Secretary Thompson [continuing]. We have also the
laboratories' capacity.
Mr. Shays. The stakes are so high that I don't think this
should be a model that is done by just general understanding. I
think there should be legal requirements, and if you don't do
it some penalties, frankly, because I think the stakes are very
high.
I have tremendous confidence with CDC. I have tremendous
confidence in NIH. WHO, World Health Organization, I think is a
phenomenal organization. I think it is under-resourced. Do you
agree that it is a huge and important element to our ability to
protect the United States?
Secretary Thompson. The World Health Organization?
Mr. Shays. Yes.
Secretary Thompson. Absolutely.
Mr. Shays. And----
Secretary Thompson. And we have direct collaboration with
them. In fact, we've had--within the last 10 days we have had
at least four teleconferences with the World Health
Organization with NIH, FDA, CDC, and the Secretary's office.
Mr. Shays. What kind of resources is our Government giving
World Health Organization?
Secretary Thompson. I think we--I'm not sure, but I think
it is about 50 percent of their budget, but I'm not sure.
Mr. Shays. Do you think it's enough? Do you think we should
do more?
Secretary Thompson. I think that at this point in time--I
didn't expect to answer this question, but I would say off the
top of my head, after being on the board of directors, I think
it is enough.
Mr. Shays. OK. Thank you, sir.
Secretary Thompson. I think other countries should be doing
more.
Mr. Shays. I just want to quickly state that I know you're
doing a great job and I know you're working hard. You're using
the laws that you have right now, but I do think that you need
to have some authority that is clear and no doubts about it and
it is not just on a gentleman or gentlelady's understanding.
Secretary Thompson. I think that's true. I agree with you.
Chairman Tom Davis. OK. Thank you.
Secretary Thompson. Could I just say one thing to you,
Congressman----
Chairman Tom Davis. Yes.
Secretary Thompson [continuing]. In response to a couple of
questions you asked Steve. We also have a cooperative
arrangement with the hospitals. If there is a mysterious
illness in the hospital, they're supposed to get their
specimens to the State laboratory and also a concurrent
specimen to the CDC laboratory. We also have leased planes in
which we can fly epidemiologists from Atlanta to a hospital at
any particular time any time a mysterious illness comes in, and
we have used that. We've had some false alarms on smallpox and
we've sent our epidemiologists into several communities, and we
have been able to do that on a regular basis. As soon as
something comes in, we have told the hospitals and emergency
wards throughout America, ``You've got something suspicious,
don't wait. Don't tarry. Call us.''
Mr. Shays. It only works though if they tell you.
Secretary Thompson. Pardon?
Mr. Shays. It only works if they tell you.
Secretary Thompson. That's right. It only works if they
contact us.
Chairman Tom Davis. Thank you.
Mrs. Maloney.
Mrs. Maloney. Thank you, Mr. Chairman. And I thank all of
the panelists for your important testimony. It seems that
Lorrie Garrett's predictions in her book, ``Betrayal of
Trust,'' have come true. I'd like permission to put in the
record an article from the New England Journal of Medicine, and
in that article it asks if we could possibly respond fast
enough to contain this epidemic.
To quote from the article: ``If the virus moves faster than
our scientific communications and control capacities, we could
be in for a long, difficult race against SARS. The race is on,
the stakes are high, and the outcome cannot be predicted.''
Chairman Tom Davis. Without objection, so ordered.
Mrs. Maloney. Thank you.
[The information referred to follows:]
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[GRAPHIC] [TIFF OMITTED] T7067.026
Mrs. Maloney. I want to know--I represent New York, and we
have 8 million people in a very small area. How contagious is
SARS? I've read articles that on the airlines you can catch it
from someone who is infected that is sitting immediately next
to you or in the immediate vicinity, but because of the
sophisticated air handling system all the passengers on the
plane would not be at risk. But in terms of mass transit, the
subway systems that do not have the air handling system, could
someone get infected by riding on the same subway train? Can
you speak about how contagious it is?
There have been many, many articles about airlines, but not
about subways, buses, other forms of meeting halls or other
ways that people could be----
Secretary Thompson. Congresswoman, I'm going to ask one of
the doctors to respond directly, too, but let me just set it up
this way and tell you how much we are doing, because I think
that may allay some of your fears from New York, as well as
others.
CDC is working around the clock. We have the best
laboratories, the best scientists, the best doctors doing this.
When the rest of the world was looking at this and came up and
said this is a paramixovirus, it was our scientists that said,
``Hey, wait a minutes. We don't think so. We think it is the
coronavirus.'' They are 99.9 percent sure that it's a
coronavirus, and that's thanks----
Mrs. Maloney. So you believe it is a naturally occurring
disease?
Secretary Thompson. Yes.
Mrs. Maloney. It's not from any type of biological agent or
anything?
Secretary Thompson. We're almost absolutely certain that it
is. We're not 100 percent, but we're going to get there
hopefully, but we are very, very certain that it's not. Second,
we also, within the last 3 weeks, we have been able to come up
with three tests. The first thing you have to do is you have to
find out what the virus is. We were able to determine that at
CDC.
Second thing we have to do is come up with a test. We've
already come up with three tests we're working on right now.
We're hoping to be able to get it FDA approved very quickly,
get that sent out to the State laboratories in New York and
throughout the country so people can test. Of the 154 cases
right now, we've only really tested approximately a handful, so
out of the 154 we're not sure all of those will be SARS. The
probability is they will not be.
And the third thing is we're still learning a great deal
about this disease. As far as the infections, we believe that
there are what we call ``super transmitters,'' like this doctor
that was in the Maripole Hotel on the 9th floor and gave it to
the seven individuals that went out and spread it throughout
the world. He was what we would call a ``super transmitter,''
and now as far as the medical I would either ask Dr. Phil
Russell or Dr. Steve Ostroff to tell you.
Mrs. Maloney. Could I just followup with another question
very briefly? You said that it was similar to a cold. And
what----
Secretary Thompson. The coronavirus is the family of the
virus that causes the common cold.
Mrs. Maloney. So if we haven't been able to develop a
vaccine for colds, how can we develop a vaccine for SARS?
Secretary Thompson. As soon as I leave here Dr. Phil
Russell and I are meeting with all the vaccine companies. We've
also asked all the pharmaceutical companies to come in with all
of their research and all of their antiviral medicines in the
pipeline for us to be able to test.
Everybody has been cooperating. We're not certain that we
can come up with it.
Mrs. Maloney. But you will try.
Secretary Thompson. Our specialists think that we're--we're
working around the clock to do so.
Steve, did you want to talk about the infection?
Dr. Ostroff. Yes. What I would add to what the Secretary
said is that we always have to keep our minds open and, as he
emphasized, we're still learning a lot about this particular
virus as we go along. The predominance of the evidence that we
have up to this point indicates to us that, as is the case with
many other types of cold viruses, that direct, very close
contact with somebody else that's ill is probably the major
mode of transmission. We always have to keep our minds open to
the fact that in some situations where there are particularly
sick people, that it might spread more widely than that. But,
like with most of these respiratory viruses, close contact,
direct transmission within a few feet seems to be the major way
that this particular virus spreads.
Secretary Thompson. Congresswoman, we also have vaccines
for the coronavirus for animals, and I'd like to ask Dr. Phil
Russell just to expand on that a little bit.
Dr. Russell. That's true. The coronavirus genus has many
members in the animal kingdom, including causes of disease of
pigs and cats and so forth. There have been some very
successful vaccines made in the veterinary community that are
used on a regular basis. The virus also grows very well in cell
culture systems that are currently used for manufacturing
vaccines. So we believe we have an advantage here that might be
able to be exploited. How fast we can do it and how successful
we are going to be remains to be seen.
Mrs. Maloney. Thank you. My time is up.
[The prepared statement of Hon. Carolyn B. Maloney
follows:]
[GRAPHIC] [TIFF OMITTED] T7067.027
[GRAPHIC] [TIFF OMITTED] T7067.028
Chairman Tom Davis. Thank you.
The gentleman from Indiana?
Mr. Burton. I'm just going to ask two quick questions, and
then I'll yield to Mr. Janklow for a question.
Either developing a vaccine or going to try to develop a
vaccine for SARS, what about the people who are older or who
have immune problems already like AIDS patients or senior
citizens who have problems like that? How are you going to deal
with them and help those who may get infected in the upper age
levels? And are we going to use anything like--are you going to
recommend anything like eucalyptus which is a natural oil which
has some properties that does fight some of these viruses?
Secretary Thompson. Dr. Phil Russell is probably one of the
world's most noted virologists, and I would ask him to respond
directly to it.
Mr. Burton. Sure.
Dr. Russell. I think the populations you describe are at a
very high risk, and whether we're going to be able to provide
substantial help for high-risk individuals remains to be seen
in the future. A very aggressive program attempting to screen
all the potential anti-viral drugs that we can get our hands on
will be underway soon. It's already started. There are some
reports that steroid treatment is of some use from the Chinese
or from the Hong Kong experience. But I have fundamentally a
very pessimistic view of dealing with an acute, severe virus
illness in those populations you described.
I think controlling the spread of the disease with a
vaccine is probably our best hope after we--if it gets around
all of our quarantine and isolation methodology.
Mr. Burton. I hope when they're looking at these vaccines
and so forth they'll look at some of the natural remedies that
might be of assistance, like the eucalyptus and other things
like that, just in the course of looking in to see if that
might be a help.
Dr. Russell. I think going forward we're going to look at
every possible option.
Mr. Burton. OK. Mr. Janklow, I yield to you.
Chairman Tom Davis. This will be the last question, because
I know you have to leave, but we'll make this a Governor-to-
Governor question.
Mr. Janklow. Thank you very much.
Secretary Thompson. Always the toughest, I might add.
Mr. Janklow. Thank you very much, and thanks for yielding.
A quick question. There have been about 3,000 cases worldwide,
and those 3,000--in that period of time that you've become
aware of it, you have put out 200,000 pamphlets on airplanes,
you're preparing a tape, you've dealt with the isolation issues
with respect to your legal authorities. In addition to that,
you've had many teleconferences with State officials. You've
called the pharmaceutical reps together in a teleconference.
You're now meeting with them.
The point that I'm trying to make is that this is a
phenomenal response. But my question is: have we pursued or
will we pursue the reason that the Chinese Government sat on
this? Congressman Shays' question dealt with our hospitals
reporting things to you. China sat on this, fibbed about it,
covered it up. And now may not be the time to deal with it, but
will there be a time when this is addressed for China so this
kind of problem with respect to world health can be dealt with
in a more satisfactory manner? And is there anything we can do
to assist in that process?
Secretary Thompson. I think it is the time to deal with it,
because this started in Guangdong Province in late October,
early November, and we had a very difficult time getting our
people to get into Guangdong Province. In fact, we didn't get
in there until--I think it was last Tuesday was the first day.
It required myself calling the Minister of Health. It required
the World Health Organization putting on a tremendous amount of
pressure. It required the CDC saying that, ``We helped you set
up a CDC counterpart,'' and we went through that avenue, and
finally they came out. And we didn't get our people in. It was
led by Dr. Robert Brenman from CDC, and he had to subsequently
leave and go back, and now we've got a Dr. Mark McGuire who is
leading our efforts there.
So they've opened up, and they have now come back,
Congressman Janklow, to contact us and say, ``We want more
collaboration.'' In fact, they want us to go into Beijing, they
want us to go into Shanghai and help them diagnose this and
help to control it. The Chinese have been very forthcoming
since last Tuesday, and they want more collaboration rather
than less, which is unusual for the Chinese. So it seems that
they have moved a great deal. Plus, the Minister of Health had
a press conference and actually apologized, and we've never
heard that happen before, so I think that's a good sign.
Chairman Tom Davis. Thank you very much. Governor, thank
you. I know you have to leave. Dr. Ostroff, I understand you're
going to stay here for additional questions as we move to Mr.
Ruppersberger.
Mr. Ruppersberger. Thank you, Mr. Chairman.
The issue of outreach, obviously we have the best doctors
and researchers in the world, and we need and we're helping
them and I think doing a great job. I'm glad that we are on top
of this. But what about the plan for the public outreach
besides nightly newscasts? What about health departments, both
local and State? How does that work, and what plan do we have
from a public outreach point of view to educate not only the
public and the other governments, but also the physicians who
might be dealing with this problem?
Dr. Ostroff. Well, we've used a variety of different
mechanisms to try to make sure that we keep our front line
public health workers, that we keep our health care providers,
and that we keep the public informed about what is happening
not only here in the United States but what's happening
elsewhere. We've done this through having constant press
conferences and telebriefings to all of our State health
departments. Our Web site has a tremendous amount of
information on SARS, and according to our public affairs people
at CDC, even in comparison to our experience with anthrax 2
years ago, the number of calls that our hotline is receiving
from the public exceeds the numbers that we had during the
anthrax outbreak in 2001. And, in addition to that, our Web
site is getting hundreds of thousands of hits over the course
of the last several weeks. So clearly the public is accessing
the information that we have available. And we're using every
modality that we can think of to keep the public informed about
what is happening with this syndrome.
Mr. Ruppersberger. Do you rely more on State and local
health departments to educate, say, physicians about what they
need to look for, where you need to go, or is it more----
Dr. Ostroff. Well, we've had communications with all of the
professional organizations, as well, and we keep them informed
about what is happening, and through the professional
organizations they've also been keeping their membership
informed about what is happening with this disease, and they
have been distributing our information, as well.
Clearly, we rely on a partnership with all of the States
and with the local health departments to help us make sure that
they get information to those who are out on the front line.
Mr. Ruppersberger. Do you have a special team that goes
into a certain location in the event that there is an outbreak?
Dr. Ostroff. We have many such teams at CDC. It is
important to point out that we always have to go in at the
invitation of the State health department in order to provide
assistance to them in conducting those----
Mr. Ruppersberger. Have you had problems with that in the
past?
Dr. Ostroff. I think that on balance it is a highly
collaborative working relationship and it continues to get
better all the time.
Mr. Ruppersberger. OK. Thank you.
Chairman Tom Davis. Ms. Davis.
Mrs. Davis of Virginia. Thank you, Mr. Chairman, and thank
you, Dr. Ostroff. A couple of questions. One, you say that it
started with the doctor on the 9th floor treating other folks.
One, I don't know why he was treating the other folks unless
they had something together. I don't know what. But how did it
originate with that doctor? I mean, where did it come from?
That's question one.
The second question you may not be able to answer because
it refers to what Secretary Thompson said when I believe it was
Mr. Waxman that asked him were we doing enough, and he very
quickly said no. Well, if we are not doing enough, what else do
we need to be doing? That's the second.
And the third question is to you. When you responded to Mr.
Shays, you talked about how great Connecticut was. Well, what
about the other 49 States.
Dr. Ostroff. Thank you for those questions. In response to
the first question, let me try to clarify the situation with
the physician who came to Hong Kong. He actually came to Hong
Kong to attend a family affair. He was from Guangdong Province.
He was directly involved in the care of patients that were ill
with the syndrome that was subsequently identified as SARS in
Guangdong Province. He had a family affair to attend in Hong
Kong. He and his wife traveled to Hong Kong. He wasn't directly
taking care of people while he was at the hotel. He arrived
ill. He attended the family event. The following morning he was
hospitalized and then 24 hours later he died.
We do know that a number of people that were staying at the
hotel, as was pointed out, subsequently became ill, and in
addition to that several of the other family members that
attended the event that he was attending, which was a wedding,
also became ill. And so that's how we think that this
originated, and that from his providing direct health care in
China that's how he got exposed.
Mrs. Davis of Virginia. To people who had the same thing.
Well, where did they get it? I mean, where did it start? The
chicken and the egg--where did it start?
Dr. Ostroff. That remains a very significant question,
which is to try to get back to the origins of the disease in
Guangdong Province and to try to get back to some of the first
patients that look like they had this syndrome, which, as the
Secretary pointed out, appears to have occurred back in
November.
The collaborators in China have identified those
individuals that they consider to be the first identified cases
in at least seven different locations in Guangdong Province,
and they actually have done a great deal of work, as has been
relayed to us by the team that we had on the ground in
Guangdong looking into the circumstances of those people to try
to get some clues as to where this may have come from.
Mrs. Davis of Virginia. Did you forget the other two
questions?
Dr. Ostroff. Sorry. The question about the capacities in
the other 49 States, we have cooperative agreements with all of
the State health departments to try to work with them to
enhance their capacities. We have two types of programs. One is
for basic epidemiology and laboratory capacity. All of the
State health departments receive that assistance from us. And
in a certain number of instances in 10 different locations
around the United States we have a more-sophisticated program
that's known as an ``emerging infections program'' whereby they
can conduct their surveillance activities on a much more active
basis. So we have a number of different programs that we use to
support all of our partners at the State level.
Mrs. Davis of Virginia. Are they pretty much up to speed,
most of the States, all of the States?
Dr. Ostroff. Well, I think that the Secretary said it very
appropriately that we certainly have made great strides over
the last several years. That has come both from these types of
resources as well as from the funds that are being used for
bioterrorism, because it has always been recognized that those
funds are basically dual-use funds. They are used primarily for
bioterrorism-related activities, but they also are used by the
States to build their intrinsic capacity to recognize both
intentional as well as naturally occurring diseases. So I think
all of those resources have been used to enhance capabilities.
And, as I think we would all say, and I think you will hear
from our partners at the State and local level, this is a
continuous process. We have to keep on building the system as
we move forward.
Mrs. Davis of Virginia. And I'll have to refer the other
question to Secretary Thompson, I suppose. Thank you. Thank
you, Mr. Chairman.
Chairman Tom Davis. Thank you.
The orders that I have on the Democratic side are Watson,
Lynch, Clay, and Norton, and I have Duncan, Murphy, and
Janklow. If that's not correct, I need to be corrected. But Ms.
Watson, you have the floor.
Ms. Watson. Thank you so much, Mr. Chairman. I want to
thank Tommy Thompson and his team for being here.
During his presentation, the Secretary mentioned the draw
down of money that is proposed to be allocated and that
California has only drawn down 51 percent. I want to know what
the process is for drawing down the money. Do they have to have
a plan proposed or in operation to be entitled to this money?
That's my first question.
And I also want to know is this smallpox threat a reality
now to take precedence over the SARS threat, because I did hear
it mentioned that 20 percent of the moneys can be used for
smallpox. So if a State doesn't want to have that program
enforced, does that get in the way from getting the money for
the other kind of epidemics or biothreats?
If you could address those points?
Dr. Ostroff. Well, let me try to address your questions.
Ms. Watson. OK.
Dr. Ostroff. I certainly can't go into the same level of
detail that the Secretary did.
Ms. Watson. Yes. I understand.
Dr. Ostroff. But what I can tell you is that all of the
States, as a condition of receiving the bioterrorism funds, had
to develop a very detailed plan. That detailed plan had to
address a number of different issues. There were, I think, 16
different priority areas that had to be developed in their
operational plans before any of the funds could be released. It
was a very rapid process because we wanted to get the funding
out there as quickly as we possibly could. But over a process
of a couple of months last year, all of the State plans were
eventually approved. And once those approvals came through,
then the States could start drawing upon the resources.
In terms of your question about the threat of smallpox
versus the threat of something like SARS, it is hard to compare
and contrast because they are quite different threats. What I
can say to you is that we would consider both of them to be
very important, and both of them very much deserving of
enhancements in preparedness.
Ms. Watson. Here is my concern: California is a Pacific Rim
nation. It is the first stop when people are coming from
Southeast Asia at LAX. The airlines might hand out or that
yellow card might be handed out, and I was wondering if there's
any requirement for them to hand out the masks. It makes sense
to me that if you are going to fly across the Pacific Ocean,
the number of hours that it takes--6 to 8 hours--we ought to be
giving out face masks if they come from one of the affected
areas.
But my other problem is, in trying to think it through as I
was listening to the testimony, is that we are having a
tremendous problem meeting the deficit in California. We are
closing in my county, Los Angeles, we're closing the clinics,
the public health clinics. That's where the indigents are taken
care of. And is there some way to expedite the applications for
this money so that we can get it out there? Can they proceed
the detail planning, because we're closing our clinics, and the
threat is greater on the coastal areas of the United States,
particularly on the West Coast. And I'm thinking that the
paperwork that's required--I have been in Government for a long
time--slows that process down. So can you--and I'm throwing
these things at you because they're on my mind.
Dr. Ostroff. Right. Well, in response to the second part of
your question, we've tried to move as expeditiously as we
possibly could once the money became available to make sure
that the States had developed their plans and that the plans
were approved by us so that we could move the resources as
rapidly as we possibly could.
In response to the first part of your question concerning
the issue of masks and other ways of potentially preventing
transmission--and I think, in response to some of the questions
that Congressman Davis also raised concerning specific guidance
for various types of groups, we have been working very, very
hard to develop recommendations and guidance for all types of
situations, including airlines, including emergency responders,
etc., so that they would have information about what is
appropriate to do in terms of protecting themselves from
potential exposure.
In terms of the guidance that both we and the World Health
Organization have provided around airline circumstances, we do
not routinely recommend that people wear masks. The emphasis in
the airline setting has been the prompt identification of
somebody who may potentially be ill, isolating that passenger
from the rest of the passengers, preferably placing a mask on
the ill individual rather than all of the other passengers.
Ms. Watson. Excuse me, if you will allow me. How in the
world would you know? When I have come out of the Far East
there are hundreds--and I know my time is up. I'll just finish
with this if you don't mind 1 second.
Chairman Tom Davis. Thank you.
Ms. Watson. How would you know, in the crowds that are
coming through, getting on those planes? I think we ought to
err on the side of requiring, because you could be sitting next
to that infected person that showed no signs as they come up to
the desk, go through security. Who is there checking them out?
I just throw that out. Think about it. You don't even have to
respond.
Thank you, Mr. Chairman.
Chairman Tom Davis. I thank the gentlelady.
At this time the Chair recognizes Mr. Duncan.
Mr. Duncan. Thank you, Mr. Chairman. Actually, my first
question is somewhat related to that last line. How difficult
is this to diagnose? And is there some simple test or
procedure, or can it be quickly, easily identified, or is it
something that it takes a test that you have to send off and
wait a day or two?
Dr. Ostroff. Well, up until 2 weeks ago we didn't even know
what the potential cause was.
Mr. Duncan. Right.
Dr. Ostroff. And so it is only once you identify what the
causative agent might be that you can develop--start developing
tests that would be directed specifically against that
diagnosis. The syndrome, itself, particularly early on, is
pretty non-specific. It looks like many other types of
respiratory illnesses. And so there is nothing, at least
initially, that distinguishes it from other types of diseases.
That's why we've gone to such great lengths to use a very wide
net in terms of being able to recognize people with the
appropriate travel histories so that we can take the
appropriate precautions and make sure that we can reduce the
risk to the minimum possible to have them potentially transmit
to other individuals.
As far as where we are with the diagnostic tests, we have
been making great strides since we identified the coronavirus 2
weeks ago to develop these tests. Right now these tests are
being refined in our laboratories in Atlanta, and when we're at
the point where we think that the tests perform the way that we
think the test ought to perform, both in terms of recognizing
people who really have the disease, as well as excluding people
who don't, then we will begin distributing it to all of the
States so that they can more rapidly make the diagnosis
appropriately.
Mr. Duncan. Well, hopefully we are going to be able to come
up with some way to contain and eradicate this disease very
shortly, but let me ask you this: what other steps can we take
if we don't come up with something very quickly, because
obviously you mentioned a few minutes ago that you're getting
more calls and more hits on the Web site than even the anthrax
scare, which was a pretty big scare, and I think you said,
what, 100,000 hits or something?
Dr. Ostroff. Hundreds of thousands.
Mr. Duncan. Hundreds of thousands. So obviously the concern
is very great. And the West Coast, of course, is the front
line, I suppose, but we have people flying in from all over the
world in my home town of Knoxville, TN, and all over the
country. What can we do? If this thing starts to explode in
some country, can we require that all passengers coming in from
that country be tested or something done before they start
spreading this all around the country, or what can we do?
Dr. Ostroff. Right. Well, before we get to that point we
have to have the test and we have to make sure the test works
the way that we think that it ought to work.
Mr. Duncan. Because some of these people may be carrying
this without realizing it.
Dr. Ostroff. Right. One of the things that the World Health
Organization has recommended is that on the embarkation end,
when people are getting on airplanes from the areas in which
there's evidence that there is local transmission occurring,
that these passengers in some way, shape, or form be screened
before they get on the airplane so that ill individuals can be
recognized and make sure that they don't get on the airplane in
the first place.
Mr. Duncan. That's good.
Dr. Ostroff. And then, in addition to that, they've
provided this information about what to do if somebody may not
necessarily have been sick at the time they got on board but if
they become sick en route.
In terms of what happens if this does explode and gets
bigger and bigger and we run into situations like have been
seen in some other parts of the world, I think the best defense
against that is some of the things that Secretary Thompson and
General Russell mentioned in terms of trying to come up with
specific therapeutics and trying to come up with preventative
measures that we can use to prevent people from getting the
disease in the first place. They obviously will take some time
to get into that position. But hopefully that would enhance the
tools that we have available to control this in the future.
Mr. Duncan. Well, I think Vice Chairman Shays made a good
point in saying that we maybe need to give you some more
authority, especially to do things concerning people who fly in
from these other countries, if this thing gets bigger and
bigger.
Thank you very much, Mr. Chairman.
Chairman Tom Davis. Thank you very much.
Mr. Lynch.
Mr. Lynch. Thank you, Mr. Chairman. I want to thank you and
also Ranking Member Waxman for your leadership on this issue. I
want to thank the Secretary for coming in, and also you,
Doctor.
I heard you mention in your earlier testimony that we are
having people on the ground in Guangdong Province, and, while I
have not been in Guangdong Province in over 2 years, I am quite
familiar with the city of Guangzhou and the province, itself.
Now, we probably have close to 7 million people in the city of
Guangzho. It is the provincial capital. You have one of the
major regional markets there. And while I need to be mindful of
the cultural sensibilities, environmentally and from a public
health standard those systems have been compromised in that
city. It is just simply overwhelmed.
Also, and to my point, we have the major U.S. and European
adoption center located at the White Swan Hotel right in the
middle of Guangzho, and on an average weekend there--and I've
seen it with my own eyes--you might have anywhere from 300 to
500 families coming in. Usually one parent comes in, adopts the
child, flies out the same weekend. And all of this is
exacerbated by the China one child policy and the fact the that
Chinese Government has taken really a--kind of closed one eye
to the adoption process, and they're sort of doing this thing
without recognizing they're doing it.
We've got a situation there that is not adoption as we
would view it in this country. You're really looking at a
humanitarian effort there and we're rescuing kids. We're saving
their lives. I have in my District recently a woman and her
sister went over and adopted a young child, which is fairly
customary, and came back, and now the child is infected and the
sister is infected, as well, in Springfield, MA.
My question is this: given the whole situation then, do we
have any protocol in place to address that situation? Have we
allocated any additional resources to State or to anybody else,
to your own people, to help that situation, given the fact that
these adoptions need to go forward and we need to protect our
people?
Dr. Ostroff. Right. Thank you very much, Congressman, for
asking that question. We, too, have been very concerned about
that situation because virtually all international adoptions
from China come from that particular region of the country.
We have been working on a highly collaborative basis with
the international adoption agencies that deal with adoptees
from China--with all of them. There are a number of them in the
United States--to make sure that we have protocols in place so
that we can provide information to the parents before they go
over there about what measures they can take to reduce their
risk, and we have been also working quite well with all of
these agencies in collaboration with our States and our local
health departments to make sure that we can monitor these
children as they do come so that we can minimize any potential
impact not only from the child but also from potentially the
parents. And so we've recognized this as a considerable issue,
and we have been working quite strenuously to make sure that we
address it in the most sensitive and appropriate way.
Mr. Lynch. Thank you, Doctor. Thank you, Mr. Chairman.
Chairman Tom Davis. I thank the gentleman.
Mr. Janklow, you have the floor.
Mr. Janklow. Thank you very much, Mr. Chairman.
Doctor, in Secretary Thompson's testimony on page 7 they
talk about this is a very infectious--SARS is very infectious
during the symptomatic phase of the disease. Then it goes on to
say, ``However, we do not know how long the period of contagion
lasts once they recover from the illness. We do not know
whether or not they can spread the virus before they experience
symptoms. The information our epidemiologists have suggests the
period of contagion may begin with the very onset of the
earliest symptoms of the viral disease.''
Then on page 8 it says, ``People who are living in a home
with a SARS patient who are otherwise well, there's no reason
to limit activities currently.''
Well, why do we draw that conclusion, sir, if we don't know
at what stage it is transmitted? And are we suggesting to
people that it is OK if you live with a SARS patient to just go
on about your business around the community if, in fact, it is
maybe transmittable before you have any of the manifestations
of the onset of the illness? Do you understand what I'm saying?
Dr. Ostroff. Right. No, I understand, Congressman. We have
been very rapidly accumulating a great deal of information, not
only here in the United States but also through our teams that
are working overseas where most of these cases are occurring,
to try to answer some of the questions that you are raising,
and the way to do this is through the collection of serial
specimens.
Mr. Janklow. But, sir, if we're telling people don't go to
Hanoi, don't go to Guangdong, Guangzho, don't go to Hong Kong,
but if you have a SARS patient in your house you can go out and
go to the supermarket, I mean, how is the public supposed to
understand what it is that we really think is the cause for
concern?
Dr. Ostroff. Right. Well, looking at the situation here in
the United States, you know, most of our cases are considerably
milder than what has been seen in other parts of the world.
Obviously, for those individuals who are ill, most of these
people have been put in the hospital appropriately and have
been put in appropriate isolation. In instances where there are
some of these milder cases, as a routine recommendation we have
made the recommendations that these individuals stay at home,
remain in their homes, and for family members of these
individuals that are living in the same household, that they
monitor themselves for illness. In the absence of illness,
however, we do not recommend that they self isolate themselves.
Mr. Janklow. But, Doctor--and I'm not trying to argue with
you, but the testimony indicates that if someone is a SARS
patient and they're cared for at home, that they should stay at
home for at least 10 days----
Dr. Ostroff. Correct.
Mr. Janklow [continuing]. After they are no longer
symptomatic.
Dr. Ostroff. Correct.
Mr. Janklow. If they should stay at home for 10 days,
aren't we really pushing our luck to suggest it is OK for the
family members to come and go and wander around the community
while I'm staying at home for 10 days after I have no more
symptoms?
Dr. Ostroff. Well, until there is information to suggest
that isn't the correct thing to do----
Mr. Janklow. OK.
Dr. Ostroff [continuing]. We have difficulty making
recommendations that non-ill people stay at home. Now, this is
an important point because in some other countries they,
indeed, have taken measures, based on their local
circumstances, to restrict well individuals that have been in
contact with SARS patients from going into the community. At
this point, we have not seen any reason to do that in this
country.
Mr. Janklow. OK.
Dr. Ostroff. And so far this has worked quite well here in
the United States.
Mr. Janklow. Doctor, some of the literature we were given
says coronaviruses can mutate and change rapidly. This is the
reason why this virus stand was not included in this year's
influenza vaccine. Is that really a conclusion by somebody?
Dr. Ostroff. Well, one influenza vaccine has nothing to do
with coronavirus.
Mr. Janklow. OK. I'm just reading the sentence that was
given to me in the briefing papers.
Mr. Janklow. Right. They are two completely different types
of viruses. The influenza vaccine has--is directed against
three different types of influenza, only. As was mentioned
earlier, there are no human vaccines against coronaviruses.
Mr. Janklow. OK. Thank you.
Chairman Tom Davis. At this time the Chair recognizes Mr.
Clay. Thank you for your patience.
Mr. Clay. Thank you, Mr. Chairman.
Doctor, in a 1992 report on micro-biothreats to health, the
Institute of Medicine recommended the development of a
worldwide disease surveillance system. This recommendation was
made again in the IOM's 2003 update to the 1992 report. Can you
tell us what steps the administration has taken to implement
this recommendation and what steps are planned for the future?
Dr. Ostroff. Well, I think I can try to address what steps
that we've been taking at CDC and in HHS to work
collaboratively with the World Health Organization to try to
enhance global capacity to be able to address the threat of
emerging infectious diseases.
Again, as was mentioned, we have been providing resources
to WHO so that they can do their job better. WHO has been
working, and I think we are seeing the fruits of many of the
things that WHO has done in terms of their ability to work
collaboratively with all of the countries in Asia that are
affected by this and be able to monitor the world's situation.
They have a global alerting network that they've built to be
able to rapidly provide information about outbreaks that are
occurring in other parts of the world. We support that.
In addition to that, we are working toward building similar
types of programs to those that I described in Connecticut in
other parts of the world, as well. This is a program that we've
just started within the past couple of years. One of them
currently exists in Thailand in Bangkok, and that program,
itself, has been one of the instrumental tools that we've had
to help provide assistance in Asia with the SARS problem. And
so we have been working to try to improve global capacity, but
I think that there would be little question, both in our minds
as well as in the minds of WHO, that there is a great deal more
that needs to be done.
Mr. Clay. Thank you. In October 2001, the minority staff of
this committee reported on the growing problem of ambulance
diversions because of crowded emergency rooms in cities across
the United States, indicating serious implications for a public
health crisis. Are there any known cases of ambulance
diversions documented by public health authorities that relate
to SARS? And, if so, how many and when did it occur?
Dr. Ostroff. I am not aware of specific circumstances, but
that doesn't mean they haven't necessarily occurred.
Mr. Clay. Are SARS cases being turned away from medical
facilities because of lack of health care insurance that you
know of?
Dr. Ostroff. None that have particularly come to my
attention. Others may have other information. Obviously, many
health facilities around the country are very concerned about
the potential risk that such patients may pose. From our
perspective, it is important that all hospitals have the
appropriate infection control procedures and precautions in
all, both outpatient as well as inpatient settings, so that
these people can be appropriately cared for.
Mr. Clay. OK. Can this disease manifest itself in our food
and water supply?
Dr. Ostroff. It's way too early to be able to answer those
types of questions. Again, we are basing everything on knowing
about the existence of the virus, itself, for only 2 weeks, and
it is far too soon to be able to answer those types of
questions.
Mr. Clay. OK. And along those lines then is there any
reason to think that SARS is or is not related to a
bioterrorism effort?
Dr. Ostroff. Well, as the Secretary mentioned, all of the
information that we have currently available to us suggests
that this is a naturally occurring event. Nature, you know, has
a lot of tricks up its sleeve of its own, and these viruses are
constantly changing and mutating, and we constantly are seeing
new naturally occurring, emerging infectious diseases. However,
we haven't done everything that we need to do until we have
been able to look at the entire genetic sequence of the virus
to be able to say with 100 percent certainty that might not be
the case. We remain open to that possibility. But at least
everything that we've heard up to this point suggests that this
is naturally occurring.
Mr. Clay. Thank you, Doctor. I thank you for your answers.
[The prepared statement of Hon. Wm. Lacy Clay follows:]
[GRAPHIC] [TIFF OMITTED] T7067.029
[GRAPHIC] [TIFF OMITTED] T7067.030
Mr. Shays [assuming Chair]. Doctor, we're almost done. I
would just like to ask you a few questions, and then we'll get
to the next panel, and maybe the Governor has a question or two
to followup.
I want outstanding understanding, because we've said it. I
want to know if it is true. Is this a highly contagious disease
or is it not? In a scale of 1 to 10, how does it fit in, 10
being highly contagious?
Dr. Ostroff. Well, I'm not sure that we necessarily have
all of the answers yet to be able to properly give it a score.
What I can say is that in most circumstances it does not appear
to be highly transmissible. However, what concerns us is that
we have seen a number of instances in Asia and also in Toronto
where there seems to be what the Secretary referred to as the
``super spreaders'' where all of a sudden we see explosive
numbers of cases in their close contacts, particularly in the
health care setting and, as I'm sure many are aware, in the
apartment complex in Hong Kong and in the hotel setting in Hong
Kong, as well, and we need to understand a little bit better
the circumstances of those particular events and why they
happened and what may have been responsible for why one
individual seems to transmit the disease to so many people
while, in the vast majority of cases, they don't seem to do
that. It may simply have something to do with the stage of
disease. It may have something to do with the severity of the
illness at the time that individual was being cared for or was
around.
So we can't say with absolute certainty, so I can't give
you a definite score, but certainly if you look at a virus,
say, like measles where almost everybody that is within an area
will--you know, if they're not vaccinated, that are exposed
will develop the disease. It doesn't appear to have that degree
of contagiousness. But, again, most of these respiratory
viruses go from one person to another, and until we gather more
information we can't say exactly what degree of contagiousness
this one has.
Mr. Shays. What is the sense of our ability--how do we
determine whether something is natural or by the malevolent act
of man, something tampered with? How do we know whether it is
an act of a terrorist or just a natural act of----
Dr. Ostroff. Well, again, it is looking at the structures
of the virus, itself, and looking at the genetic material----
Mr. Shays. But there is a way to tell?
Dr. Ostroff [continuing]. And looking to see whether or not
there are sequences that would correspond with other sequences
that would suggest that maybe something was introduced into the
virus. All of that, you know, would go into making a
determination that something may not necessarily be natural.
Mr. Shays. Let me be clear on this. Do we learn from
analyzing the virus, the pathogen, or do we learn by just
tracking it down to its beginning and then learn that way?
Dr. Ostroff. Well, it is both.
Mr. Shays. OK.
Dr. Ostroff. Clearly. And that's one of the reasons why we
have been making such great efforts to try to get back to some
of these very early cases in Guangdong Province so that we
could learn about the types of exposures that these individuals
had that may give us some clue as to exactly what you're
talking about. But a lot of it is also based on what we learn
about the virus, itself.
Mr. Shays. You're one seat over from a gentleman who was at
our hearing on national security about 3 years ago, and he
closed--he was a doctor of a major medical magazine, and he
shared with us his biggest concern. His biggest concern was
that a small group of dedicated scientists would alter a
biological agent such that there would be no antidote and it
would wipe out humanity as we know it. He was not saying that
in an attempt to draw attention; he was just answering an
honest question and giving an honest answer. That scared the
hell out of me, though, and it makes me very interested just to
come back again, because I don't have a handle or a sense of
the concept of surveillance, which we believe is the most
important issue. I think the Secretary has said that.
When will a national surveillance system with real-time
data be put in place?
Dr. Ostroff. Well, what I can say in addressing that issue
is this is a system that we are working on developing.
Mr. Shays. Right.
Dr. Ostroff. We are looking at ways to access data on a
real-time basis at the national level, collect that
information, be able to analyze it and look for aberrancies.
That work is going on as we speak. It's a system that we refer
to as biointelligence.
Mr. Shays. And when will this biointelligence--when do you
think--what's your time table for getting this in place?
Dr. Ostroff. We hope that we will be able to move toward
pilots of such a system in the not-too-distant future. When
will a national system be in place? I think it is a little
premature----
Mr. Shays. I don't know about not-too-distant future. I've
got to pin you down a little more.
Dr. Ostroff. Well----
Mr. Shays. This is too important. You know, I mean, you
have to have some time. If you want to say within the next year
or you want to say within the next 5 years----
Dr. Ostroff. Well, we would certainly hope to have pilots
in place within the next year, Congressman.
Mr. Shays. OK. Within the next 12 months. And what does
``pilots'' mean?
Dr. Ostroff. Well, again, to look at different mechanisms
to be able to collect the information and try to figure out
which is the best way to do it efficiently.
Mr. Shays. OK. So presently we have a basic ad hoc system
that hospitals report to the States in some States and that you
try to grab any information where you can get it, directly from
the States or directly from New York City, and maybe the State
of New York, any way you can do it, and you're trying to
compile it. But right now we don't have a nationwide system
that captures in real time all the data around the country in a
matter of seconds or minutes all at once to be able to compare
data, right?
Dr. Ostroff. No. I think it is fair to say that we don't
have such a system, but I'd also point out to you that, at
least in our experience, a one-size-doesn't-fit-all system, and
what might necessarily work, say, in Connecticut may not
necessarily work in Los Angeles. That's why we have been--you
know, with the bioterrorism resources, one of the major efforts
of those resources is to develop the type of syndromic
surveillance that you have been describing, and there are many
different models that are being used at the State and local
level to be able to do that.
Mr. Shays. Let me just say my time has run out. I'm just
going to go a few minutes longer and then go to my other
colleagues.
Mr. Janklow. Very briefly?
Mr. Shays. Sure.
Mr. Janklow. Very briefly, I have three very quick
questions.
One, you say there's indications that it may be weaker in
this country. Does that give us hope that this thing may kind
of peter itself out as it continues to move through society,
that there's any logical reason for it?
Dr. Ostroff. I think, Congressman, the term ``weaker'' is
probably not the right term. The spectrum of illness that we've
seen so far in the United States seems to be milder than what
has been seen elsewhere. We believe that's probably a
phenomenon of the fact that we're casting a very wide net, and
as you cast a wide net and become less specific in terms of
what you're looking for, to try to be as sensitive as possible
to find all even theoretically possible cases, we're probably
picking up people with milder illness who have something else.
Mr. Janklow. Sir, the second thing, when you were asked the
question by the gentleman from Maryland about cooperation, you
took a deep breath, let it out, and you said ``on balance,
things are highly collaborative.'' Is there a problem at all
with collaboration with the other health agencies in the
country? And I realize I put you on the spot, sir, but it is
very important as we're talking about this kind of problem.
Dr. Ostroff. Right. Congressman, what I can say is that we
work on a highly collaborative basis with all of our partners
at the State health departments.
Mr. Janklow. Is that happening now with this disease?
Dr. Ostroff. Absolutely.
Mr. Janklow. OK.
Dr. Ostroff. All of--you know, we've had--currently we've
had reports of suspected cases from, you know, that we have
been including on our line listing from at least 30 States. I
don't know what today's count will be, but at least 30
different States. And, in addition to that, there have been
many hundreds more, individuals that have either directly
contacted us, their health care providers have contacted us----
Mr. Janklow. I'm talking about the agencies, not----
Dr. Ostroff [continuing]. Or the States have.
Mr. Janklow. Not the individuals.
Dr. Ostroff. Or the States have. And we have worked
collaboratively with every single health department in this
country to be able to investigate those cases and figure out
whether----
Mr. Janklow. One last question.
Dr. Ostroff [continuing]. They meet our definition.
Mr. Janklow. Thank you. One last question, sir. There's a
suspicion that this may have jumped from animals to people. Do
we know of any animal that has carried this disease in the past
that gives us that suspicion?
Dr. Ostroff. Right. This coronavirus, at least based on the
work that we have done up to this point, appears to be unique
and new, different than other coronaviruses that we've seen. We
do know that there are a number of coronaviruses that naturally
infect animals, and so what we have been doing is we have been
doing additional work to actually look at the virus, itself,
and see if it will give us any clues as to the type of animal
that it may have come from. We're not there yet.
Mr. Janklow. Thank you, Mr. Chairman.
Mr. Shays. Thank you. We're almost done here. This is a
live-fire exercise. If it was more contagious, obviously we
would be presented with a more difficult challenge. There's
nothing in nature's law that says there couldn't be something
more contagious, correct?
Dr. Ostroff. Oh, absolutely.
Mr. Shays. Yes. So in one sense this is a good practice for
us, would you agree?
Dr. Ostroff. Well, all I can say is that we remain highly
concerned about even this particular virus and the potential
impact it can have, not only around the world but also here in
the United States.
Mr. Shays. OK.
Dr. Ostroff. I think we have to be very vigilant about the
potential for this virus.
Mr. Shays. OK. And we have to move as quickly as we can to
get those pilot programs----
Dr. Ostroff. Absolutely.
Mr. Shays [continuing]. Moving, and I think, frankly, if I
could express an opinion, not a question, a little more
forcefully, I think that the Secretary and you and others have
to be a little more outspoken. I tend to think that the
Secretary doesn't want to alarm people because obviously that's
not healthy, but at the same time he doesn't want us to feel
like things are moving along and we don't need more resources
or we don't need more legislation. It strikes me that we need
to push the surveillance as quickly as we can.
It's a fact, isn't it, that a terrorist act could tamper
with a biological agent or they could take a natural agent and
just try to spread it, and then it's a little more difficult to
know because you can't know from looking at the virus or the
pathogen where it hasn't been altered, it hasn't been changed,
it's natural in that sense, correct?
Dr. Ostroff. That's correct. I mean, it is important to
have some baseline of other viruses to be able to compare it
to.
Mr. Shays. One last area real quick. At one point we were
going to destroy the smallpox virus, both sites. The Russians
had it, we had it. And there were a number of us who said,
``We're not sure that's a good idea.'' Even within HHS also had
some concerns. But ultimately we didn't do it, and it is
probably proved wise that we haven't. But in the process of
creating a vaccine, is it possible that someone can take from a
vaccine and create the virus from a vaccine? Is that possible?
Dr. Ostroff. Well, you know, to some degree. It depends on
the virus. We certainly know many live virus vaccines where--
and probably the best example of that would be, for instance,
polio, where even the vaccine strains can revert themselves in
nature to become more virulent and actually produce disease,
and so it is----
Mr. Shays. What about----
Dr. Ostroff [continuing]. Theoretically possible to do
that.
Mr. Shays. What about smallpox?
Dr. Ostroff. Well, the smallpox is not so much of an issue
because the vaccine, itself, is a different virus.
Mr. Shays. Well, let me ask you this, though. Why is it,
though, that if one partner in a marriage can't take the
vaccine the other doesn't? In other words, if you're pregnant
you choose not to, so the husband is determined that he should
not, you know, have the----
Dr. Ostroff. Right.
Mr. Shays. And why would that be?
Dr. Ostroff. Well, because the virus, itself, is
transmissible from one individual to another through direct
contact.
Mr. Shays. Well, is----
Dr. Ostroff. And because of that and because of the health
threat that the virus could potentially pose to pregnant women
and other people with immunocompromised health conditions, the
recommendation is that if there is someone in your household
who fits into one of those categories that you defer from
vaccination.
Mr. Shays. OK. I don't want to dwell on this. I just want
to understand it, though. I want to understand that--is that--
are you saying, in essence, that someone could basically have
the vaccine--is it called a vaccine, smallpox vaccine?
Dr. Ostroff. The smallpox vaccine is vaccinia.
Mr. Shays. Right. OK. You have the vaccine. It is possible
that someone could contract smallpox from a person who has had
a--I'm seeing a shaking of the head behind.
Dr. Ostroff. No. Not smallpox.
Mr. Shays. OK. Some other----
Dr. Ostroff. Vaccinia in some circumstances can produce
illness.
Mr. Shays. OK. It would be an illness, but not----
Dr. Ostroff. Not smallpox.
Mr. Shays. Happy to have that on the record.
Dr. Ostroff. OK.
Mr. Shays. We'll be real clear.
Dr. Ostroff. Right.
Mr. Shays. You can't transmit it. OK.
Dr. Ostroff. Thank you.
Mr. Shays. Thank you very much. We appreciate it, Doctor.
We're going to our second panel, which is: Janet Heinrich,
Director, Public Health Issues, U.S. General Accounting Office;
Dr. Margaret Hamburg, vice president for biological programs,
the Nuclear Threat Initiative; and Dr. David Goodfriend,
director, Loudoun County Health Department.
If you'd remain standing, we'll swear you in. If you'd
raise your right hands.
[Witnesses sworn.]
Mr. Shays. Note for the record our witnesses have responded
in the affirmative.
Chairman Tom Davis [resuming Chair]. Thank you for being
patient with us. The rules of the committee, 5 minutes to give
your testimony. Your full statement is going to be in the
record. There's a light on in front of you. When it turns
orange, that means 4 minutes have expired, you've got a minute
to sum up. When it turns red, we'd appreciate your moving to
summary as quick as you can, and then we can get right to the
questions.
We'll start with Ms. Heinrich and move to Dr. Hamburg and
then to Dr. Goodfriend. Thank all of your for your patience and
for being with us today for what we think is a very important
hearing.
Ms. Heinrich, you may proceed.
STATEMENTS OF JANET HEINRICH, DIRECTOR, PUBLIC HEALTH ISSUES,
U.S. GENERAL ACCOUNTING OFFICE; DR. MARGARET HAMBURG, VICE
PRESIDENT, BIOLOGICAL PROGRAMS, THE NUCLEAR THREAT INITIATIVE;
AND DR. DAVID GOODFRIEND, DIRECTOR, LOUDOUN COUNTY HEALTH
DEPARTMENT
Ms. Heinrich. Mr. Chairman and members of the committee, I
appreciate the opportunity to be here today as you consider the
Nation's preparedness to manage a major public health threat.
Whether an outbreak occurs naturally, as with influenza
epidemics or the new SARS or is due to the intentional release
of a harmful biological agent by a terrorist, much of the
initial response would occur at the State and local level. In
particular, hospitals and their emergency departments, as well
as physicians and nurses, would be the first to respond as
individuals with symptoms seek treatment.
Public health agencies would be involved in gathering
information about the extent of the problem and initiating a
global response effort. There is widespread concern, however,
that our public health agencies and hospitals do not have the
capacity to manage a major public health event.
We have been examining the capacity of State and local
preparedness for a bioterrorism attack as part of a mandate in
the Public Health Improvement Act of 2000. My remarks will
focus on what we know about the preparedness at the State and
local level, about hospital preparedness for such an event, and
Federal and State efforts to prepare for an influenza pandemic,
an important component of public health preparedness. All of
these issues have become much more pertinent in light of
emerging infectious diseases like SARS.
As you noted, we released our review of State and local
preparedness for bioterrorism on Monday. In visiting selected
States and cities, local officials reported varying ability to
respond to a major public health threat. They recognize gaps in
elements such as communication to the public, and have begun to
address these. However, gaps remain in elements such as disease
surveillance, laboratory capacity, and the trained work force.
Although States have moved to electronic systems to compile
data, for the most part they still rely on voluntary reporting
of unusual diseases by health care providers. Such passive
systems suffer from chronic under-reporting and time lags
between diagnosis of a condition and the health department's
receipt of the report. State officials were planning to
purchase new equipment for public health laboratories, hire
additional staff, and incorporate clinical laboratories into
cooperative systems. Hiring epidemiologists and laboratory
personnel trained to do the appropriate investigations in an
emergency has been hampered by a general shortage of these
trained individuals and by non-competitive salaries, as well.
Other recent work shows that progress in improving public
health response capacity has lagged in hospitals. Although most
hospitals across the country reported participating in basic
planning activities for large-scale infectious disease
outbreaks and had provided training to staff on symptoms to
watch for and likely biological agents, few have acquired the
medical equipment and isolation facilities they would need.
For example, from our survey of almost 1,500 hospitals, we
found that almost all hospitals had at least one ventilator,
one protection suit, or an isolation bed, but half of hospitals
had less than six ventilators, three or fewer protective suits,
and less than four isolation beds per 100 staffed beds.
Even before September 11th, the need to plan for a
worldwide influenza pandemic was acknowledged. In the 20th
century, there have been three such pandemics, the last in
1968.
While efforts to develop plans have been in the works for a
while, officials have been slow to finalize plans. Thirty-four
States are in various stages of completion of preparing a
pandemic response. Key Federal decisions related to vaccines
and antiviral drug distribution have yet to be made, such as
the amount of vaccines and antiviral drugs that will be
purchased at the Federal level, the division of responsibility
between the public and private sectors for the purchase,
distribution, and administration of these vaccines and drugs,
and how population groups will be prioritized.
In summary, many actions taken at the State and local level
to prepare for a bioterrorist event have enhanced the ability
of response agencies to manage a major public health threat;
however, there are significant gaps in public health capacity,
local hospitals' ability to handle large-scale infectious
disease outbreaks, and the supply and distribution of vaccines
and drugs in short supply. Clearly, progress has been made and
much more needs to be done.
Mr. Chairman, that completes my remarks. I'm happy to
answer any questions.
Chairman Tom Davis. Thank you very much.
[The prepared statement of Ms. Heinrich follows:]
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Chairman Tom Davis. Dr. Hamburg, thanks for being with us.
Dr. Hamburg. Thank you. Mr. Chairman and members of the
committee, I really appreciate the opportunity to testify and
thank you for holding this timely and important hearing.
SARS is a serious public health threat that has surprised
government officials and scientists around the globe,
constrained travel, shut down schools and businesses, and
caused widespread fear. At present, no one can predict how far
the disease will spread and how much higher the toll will be.
Will this outbreak be contained or will it become the next
global pandemic?
Many organizations and their leaders should be commended
for the robust international response mobilized, yet SARS
demonstrates gaps in our systems for disease prevention,
response, and control. These will require increased domestic
attention, but also demand greater global cooperation and
support. For example, the failure of China to initially report
was a missed opportunity for rapid investigation, adding
unnecessary delay to an already difficult diagnostic and
disease control challenge, and clearly we need research to
provide better diagnostic tools, as well as the drugs and
vaccines necessary to treat or prevent disease.
In addition, SARS has demonstrated how easily health care
systems can be overwhelmed and has revealed troubling questions
about how and when travel and commerce should be constrained in
the context of communicable disease. On both the domestic and
international level, a great deal must be done to develop
appropriate policies, define authorities, and design strategies
for implementation. We must recognize that SARS is but one of a
series of new and deadly infectious diseases that have emerged
in recent times, not to mention old diseases that have
resurged, often in new and more frightening forms because of
the development of drug resistance.
What is more, we live in an age when we must think
seriously about the intentional use of biological agents to do
harm.
The ability of infectious agents to destabilize
populations, economies, and governments is fast becoming an
unfortunate fact of life. Over the past decade, the United
States has taken important steps to strengthen capacity to
address the threats posed by infectious diseases, but were
inadequately prepared. Public health is public safety, and an
important pillar in our national and international security
framework. We must do more to improve our ability to prevent,
detect, and control microbial threats to health.
Several weeks ago the Institute of Medicine released a new
report, ``Microbial Threats to Health,'' focused on just these
concerns. The report represents an effort to describe the
spectrum of microbial threats, the factors affecting their
emergence and resurgence, and measures needed to address them.
The major thrust of this report and its recommendations are
almost uncannily relevant to our current experience with SARS.
As co-chair of this effort, I'd like to briefly discuss some of
our major themes and conclusions.
More than a dozen factors, some reflecting the ways of
nature, most reflecting our ways of life, are described in the
report to account for new or enhanced microbial threats. Any of
these factors alone can trigger problems, but their convergence
creates especially high-risk environments where infectious
diseases may readily emerge, take hold, and spread. In our
transforming world, conditions are ripe for the convergence of
multiple factors to create microbial perfect storms, yet,
unlike meteorological perfect storms, these events are not to
be once-in-a-century events, but frequent or ongoing. SARS is
not an isolated phenomenon.
An effective national response to infectious diseases must
be global, so our recommendations begin with a strong call for
the United States to support enhancement of global disease
surveillance and the capacity to respond to infectious disease
threats. The report also stresses the need to bolster the U.S.
public health infrastructure. State and local health
departments represent the backbone of response to a major
outbreak of disease, whether naturally occurring or
bioterrorist attack, yet we've never adequately equipped these
agencies to do that job.
Upgrading current public health capacities will require us
to strengthen and extend effective disease surveillance
systems, laboratory capacity, and systems to ensure the rapid
use and sharing of information. These efforts will require
enhancement of both the capacity and expertise of the work
force, greater partnership between public health and medicine,
and the need to develop and use better diagnostics.
It was felt that we faced a serious crisis in vaccine and
drug development, production, and deployment, as well. A more
coordinated approach among government, academia, and industry
is necessary, and issues of identification of priorities for
research, determination of effective incentive strategies for
developers and manufacturers, liability concerns, and
streamlining the regulatory process must be addressed in a more
meaningful and systematic fashion.
Other recommendations address ways to reduce microbial
resistance, control vector-borne diseases, and the need for
interdisciplinary approaches to infectious disease research.
In conclusion, prevention and control of infectious disease
is fundamental to individual, national, and global security.
Failure to recognize and act on this essential truth will
surely lead to disaster. Recent Federal investments in
bioterrorism preparedness are resulting in some improvements;
yet, while we've taken some steps forward, we are at risk for
serious backsliding. Cutbacks in crucial but nonbioterrism
programs at the Federal level, such as in CDC's emerging
infectious disease program or USAID dollars for global disease
surveillance, combined with cuts to public health programs in
State budgets across the country, along with the many competing
priorities at the State, local, and Federal level means that
overall dollars to build and sustain the necessary elements for
infectious disease preparedness and response may not be there.
Our country has always been willing to meet the
requirements and pay the bills when it comes to our military
defense needs. We must now be willing to do the same when it
comes to public health needs. SARS is yet another wakeup call.
While there is an enormous human and economic toll, it is a far
milder version of what we might experience with a more deadly
or contagious disease.
The best defense against any outbreak is robust public
health, both science and practice. Given our significant and
growing vulnerabilities, markedly greater attention and
resources must be devoted toward this end. Effective strategies
will require sustained efforts, as well as greater coordination
and cooperation with partners around the globe. We must
endeavor now to create a system that really works so that we
will be prepared for the next attack, whether it is Mother
Nature or an act of bioterrorism.
Thank you.
Chairman Tom Davis. Thank you very much.
[The prepared statement of Dr. Hamburg follows:]
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Chairman Tom Davis. Dr. Goodfriend, thanks for being with
us.
Dr. Goodfriend. Mr. Chairman and distinguished Members,
thank you for the opportunity to discuss current responses to
public health threats at a local level, particularly during
National Public Health Week.
Loudoun County, VA, is one of the Nation's fastest-growing
communities and includes Washington Dulles International
Airport. The Loudoun County Health Department is part of
Virginia's Department of Health. It includes about 75 State and
county employees who perform a variety of functions, all tied
to the protection of the public's health, such as permitting
well and septic systems, conducting restaurant inspections,
providing direct care to pregnant women and children,
administering immunizations, and investigating outbreaks of
disease, whether occurring naturally or through terrorist
action.
During my 2 years as its director, our Health Department
has confronted numerous communicable disease challenges within
Loudoun County, including an anthrax attack, Virginia's first
human death from West Nile Virus, and three cases of locally
acquired malaria. Lessons learned from these experiences--in
particular, the necessity of having effective partnerships with
other involved agencies, with our local media and citizenry,
and with our health care community--put us in a good position
to effectively respond to the Nation's first suspect case of
Severe Acute Respiratory Syndrome [SARS].
Specifically, since September 11, 2001, the Loudoun County
Health Department has developed an e-mail distribution list to
send out timely public health information to key hospital
personnel and to a large majority of physicians in our county,
it has taken an increasingly active role in our hospital's
Infection Control Committee and our County's EMS Advisory
Council, has established the ability of citizens concerned
about bioterrorism or other unusual diseases to contact us 24
hours a day, and has been conducting daily reviews of the
complaints of all patients seen in our local emergency
department as part of the syndromic surveillance that was
discussed earlier.
We have also taken a much more active role in regional
agencies, and with interactions with our other northern
Virginia health departments.
Loudoun Hospital Center, our county's only hospital, has
responded to these threats by creating an Emergency
Preparedness Committee, sponsoring numerous lectures on
emerging diseases and bioterrorism, and instituting new
policies and algorithms for quickly diagnosing, isolating, and
treating any patient presenting with a potentially communicable
disease. They have also improved communication with other
hospitals in the region, including establishing a radio
frequency for rapid notification.
On February 17, 2003, a woman who had recently traveled to
Guangdong Province in China presented to Loudoun Hospital
Center's Emergency Department with pneumonia. SARS had not yet
been identified as a syndrome, but there had been reports of
unusual pneumonias being seen in Guangdong. As a precaution,
hospital staff quickly moved the patient into an isolation
room. They then contacted the hospital's infection control
chief, who is with me today, and the Health Department as part
of their infectious disease notification algorithm.
The patient was subsequently admitted to Loudoun Hospital
under airborne and droplet precautions and started on empirical
antibiotic therapy. Anita Boyer, who is also here with me
today, is one of our two new employees funded through a Federal
bioterrorism grant. She investigated the case the following day
and quickly consulted with her counterparts at the Virginia
Department of Health and the Centers for Disease Control and
Prevention. Over the course of that weekend, all hospital and
household contacts were interviewed either by hospital staff or
by the Health Department, and any ill person was tested.
Our investigation found that the patient had not
transmitted her infection to any one else, and she was
discharged when she was medically stable and we were confident
she was no longer contagious.
Three elements combined to ensure successful outcome in
this case, both for the patient's health and for the prevention
of disease spread: one, having plans in place in the Emergency
Room to isolate the patient and notify key personnel quickly;
two, having effective communication patterns established
throughout the public health chain from the hospital to the
local and State health departments and to the CDC; and, three,
having a history of established partnerships between our local
medical community and public health.
Some gaps were identified during our review, which in this
case fortunately did not negatively impact on patient care.
First, there were insufficient materials preplaced in
northern Virginia for all the contacts we needed to test.
Second, we had procedures in place to transport specimens
quickly to our State's lab, but similar procedures didn't exist
for transportation to the CDC over the weekend.
And, third, all hospitals in northern Virginia are equipped
with isolation rooms, but there is limited additional surge
capacity to handle an epidemic of respiratory diseases in the
region. If there had been many suspected SARS cases presented
to hospitals throughout the region, it would have been
difficult to appropriately isolate all potentially contagious
patients.
There are many challenges currently facing local health
departments. In addition to an increasing demand for our core
environmental health and safety net medical services, our staff
are responding to new naturally occurring threats such as West
Nile Virus, as well as preparing for the potential of chemical,
biologic, or radiologic attacks.
Our federally funded local and regional epidemiologists
were crucial to the successful handling of this country's first
suspect SARS case. Appropriate funding, training, and
leadership are essential to meeting the ongoing and emerging
public health challenges facing our communities. Equally
important, though, is the need to continuously work to maintain
and improve effective communication with all our community
stakeholders and with related agencies at
the regional, State, and Federal levels.
I thank you again, and I would be happy to address any
questions you may have.
Chairman Tom Davis. Thank you very much.
[The prepared statement of Dr. Goodfriend follows:]
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Chairman Tom Davis. Let me start the questioning with Dr.
Goodfriend. When did the Federal Government inform the County
Health Department of the potential threat of SARS?
Dr. Goodfriend. SARS as a syndrome? Well, we were aware of
unusual pneumonias before the diagnosis of SARS came out----
Chairman Tom Davis. Right.
Dr. Goodfriend [continuing]. Through a variety of
mechanisms.
Chairman Tom Davis. But specifically when they identified
SARS, how long did it take them to get the word to you in
Loudoun?
Dr. Goodfriend. When it came out in mid-March, actually we
heard about it when the rest of the world heard about it as a
syndrome. It was only in retrospect that we went back and
looked at this case, when we saw what the case definition that
the CDC and the World Health Organization had for SARS, and
realized that this patient actually did meet the case
definition for SARS.
Again, this patient became symptomatic in the beginning of
February, and SARS as a syndrome didn't come out until mid-
March.
Chairman Tom Davis. So you had this patient, you started
treating them, and, frankly, as soon as it was identified the
Federal Government did--you think was timely in terms of its
response?
Dr. Goodfriend. Yes. At the time there was concern of
unusual pneumonias in Guangdong Province, and particular
concern of an influenza type called Avian Flu, and that was the
main reason that we were very concerned at that time. The
process we went through is we notified our State. The State
talks to the CDC. And from our view the CDC did exactly what
they should do for us.
Chairman Tom Davis. Great.
Dr. Goodfriend. They provided the expertise and offered
bodies if we needed them, and in this case we didn't need them
but they were willing to fly them up that night to us to assist
in doing the contact investigations.
Chairman Tom Davis. After handling the SARS case, did your
Health Department recognize any deficiencies in the
coordination, the communication, and capacity at this point, or
did everything go about as well as you could expect?
Dr. Goodfriend. I think as I said, the communication went
very well. The patient came in on a Sunday afternoon. Both the
head of the Emergency Department and our epidemiologist were
notified that afternoon. The patient was isolated
appropriately. We then had discussions with the State and with
the CDC, and the good news is during all that time the patient
was isolated, so there wasn't a concern of ongoing spread to
patients in the hospital or staff.
Chairman Tom Davis. So from your perspective at least the
dissemination of information on SARS to State and local
governments, as it applies to you, at least, it was fine?
Dr. Goodfriend. Yes. And since then I have been very
impressed with how the CDC has been getting information out. We
all have a piece of this. The CDC, from our standpoint, has
been doing a great job. Their Web site, if people haven't seen
it, on SARS is tremendous, really targeted at different
individuals. The general public, the health care community,
public health community--all in different languages.
The key piece for us is getting that to the local level,
since many people don't have access to the Internet.
Chairman Tom Davis. And how did you ensure the safety of
your own health care workers? For a while you are kind of
flying blind, not sure what's going on. It doesn't seem to have
spread to anybody else. Once you found out the type of disease
it might be or suspected that, obviously you took some steps to
isolate.
Dr. Goodfriend. In this case fortunately we didn't find out
it was a suspect SARS case until over a month after we came in
contact with the person.
Chairman Tom Davis. Right.
Dr. Goodfriend. But we take the same precautions no matter
what, whether it is a potential SARS case or a potential
tuberculosis case. Our nurses are not going to visit someone
who is coughing without wearing an M-95 mask.
Chairman Tom Davis. OK. Dr. Hamburg, you stated that micro-
biothreats to health are global problems and really require
global solutions. What can we do, the United States, to develop
a worldwide mechanism and solutions that will be followed by
the nations of the world?
Dr. Hamburg. Well, I think that SARS represents an example
of how progress has already been made. The World Health
Organization I think has been providing critical leadership in
response to SARS, and we need to continue to support them and
help add to their capabilities for leadership and coordination
of global efforts. Through various of our own Federal agencies,
we can contribute--we have in the past but can do so more
extensively in the future--to strengthening global disease
surveillance, both in terms of helping to expand the cadre of
trained personnel to do disease surveillance and epidemiology,
to support expanded laboratory capacity around the world, and
by efforts to better coordinate and integrate communication
systems so we can both share information about emerging
problems, we can analyze information as it is available, and we
can have that important feedback loop as we gain new
understandings, make sure it gets to where it needs to get for
action, wherever that may be around the world.
Chairman Tom Davis. Well, let me ask both you and Ms.
Heinrich, drawing from your experience with micro-biothreats,
any feel for whether the SARS virus will continue to spread at
the same rate, or do you think it will lose strength? Or is
that an unwritten chapter and it depends how we handle it? Any
inclination on that?
Dr. Hamburg. Well, I think your characterization of it as
an unwritten chapter is exactly apt. We are learning more every
day. There are some encouraging signs in terms of dropoff, in
terms of number of cases in certain areas, but we also are
seeing ongoing spread and cases appearing in new countries and
new areas, so I think we need to watch it carefully and we need
to continue to implement some of the control measures that are
in place, and certainly as we know more about the etiologic
agent and can develop actual diagnostic tests and even perhaps
better treatment strategies, we'll have new opportunities to
enhance our control.
Chairman Tom Davis. OK. Ms. Heinrich, any reaction?
Ms. Heinrich. We are really very dependent on infection
control measures in our emergency rooms, our hospitals, and, as
Dr. Hamburg says, it could get out of control. It's possible,
because not all hospitals are as well equipped or as well
trained as others.
Certainly in our extensive survey of hospitals we found a
great deal of variability in how well hospitals are equipped.
Chairman Tom Davis. Great. All right. Thank you very much.
Mr. Shays.
Mr. Shays. Thank you. I think this is a great panel, and I
am intrigued. We have Ms. Heinrich. You basically have looked
at what our capacity is in surveillance right now and where we
are at, and I want to get into it. Dr. Hamburg, basically you
were the co-chair of this document. Was it completed this year
or----
Dr. Hamburg. It was released 3 weeks ago, I think.
Mr. Shays. I had--before I chaired the National Security
Subcommittee of this full committee, I chaired the Human
Resource Committee, and for 4 years we had oversight of HHS and
CDC and FDA and so on, and I just found the committee
fascinating. But your executive summary I think should be read
by everyone in this. It is quite excellent, in my judgment.
Dr. Hamburg. Thank you.
Mr. Shays. I want to nail down, to the best we can, where
we are in the surveillance side of it. Dr. Hamburg, you should
be able to add, and Dr. Goodfriend, as well. Should I feel
comfortable right now that we have a real-time sense of what is
happening all around the United States, or should I feel that
we have a good sense what's happening maybe in New York City
and maybe not, and maybe in Washington, and a few places? So
tell me where do you think we are in that ultimate system, it
would seem to me, of knowing every hour what the condition is
in every area around the country. How far away are we from
that.
First off, is that something we should want every hour or
at least every 24 hours? What would be the model?
Ms. Heinrich. I'll start with an initial response to the
question. What we found again is that it is highly----
Mr. Shays. Before we know what we found, I want to know
what the model should be. What is our target? What do we want
to achieve ultimately. So tell me what you think we want to
achieve, each of you, in terms of surveillance, monitoring, so
on.
Ms. Heinrich. If it were possible, you'd want to have very
fast reporting from hospitals, emergency rooms to the State or
local health department, and that would go quickly to CDC so
that you could, in fact, analyze the overall picture.
Mr. Shays. So CDC should be the one to capture this
information?
Ms. Heinrich. Well, it should be captured at the State
level, as well as at the CDC level.
Mr. Shays. Goes to State and then--and this should be able
to happen, transmitted pretty instantly. So would we want to
have an update every hour, every 3 hours, every 10 hours?
First, Ms. Heinrich, what do you think? And if you don't have
an opinion, that's fine.
Ms. Heinrich. Yes. Well, it depends on what kind of
electronic systems you have for reporting from the hospitals,
and what you don't have then in that equation is your private
physicians or physician groups, and they are another component.
Mr. Shays. I don't want to know the obstacles yet. I want
to know what we want to achieve and then I want to--Dr.
Hamburg?
Dr. Hamburg. Well, perhaps I can offer some perspectives. I
think we need to recognize that disease surveillance serves
many important purposes, and it needs to be done in a variety
of different complementary and integrated ways to give us the
best possible picture. We want to use disease surveillance to
detect emerging problems as early as possible so that we can go
in and investigate them and implement what needs to be done.
We also want disease surveillance to give us the tools to
monitor trends over time in disease that allows us also to get
a sense of whether our interventions are making a difference.
I think what we need to do--and it needs to be done on a
regional as well as a national level, but I think that you are
absolutely right that CDC must play an absolutely central role,
and that we have to recognize that, especially with infectious
disease threats, they don't respect State borders. We need to
have harmonized disease tracking standards, data collection
standards, etc.
Mr. Shays. But should the data collection be updated every
hour, every----
Dr. Hamburg. What we need is a system that will allow us to
collect information in an ongoing way that reflects information
about diseases in a community, but we also need a system that
allows us to get that early warning about an emerging problem
that may not yet even have a name.
Mr. Shays. Right.
Dr. Hamburg. So we need to continue and strengthen
traditional disease reporting, notifiable disease reporting. We
need to enhance that with better diagnostics and information
technology that will allow us to use electronic patient records
and electronic laboratory reporting that can feed right into
health departments at the local, State, and Federal level.
We also need to pursue new tools of surveillance, the so-
called ``syndromic surveillance,'' that allows us to really tap
into various kinds of data bases to give us that early warning.
It may be over-the-counter sales of anti-diarrheal medications
to tell you something is going on in the community where people
haven't even gone in to see their doctors. We need to monitor
visits to emergency rooms, ambulance runs, etc., so that we
can, if there's unusual symptoms or patterns emerging, we can
catch them early.
Mr. Shays. I understand why we want to do that. I do. And I
understand, just from reading your summary in the publication--
you point out, for instance, AIDS is natural causes, not
terrorist induced, 20 million people have died, many are
infected. If we had a better surveillance system worldwide,
clearly in the United States but worldwide, would we have been
able to do so much more than we ultimately--would the condition
of AIDS today be very different?
Dr. Hamburg. I think AIDS is an interesting example because
it speaks to the fact that it depends on not just collecting
information but the appropriate recognition of the importance
of that information and the response. I think, had we
understood decades ago, when the first cases of so-called
``Slim Disease'' were being reported out of Africa that this
might have important international public health significance
and really taken a greater interest in that, we might have
gotten a huge head start on our understanding of HIV/AIDS. If
you look at West Nile, it was a couple of astute clinicians who
really triggered the investigation, not a fancy surveillance
system. You need an infrastructure of systems in place, but you
also need educated and trained personnel.
Mr. Shays. My time has run out times 10, and I know Mr.
Waxman is--but with the indulgence of the Chair and Mr. Waxman
I just want to nail down this one issue. I have a briefing that
I have to go to at 1. I want to understand, one, is this a--and
it doesn't take a long answer on this--is this a meaningful and
absolute requirement that we have a nationwide surveillance
system? And if we did, would we be able to protect the American
people in a very significant way? And I'd like all of you to
answer that question.
Dr. Hamburg. Well, in my view the answer to your question
is yes, but it is not one system, it is a system of systems
that are integrated, coordinated, and harmonized.
Mr. Shays. Fair enough. Ms. Heinrich.
Ms. Heinrich. And I do want to emphasize that there has
been progress made in terms of our States, counties----
Mr. Shays. Right.
Ms. Heinrich [continuing]. Moving toward an electronic
system. But you keep use the term ``real time.'' It is not real
time. You're still--it's passive. You are depending on
clinicians, hospitals voluntarily reporting.
Mr. Shays. Dr. Goodfriend.
Dr. Goodfriend. I agree with what has previously been said.
From our view and our experience since we have been doing
syndromic surveillance since September 12, 2001, it missed
anthrax. It's not good at this point enough, with what we're
doing, to pick up a sentinel event, one strange case. So we're
attacking it on two fronts--one is making the surveillance
better and removing to a better system so that we have one
system for all the national capital region, and second is
keeping people educated, as was said, so when they do see
something strange, someone in pneumonia in a postal worker,
they'll give us a call, and that's the best way they'll pick it
up.
Mr. Shays. Thank you for the Chair's indulgence.
Chairman Tom Davis. Thank you very much.
Mr. Waxman.
Mr. Waxman. Thank you, Mr. Chairman.
Dr. Hamburg, the Institute of Medicine concluded just last
month that the U.S. public health system is in a state of
disrepair and is vulnerable to an emerging epidemic, and I
asked Secretary Thompson about this finding this morning. He
said that, while there is always more to be done, HHS has
significant funding available to send to States and to patch
holes in the system. I'd like to ask you your opinion. Do you
think that the funds now available to States are sufficient to
fix the public health care system and protect us to the maximum
extent possible against SARS?
Dr. Hamburg. Well, I think we have made progress, but it
needs to be understood that our public health system has
suffered from years of underfunding and neglect. We have a
great deal that needs to be done to build fundamental
capabilities in many parts of our country, and certainly
looking internationally it's even more true. So we have a need
for a sustained investment of resources to build a set of
critical needs. I think your concerns about the competing
demands and priorities created by the smallpox immunization
campaign and other things is a very real one. We have at the
moment a fragile set of systems and we don't have adequate on-
the-ground personnel to use all of that money and to put in
place some of these programs. We're going to have to build this
over time. It is going to be an incremental process.
I think we also have to recognize that, while there was a
chunk of new money for bio-defense, and very important in terms
of strengthening the public health infrastructure at the State
and local level, there have been cuts in other critical
components of CDC activity and other activity that is necessary
to help support our public health system and our medical care
system to respond to a naturally occurring or a bioterrorist
threat, and there are very significant cuts, as I'm sure you
know, severe fiscal constraints at the State and local level,
which has caused the overall dollars available for public
health at the State and local level to be compromised.
So I think we're moving in encouraging directions, and I am
just astounded and delighted by the renewed appreciation of the
importance of public health and the necessity to fund it, but
we certainly are not there yet. We can't be complacent that
we're doing enough. And I think Congressman Shays suggested we
better use SARS as yet another wakeup call to make sure that we
do the things that need to be done, and they can be done, and
they will afford us broad health protection, greater public
safety, and strengthen our national and international security.
Mr. Waxman. Ms. Heinrich, your findings on hospital
preparedness are striking. It is startling to think that our
Nation's health care system may have trouble handling a surge
of severe respiratory illnesses. This morning Secretary
Thompson expressed enthusiasm about additional funding that
will be available or is already available to the States. Will
the funding now available to States, localities, and hospitals
significantly increase the capacities of hospitals to care for
SARS patients?
Ms. Heinrich. The money that is currently available to the
States to work with hospitals is primarily for planning
purposes, so what States reported to us is that they were
planning to plan, if you will. So what they're beginning to do
is identify the needs.
When we went out with our survey of hospitals, we found
that the hospitals had planned or have plans in place, they
were beginning to coordinate with other local agencies in that
planning process. They have done some training, but they have
not, in fact, expanded their facilities for isolation purposes,
for example, and they had not invested in equipment such as
ventilators.
Mr. Waxman. So we have funding for planning, but we don't
have funding to deal with the actual demand that the hospitals
are going to be placed under with an epidemic like SARS?
Ms. Heinrich. Not so far.
Mr. Waxman. So far. And the House appropriated $95 million
in the emergency supplemental for implementing the smallpox
vaccination program. Will this money be sufficient to allow the
States to carry out this vaccination program without forcing
the States to sacrifice funding for other public health care
functions?
Ms. Heinrich. What we had found when we reviewed the
progress reports of the States that we had visited for the
report that we did on State and local preparedness, we found
that at least two of the States had already committed their
moneys, over 70 percent. By now it would be much higher than
that. And most of the States we visited had committed over 50
percent. So I would suggest that from that Federal money many
States and certainly the counties would not have the additional
funds for the smallpox program.
Mr. Waxman. So they're going to have to take funds from
what they'd spent on their core public health programs to help
pay for the deficit in the money for smallpox?
Ms. Heinrich. They'd have to find it from something. Maybe
our county health officer can tell us how he has managed.
Mr. Waxman. I want to hear from him, but let me ask him the
question maybe, then he can further elaborate on this issue. In
your testimony you said the hospital system in Loudoun County
might not be able to handle a large respiratory outbreak. How
many critically ill SARS patients would you be able to handle
without being overwhelmed, and would Federal support to
increase the capacity to care for victims of an epidemic be
essential because of the cutbacks at the State and local levels
on funding for health issues?
Dr. Goodfriend. Well, Loudoun Hospital Center has two
isolation rooms in their Emergency Department and five
isolation rooms on the floor, and definitely we want SARS
patients, if they are going to be hospitalized, to be in
isolation, but there are other patients that also may need to
be in isolation--active tuberculosis cases and others that may
have unusual pneumonia--so you may not have all of those rooms
available.
If there were multiple cases, we'd have to look elsewhere
of where we would have those people separate from the rest of
the hospital community. But, as you can see, with that small
number of beds in our county--and it is probably a very similar
answer in surrounding counties--it doesn't take many cases to
overwhelm that system.
Mr. Waxman. So what we have is a public health
infrastructure that has been neglected for some period of time.
Federal Government has now appropriated money to deal with
smallpox but not enough. The States are squeezed because of the
recession and their lack of revenues, so they are cutting back
on health care infrastructure expenditures. And we're looking
at a new epidemic of SARS that could overwhelm the whole
hospital system in your county and maybe the whole public
health system throughout the Nation. Is that a fair statement
of where we are?
Dr. Goodfriend. Well, if I could say it from my
perspective----
Mr. Waxman. Yes.
Dr. Goodfriend [continuing]. One of the things we look for
and why we do surveillance is to make that difference between 1
person with SARS in your community or 50 people.
Mr. Waxman. Sure.
Dr. Goodfriend. And so we want to get that one person not
only identified and isolated as quickly as possible----
Mr. Waxman. Prevent it spreading. Sure.
Dr. Goodfriend [continuing]. But so that we don't have that
problem. And so far the good news is that we haven't seen that
as a problem here, and probably for various reasons in
different communities. And I think from our community I think
it was because the person was isolated quickly. And again it is
the same thing that we do every day with tuberculosis--keeping
the active person with tuberculosis away from others so we
don't have 10----
Mr. Waxman. Tuberculosis we know about, SARS is new, and it
is spreading rapidly. And while we certainly need to detect the
one case to prevent others, we may not be able to control it
because it is an international epidemic that is moving very
rapidly. And my concern is whether you are going to be able to
deal with that epidemic should it hit.
Dr. Goodfriend. And there are two related issues. The
public health issue related to that is how do we identify them
and make sure they're isolated somewhere, which is a little
different from the hospital's capacity issue of where to put
them. Hopefully, in theory if people are communicable but
otherwise doing well, they don't have to necessarily be in a
hospital and so don't have to use an isolation bed, because
again, at this point, as far as we've been told, if people are
doing pretty good there's not much treatment we're going to
offer them anyway in the hospital aside from isolating them
from others.
From our perspective we have been beefed up with
bioterrorism dollars with two positions, and that has helped us
with this because our epidemiologist, although she was hired to
do smallpox and Ricin, has been very busy doing malaria and
West Nile and SARS.
But, going to your point of the other functions, we have
cut back on some of the other things we have been doing in
order to meet this need, and that's what we always do in public
health. Again, going back to tuberculosis, whether we need to
take our nurses out of the clinic to do directly observed
therapy on people in the community, whether it's investigating
malaria, whether it is investigating SARS, that takes nurses
out of providing care for pregnant women or providing
immunizations to children, and that has happened to us in
Loudoun County.
Mr. Waxman. Thank you.
Thank you very much, Mr. Chairman.
Chairman Tom Davis. Thank you very much.
Mr. Janklow.
Mr. Janklow. Thank you very much, Mr. Chairman.
Dr. Goodfriend, when I look at the symptoms of SARS--fever,
chills, headache, body aches, and a dry cough--and at this
point in time there's no test for it, I think those symptoms
describe most maladies that people get at different times of
the year. Historically, they tell you to take a couple of
aspirin. As a matter of fact, the aspirin bottle describes all
of these as things that they can deal with. So, I mean, my
question is: first of all, what percent of people--and maybe
Dr. Hamburg, you or Ms. Heinrich know--what percent of the
people so far that have contacted SARS have been hospitalized,
because we're talking about overwhelming the system. What
percent have had to be hospitalized? I know some have to be
incubated and ventilated, but does anybody know the percentage?
Dr. Goodfriend. I don't know.
Dr. Hamburg. I don't actually know.
Mr. Janklow. Pardon?
Dr. Hamburg. I don't know. I apologize.
Mr. Janklow. OK. And when we talk about the surveillance
system that we have in place, out there are an immense number
of facilities--county health laboratories, city health
laboratories, State laboratories, Federal through the military
and other laboratories. We have a lot of laboratories. We talk
about the collaboration that we have, and everybody has got
regional associations. I mean, part of our problem is that we
don't have a history in this country of serious outbreaks until
of recent vintage. We have been able to stay on top of it, and
I think you, Dr. Hamburg, talk about that in your presentation.
In today's world where we have extraordinary increase in
travel, the urban settings the way they are, agricultural
practices, the continuing difficulties of translating existing
medical knowledge--I mean, all of these things have changed the
dynamic as they come together of these new emerging sicknesses,
diseases, and weapons, if I can use it that way.
How do we really devise a system, given what we have today?
And I'll ask all of you, how do we devise a system to really
get the kind of surveillance and reporting that we need? And,
Dr. Goodfriend, I think you highlighted it very well. I don't
think anybody could question the competence of you and your
organization, and as you said, ``We noticed some additional
pneumonia type things, but nobody had it figured out.''
Obviously, you work off of clusters, but how do we really
bring about this coordinative collaboration that is necessary
for survival?
Ms. Heinrich. Let me try to answer first. One of the things
that is happening at the local level is that they are beginning
to link their clinical laboratories with the State
laboratories. One of the issues is not all laboratories are
equipped and trained to be able to identify all kinds of
biological agents.
Mr. Janklow. But there isn't enough money in America to
equip all the laboratories----
Ms. Heinrich. And so some of----
Mr. Janklow [continuing]. With all the equipment they have
to have to deal with all the biological agents.
Ms. Heinrich. Right, and so we are beginning to see some
regionalization, and that's also where CDC comes in with their
expertise and actually taking a real lead in having special
laboratories and people that have special training. There's
also then the linkages with a worldwide network, and I think we
have seen that working especially well with SARS.
Mr. Janklow. If I can modify my question a little, if we
were designing a system from scratch, would it look like what
we're starting to work with today?
Ms. Heinrich. I think that we are a very pluralistic
society and our public health system is as pluralistic as other
aspects of society.
Dr. Hamburg. If I can make an attempt to answer your
question, which is a big one, you are absolutely right: in the
world we live in today, we need to expect that we are going to
be facing a whole array of new infectious disease threats, the
resurgence of old ones, and possibly the intentional use of
biological agents as weapons, and so we need--and we have
limited resources to make a difference. So we need to really
try to build systems that will make us better able to prevent,
detect, and respond to what is an uncertain but significant set
of future threats.
I think the basic framework that we are trying to build on
today is the right one--to strengthen disease surveillance,
extend it, and also to bring new tools for better surveillance
to give us new capacities for early warning. To support that,
you have to have trained personnel, you have to strengthen
laboratories, and on a regional basis you're right--not every
laboratory can do each and every diagnostic test, but we need
to have regional capacities that are significantly upgraded,
and we need to have systems so that people know, when they see
an unusual case, when they have a specimen that may require
special attention, that they know how to feed into the system
so that it will get the attention that it needs.
We also need to dramatically improve the ability of all the
different levels of government and the private partners--
because a lot of health care in this country is in the private
sector, clearly--we need to enhance those communication systems
and bring to bear, you know, the tools of the Information Age
on our activities. We also have to support a short-term and
long-term research agenda because we need better diagnostics,
we need new drugs and----
Mr. Janklow. If I could, let me add one other factor. My
time is up, but I need, if I could, add one other factor.
Historically we have dealt with what I'll call the ``normal
progression'' of sickness, illness, whether it starts in a
village some place and moves slowly or, as you say, Dr.
Hamburg, as you delineate here in your testimony, far more
rapidly in a world where everybody is on an airplane. But we've
got to add a new dimension to that now, and that is someone who
gets on an airplane, or many someones, and travels the world to
deliberately spread an illness will change in a phenomenal way
the dynamic of how disease spreads and the number of people
that are going to contract the illness at a particular point in
time. That will overwhelm any system that anybody can devise.
What can we do? Is there anything we need to do in the law,
other than funding--let's take funding and put it on a shelf
for a second. Is there anything that we need to do in terms of
national law--let me ask all three of you--that will better
facilitate the investigation or the determination of a new
illness that's circulating some place around the globe? What
can we do? Is there anything we can do other than money? And I
realize money is important, but, you know, is there anything
else we can do, or is everything else fine?
Dr. Hamburg. Well, certainly building greater global
cooperation and collaboration is key, you know. If we had
fuller disclosure of what was going on in Guangdong Province
back in the fall, I think the opportunity to much more rapidly
understand what was going on and contain spread might have----
Mr. Janklow. No, but I mean we the Congress. Is there
something we can do? Is there a law we can pass? Is there a
hearing we can hold? Is there something we can do to facilitate
the solution to this type of problem?
Dr. Hamburg. Well, a lot of it does have to do with money.
I mean, you know, we do know a lot about what needs to be done
and----
Mr. Janklow. That's on the shelf.
Dr. Hamburg [continuing]. And it needs to be done. I think,
you know, that there are opportunities to look at other
important components of the problem and controlling disease
that are outside of some of the stuff we have been talking
about now with respect to strengthening the public health
infrastructure and the health care system to respond and the
research base. For example, just one example, but Congresswoman
Maloney mentioned about airplane travel, and you raised it
again. And while, you know, we have not seen a lot of spread on
the airplanes of SARS to date, it certainly is a concern, and
we may learn more about it as time goes on, but, you know, a
systematic look at some of the environmental conditions that
may either help to reduce or help to foster spread is
important.
When I was health commissioner in New York City, we were
dealing with an epidemic of tuberculosis and greatly concerned
about possible transmission on airplanes, and what I understood
at that time was that we had actually reduced our protections
in terms of how air was handled, making us more vulnerable to
potential spread of disease on airplanes. Airlines don't need
additional costs at the moment, that's for sure.
But, you know, I do think, you know, for example, looking
at some of the environmental conditions, ventilation systems on
airplanes and in buildings is important in terms of other
protections that might be important, and there are other
examples like that where you can look at where are some of our
vulnerabilities and how can we shore them up. Public health and
medical care is a critical component, but there are other
elements, as well.
Mr. Janklow. Thank you very much. Thank you, sir.
Chairman Tom Davis. Thank you very much. I appreciate very
much your testimony here today. It has been helpful to us. Let
me just kind of ask a question. How can we upgrade our current
health capacities at the local and the State level, where most
of the response to bio-terrorism attack or infectious disease
outbreak would occur? I mean, it is the local level that is
going to have to respond. We have the Center for Disease
Control. We can have outreach and everything else at the
Federal level, and that's important. Is there anything else we
can do at the local level? I mean, we're sending money. It is
not all spent. Any of you have any thoughts on that?
We'll start with you, Ms. Heinrich, as you issued the
report.
Ms. Heinrich. Well, certainly one of the things that we
found after doing our work and talking with local officials is
they did say that they wanted more guidance from CDC. And the
other thing that they said is that they really wanted to know
about best practices. In other words, what have other
communities done that really works well and how can we learn
from that. And so I would think that focusing some resources to
make that happen would be very helpful at the local level.
The other thing they need--and I don't know how, you know,
we assure this, but to really make some of the big changes that
they have to put in place, they need the sustained funding.
Sorry about the dollars here, but they can't hire people if
they can't guarantee the person that they will be employed for
more than a year, and that's especially true for highly trained
epidemiologists, nurses, across the board--laboratory
technicians. And I think that's harder, the work force. The
trained work force issue is harder for them than even upgrading
a laboratory.
Chairman Tom Davis. Dr. Goodfriend, would you agree with
that?
Dr. Goodfriend. I do agree. And one of the challenges in
public health--and I've worked in various settings, in the
military and Federal and State and rural before coming here--is
every local health department is different, and what will help
them is very different. There are many health departments who
don't have a physician full time employed. They are contracted
out to sign off on forms, which makes it very difficult to have
those communications. And we know that smallpox can show up as
easily in Washington, DC, as it can in southwest Virginia or in
the midwest.
From my standpoint, the funding with the fewest strings
attached is the best way that we can use it, and in our case in
Loudoun County we would use that funding to improve training,
to improve education with not only our local health care
providers, but our fire rescue people who are at the front
lines of all this, our school nurses who are maybe the first
ones to find it in the student coming in to work, and our local
officials, etc.
Chairman Tom Davis. All right. Well, thank you all very
much. I want to thank all the witnesses for their testimony
today. I'd like to thank the committee staff that worked on
this hearing from the majority and the minority staff.
This hearing is now adjourned. Thank you.
[Whereupon, at 2:12 p.m., the committee was adjourned, to
reconvene at the call of the Chair.]
[The prepared statement of Hon. Edolphus Towns and
additional information submitted for the hearing record
follows:]
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