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08 May 2003

CDC Directory Says U.S., Global Health "Inextricably Linked"

(Julie Gerberding May 7 testimony before House panel) (2740)


The health of people around the globe and those in the United States
are "inextricably linked," says Julie L. Gerberding, director for the
Centers for Disease Control and Prevention (CDC) at the Department of
Health and Human Services.

The recent outbreak of Severe Acute Respiratory Syndrome (SARS) has
demonstrated that link and serves as a reminder that "we must always
be prepared for the unexpected," she told the House Energy and
Commerce Subcommittee on Oversight and Investigations.

In prepared testimony delivered May 7, Gerberding said "infectious
diseases are a continuing threat to our nation's health. Although some
diseases have been conquered by modern advances, such as antibiotics
and vaccines, new ones are constantly emerging."

"CDC's domestic mission to protect the health of the U.S. population
requires global awareness and collaboration with domestic and
international partners to prevent the emergence and spread of
infectious diseases," she said.

"The SARS experience," Gerberding said, "reinforces the need to
strengthen global surveillance, to have prompt reporting, and to have
this reporting linked to adequate and sophisticated diagnostic
laboratory capacity. It underscores the need for strong global public
health systems, robust health service infrastructures, and expertise
that can be mobilized quickly across national boundaries to mirror
disease movements."

"We must continue to strengthen the public health systems and improve
linkages with domestic and global colleagues," Gerberding said.
"Priorities include strengthened public health laboratory capacity;
increased surveillance and outbreak investigation capacity; education
and training for clinical and public health professionals at the
federal, state, and local levels; and communication of health
information and prevention strategies to the public. A strong and
flexible public health infrastructure is the best defense against any
disease outbreak."

Following is the text of Gerberding's remarks, as prepared for
delivery:

(begin text)

Testimony
Before the Subcommittee on Oversight and
Investigations
Committee on Energy and Commerce
U.S. House of Representatives

CDC Response to Severe Acute
Respiratory Syndrome (SARS)

Statement of
Julie L. Gerberding, M.D., M.P.H.
Director
Centers for Disease Control and Prevention
Department of Health and Human Services
May 7, 2003

Good afternoon, Mr. Chairman and Members of the Committee. I am Dr.
Julie L. Gerberding, Director, Centers for Disease Control and
Prevention (CDC). Thank you for the invitation to participate today in
this timely hearing on a critical public health issue: severe acute
respiratory syndrome (SARS). I will update you on the status of the
spread of this emerging global microbial threat and on CDC's response
with the World Health Organization (WHO) and other domestic and
international partners.

As we have seen recently, infectious diseases are a continuing threat
to our nation's health. Although some diseases have been conquered by
modern advances, such as antibiotics and vaccines, new ones are
constantly emerging, such as Nipah virus, West Nile Virus,
vancomycin-resistant Staphylococcus aureus (VRSA), and hantavirus
pulmonary syndrome. SARS is the most recent reminder that we must
always be prepared for the unexpected. SARS also highlights that U.S.
health and global health are inextricably linked and that fulfilling
CDC's domestic mission to protect the health of the U.S. population
requires global awareness and collaboration with domestic and
international partners to prevent the emergence and spread of
infectious diseases.

Emergence of SARS

In February, the Chinese Ministry of Health notified WHO that 305
cases of acute respiratory syndrome of unknown etiology had occurred
in Guangdong province in southern China since November 2002. In
February 2003, a man who had traveled in mainland China and Hong Kong
became ill with a respiratory illness and was hospitalized shortly
after arriving in Hanoi, Vietnam. Health care providers at the
hospital in Hanoi subsequently developed a similar illness. During
late February, an outbreak of a similar respiratory illness was
reported in Hong Kong among workers at a hospital; this cluster of
illnesses was linked to a patient who had traveled previously to
southern China. On March 12, WHO issued a global alert about the
outbreak and instituted worldwide surveillance for this syndrome,
characterized by fever and respiratory symptoms.

Since late February, CDC has been supporting WHO in the investigation
of a multi-country outbreak of unexplained atypical pneumonia now
referred to as severe acute respiratory syndrome (SARS). On Friday,
March 14, CDC activated its Emergency Operations Center (EOC) in
response to reports of increasing numbers of cases of SARS in several
countries. On Saturday, March 15, CDC issued an interim guidance for
state and local health departments to initiate enhanced domestic
surveillance for SARS; a health alert to hospitals and clinicians
about SARS; and a travel advisory suggesting that persons considering
nonessential travel to Hong Kong, Guangdong, or Hanoi consider
postponing their travel. HHS Secretary Tommy Thompson and I conducted
a telebriefing to inform the media about SARS developments.

CDC's interim surveillance case definition for SARS has been updated
to include laboratory criteria for evidence of infection with the
SARS-associated coronavirus As of May 5, 2003, a total of 6,583
probable cases of SARS have been reported to WHO, and 461 of these
persons have died. In the United States, there have been 65 probable
SARS cases reported, of which 6 are laboratory confirmed, and none
have died. In addition, 255 suspect cases of SARS have been reported
and are being followed by state and local health departments.

CDC Response to SARS

CDC continues to work with WHO and other national and international
partners to investigate this ongoing emerging global microbial threat.
We appreciate the continued support of Congress in our efforts to
enhance our nation's capacity to detect and respond to emerging
disease threats. The recent supplemental appropriation of $16 million
to address the SARS outbreak will aid our identification and response
efforts. SARS presents a major challenge, but it also serves as an
excellent illustration of the intense spirit of collaboration among
the global scientific community to combat a global epidemic.

CDC is participating on teams assisting in the investigation in
Canada, mainland China, Hong Kong, the Philippines, Singapore, Taiwan,
Thailand, and Vietnam and at WHO headquarters in Geneva. In the United
States, we are conducting active surveillance and implementing
preventive measures, working with numerous clinical and public health
partners at state and local levels. As part of the WHO-led
international response thus fair, CDC has deployed approximately 50
scientists and other public health professionals internationally and
has assigned over 500 staff in Atlanta and around the United States to
work on the SARS investigation.

CDC has organized SARS work teams to manage various aspects of the
investigation, including providing domestic and international
assistance and developing evolving guidance documents. These work
teams have issued interim guidance regarding surveillance and
reporting; diagnosis; infection control; exposure management in health
care settings, the workplace, and schools; biosafety and clean up;
specimen handling, collection, and shipment; travel advisories and
health alerts; and information for U.S. citizens living abroad and for
international adoptions. We have updated our travel advisories and
alerts for persons considering travel to affected areas of the world.
We have distributed more than 850,000 health alert notice cards to
airline passengers entering the United States from mainland China,
Hong Kong, Singapore, Taiwan, Vietnam, and Toronto, Ontario, Canada,
alerting them that they may have been exposed to SARS, should monitor
their health for 10 days, and if they develop fever or respiratory
symptoms, they should contact a physician. We have begun distributing
health alert notices at selected sites along the U.S.-Canada border.

WHO is coordinating frequent, regular communication between CDC
laboratory scientists and scientists from laboratories in Asia,
Europe, and elsewhere to share findings, which they are posting on a
secure Internet site so that they can all learn from each other's
work. They are exchanging reagents and sharing specimens and tissues
to conduct additional testing.

On April 14, 2003, CDC announced that our laboratorians have sequenced
the genome for the coronavirus believed to be the cause of SARS.
Sequence information provided by collaborators at National
Microbiology Laboratory, Canada, University of California at San
Francisco, Erasmus University, Rotterdam and Bernhard-Nocht Institute,
Hamburg facilitated this sequencing effort. The sequence data confirm
that the SARS coronavirus is a previously unrecognized coronavirus.
The availability of the sequence data will have an immediate impact on
efforts to develop new and rapid diagnostic tests, antiviral agents
and vaccines. This sequence information will also facilitate studies
to explore the pathogenesis of this new coronavirus. We are also
developing and refining laboratory testing methods for this novel
coronavirus, which will allow us to more precisely characterize the
epidemiology and clinical spectrum of the epidemic. These discoveries
reflect significant and unprecedented achievements in science,
technology, and international collaboration.

Currently, CDC is recommending that persons postpone non-essential
travel to mainland China, Hong Kong, Singapore, and Taiwan. We are
recommending that U.S. travelers to Toronto, Canada, and Hanoi,
Vietnam, observe precautions to safeguard their health, including
avoiding settings where SARS is most likely to be transmitted, such as
health care facilities caring for SARS patients. Persons planning
travel to Toronto or Hanoi should be aware of the current SARS
outbreak, stay informed daily about SARS, and follow recommended
travel advisories and infection control guidance, which are available
on CDC's website at www.cdc.gov/ncid/sars.

Persons who have traveled to affected areas and experience fever or
respiratory symptoms suggestive of SARS should use recommended
infection control precautions and contact a physician. They should
inform their health care provider about their symptoms in advance so
any necessary arrangements can be made to prevent potential
transmission to others. Health care facilities and other institutional
settings should implement infection control guidelines that are
available on CDC's website.

We know that individuals with SARS can be very infectious during the
symptomatic phase of the illness. However, we do not know how long the
period of contagion lasts once they recover from the illness, and we
do not know whether or not they can spread the virus before they
experience symptoms. The information to date suggests that the period
of contagion may begin with the onset of the very earliest symptoms of
a viral infection, so our guidance is based on this assumption. SARS
patients who are either being cared for in the home or who have been
released from the hospital or other health care settings and are
residing at home should limit their activities to the home. They
should not go to work, school, or other public places until ten days
after their fever has resolved and respiratory symptoms are absent or
improving.

In order to better understand the natural history of SARS, CDC is
investigating aspects of the epidemiologic and clinical manifestations
of the disease. In collaboration with our partners, we have
implemented or planned investigations to describe the spectrum of the
illness, to assess the natural history of the disease, to estimate the
risks of infection, and to identify risk factors for transmission.
These investigations are being conducted in concert with ongoing
surveillance and epidemiologic efforts.

Rapid and accurate communications are crucial to ensure a prompt and
coordinated response to any infectious disease outbreak. Thus,
strengthening communication among clinicians, emergency rooms,
infection control practitioners, hospitals, pharmaceutical companies,
and public health personnel has been of paramount importance to CDC
for some time. CDC has had multiple teleconferences with state health
and laboratory officials to provide them the latest information on
SARS spread, implementation of enhanced surveillance, and infection
control guidelines and to solicit their input in the development of
these measures and processes. WHO has sponsored, with CDC support, a
clinical video conference broadcast globally to discuss the latest
findings of the outbreak and prevention of transmission in health care
settings. The faculty was comprised of representatives from WHO, CDC,
and several affected countries who reported their experiences with
SARS. The video cast is now available on-line for download. Secretary
Thompson and I, as well as other senior scientists and leading experts
at CDC, have held numerous media telebriefings to provide updated
information on SARS cases, laboratory and surveillance findings, and
prevention measures. CDC is keeping its website current, with multiple
postings daily providing clinical guidelines, prevention
recommendations, and information for the public.

Prevention Measures

If a SARS patient is coughing or sneezing, he should use common-sense
precautions such as covering his mouth with a tissue, and, if possible
and medically appropriate, wearing a surgical mask to reduce the
possibility of droplet transmission to others in the household. It is
very important for SARS patients and those who come in contact with
them to use good hand hygiene: washing hands with soap and water or
using an alcohol-based hand rub frequently and after any contact with
body fluids.

For people who are living in a home with SARS patients, and who are
otherwise well, there is no reason to limit activities currently. The
experience in the United States has not demonstrated spread of SARS
from household contacts into the community. Contacts with SARS
patients must be alert to the earliest symptom of a respiratory
illness, including fatigue, headache or fever, and the beginnings of
an upper respiratory tract infection, and they should contact a
medical provider if they experience any symptoms.

Emerging Global Microbial Threats

Since 1994, CDC has been engaged in a nationwide effort to revitalize
national capacity to protect the public from infectious diseases.
Progress continues to be made in the areas of disease surveillance and
outbreak response; applied research; prevention and control; and
infrastructure-building and training. However, SARS provides striking
evidence that a disease that emerges or reemerges anywhere in the
world can spread far and wide. It is not possible to adequately
protect the health of our nation without addressing infectious disease
problems that are occurring elsewhere in the world.

Last month, the Institute of Medicine (IOM) published a report
describing the spectrum of microbial threats to national and global
health, factors affecting their emergence or resurgence, and measures
needed to address them effectively. The report, Microbial Threats to
Health: Emergence, Defection, and Response, serves as a successor to
the 1992 landmark IOM report Emerging Infections: Microbial Threats to
Health in the United States, which provided a wake-up call on the risk
of infectious diseases to national security and the need to rebuild
the nation's public health infrastructure. The recommendations in the
1992 report have served as a framework for CDC's infectious disease
programs for the last decade, both with respect to its goals and
targeted issues and populations. Although much progress has been made,
especially in the areas of strengthened surveillance and laboratory
capacity, much remains to be done. The new report clearly indicates
the need for increased capacity of the United States to detect and
respond to national and global microbial threats, both naturally
occurring and intentionally inflicted, and provides recommendations
for specific public health actions to meet these needs. The emergence
of SARS, a previously unrecognized microbial threat, has provided a
strong reminder of the threat posed by emerging infectious diseases.

Conclusion

The SARS experience reinforces the need to strengthen global
surveillance, to have prompt reporting, and to have this reporting
linked to adequate and sophisticated diagnostic laboratory capacity.
It underscores the need for strong global public health systems,
robust health service infrastructures, and expertise that can be
mobilized quickly across national boundaries to mirror disease
movements. As CDC carries out its plans to strengthen the nation's
public health infrastructure, we will collaborate with state and local
health departments, academic centers and other federal agencies,
health care providers and health care networks, international
organizations, and other partners. We have made substantial progress
to date in enhancing the nation's capability to detect and respond to
an infectious disease outbreak; however, the emergence of SARS has
reminded us yet again that we must not become complacent. We must
continue to strengthen the public health systems and improve linkages
with domestic and global colleagues. Priorities include strengthened
public health laboratory capacity; increased surveillance and outbreak
investigation capacity; education and training for clinical and public
health professionals at the federal, state, and local levels; and
communication of health information and prevention strategies to the
public. A strong and flexible public health infrastructure is the best
defense against any disease outbreak.

Thank you very much for your attention. I will be happy to answer any
questions you may have.

(end text)

(Distributed by the Office of International Information Programs, U.S.
Department of State. Web site: http://usinfo.state.gov)