[Senate Hearing 108-36]
[From the U.S. Government Publishing Office]
S. Hrg. 108-36
SEVERE ACUTE RESPIRATORY SYNDROME THREAT (SARS)
=======================================================================
HEARING
BEFORE THE
COMMITTEE ON HEALTH, EDUCATION,
LABOR, AND PENSIONS
UNITED STATES SENATE
ONE HUNDRED EIGHTH CONGRESS
FIRST SESSION
ON
EXAMINING THE SEVERE ACUTE RESPIRATORY SYNDROME THREAT, FOCUSING ON THE
ISSUES OF VACCINE DEVELOPMENT, DRUG SCREENING, AND CLINICAL RESEARCH
__________
APRIL 7, 2003
__________
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COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
JUDD GREGG, New Hampshire, Chairman
BILL FRIST, Tennessee EDWARD M. KENNEDY, Massachusetts
MICHAEL B. ENZI, Wyoming CHRISTOPHER J. DODD, Connecticut
LAMAR ALEXANDER, Tennessee TOM HARKIN, Iowa
CHRISTOPHER S. BOND, Missouri BARBARA A. MIKULSKI, Maryland
MIKE DeWINE, Ohio JAMES M. JEFFORDS (I), Vermont
PAT ROBERTS, Kansas JEFF BINGAMAN, New Mexico
JEFF SESSIONS, Alabama PATTY MURRAY, Washington
JOHN ENSIGN, Nevada JACK REED, Rhode Island
LINDSEY O. GRAHAM, South Carolina JOHN EDWARDS, North Carolina
JOHN W. WARNER, Virginia HILLARY RODHAM CLINTON, New York
Sharon R. Soderstrom, Staff Director
J. Michael Myers, Minority Staff Director and Chief Counsel
(ii)
C O N T E N T S
__________
STATEMENTS
Monday, April 7, 2003
Page
Gregg, Hon. Judd, a U.S. Senator from the State of New Hampshire. 1
Kennedy, Hon. Edward M., a U.S. Senator from the State of
Massachusetts.................................................. 2
Gerberding, Julie L., M.D., M.P.H., Director, Centers for Disease
Control and Prevention; Anthony S. Fauci, M.D., Director,
National Institute of Allergy and Infectious Diseases, National
Institutes of Health; and David L. Heymann, M.D., Executive
Director, Communicable Diseases, World Health Organization..... 5
ADDITIONAL MATERIAL
Statements, articles, publications, letters, etc.:
Julie L. Gerberding, M.D..................................... 36
Anthony S. Fauci, M.D........................................ 39
David L. Heymann, M.D........................................ 41
(iii)
SEVERE ACUTE RESPIRATORY SYNDROME THREAT (SARS)
----------
MONDAY, APRIL 7, 2003
U.S. Senate,
Committee on Health, Education, Labor, and Pensions,
Washington, DC.
The committee met, pursuant to notice, at 12:01 p.m., in
room SD-430, Dirksen Senate Office Building, Senator Gregg
[chairman of the committee] presiding.
Present: Senators Gregg, Sessions, Kennedy, and Dodd.
Opening Statement of Senator Gregg
The Chairman. We will begin this hearing. I want to thank
Senator Kennedy for persisting in making this hearing possible
on the fast track, but I especially want to thank our three
witnesses today, who are leading the effort to try to contain
and address the threat of SARS, the sickness which has
obviously gained international attention and represents a
significant health concern for all of us.
The SARS disease has spread across the world, although it
is centered obviously in China, but I noted in the most recent
statistical analysis that after China, if you consider Hong
Kong to be part of China, which it is, Canada becomes the
Nation with the second largest known cases of SARS.
It obviously raises huge issues for us as a nation and for
the world as a community, issues of how we contain it, issues
of how we address it and hopefully find a cure for it, issues
of how we identify it to begin with, of course.
The health community has worked extremely aggressively on
the international and national level, and I certainly want to
congratulate the World Health Organization for their superb
effort at trying to bring coherence to how we address this
health threat, and we will have with us today, addressing us
from Geneva, Dr. Heymann, who is the head of the World Health
Organization in this area.
We also have joining us today the head of CDC, Dr. Julie
Gerberding, who has done an exceptional job in a lot of
different areas, but is obviously leading the fight in this
area; along with Dr. Fauci, who is the leader at NIH in the
area of communicable diseases, who has been before the
committee on numerous occasions and is also coordinating and
leading this aggressive effort to try to get our hands around
and arms around this significant health threat, to not only our
country but to the world.
These two agencies, NIH and CDC, are the premiere agencies
not only in our country but in the world in the area of
combating communicable diseases, and therefore, their
leadership is important, not only to us here in the United
States, but to the world community as a whole, as we address
the SARS threat.
So it is a pleasure to have them here today to testify
before us. They are the ones we want to hear from. We are
limiting opening statements to myself and Senator Kennedy, and
I yield to Senator Kennedy at this time.
Opening Statement of Senator Kennedy
Senator Kennedy. Thank you very much, Senator Gregg, for
calling this hearing, which is enormously important, and
incredibly significant to our fellow citizens here in this
country and people around the world, and I join you in
welcoming Dr. Gerberding and Dr. Fauci who are two very special
leaders, not only in understanding this challenge, but in so
many other health-related areas.
It is less than a month since the first report surfaced of
this dangerous new disease and it has already spread around the
globe with thousands of cases and dozens of deaths. We live in
a time when deadly disease can leap oceans and travel the globe
in a matter of hours, as fast as an airline passenger can fly.
It spreads easily from person to person and there is no vaccine
or miracle cure. The evidence indicates that it is caused by a
virus. Treatments based on how we treat flu-like disease are
all we can provide so far. The best weapons in combating this
deadly disease are the skill of our health care workers and the
ingenuity of our scientists.
I had the opportunity to hear from some of the Nation's
best doctors and scientists at a forum on SARS on Friday in
Boston. We drew on experts from clinical medicine, public
health and basic science to hear the best insights and
recommendations of how to respond to this extraordinary new
health challenge. Even without a single death so far in the
United States, the impact of SARS has been significant. I heard
on Friday that restaurant bookings at Boston's Chinatown have
dropped by over 60 percent because of fears of an outbreak
there. The State health department is receiving over 200 calls
a day about the disease. A recent town meeting held by the
Boston Department of Public Health drew over 100 people last
week when they were expecting 15 or 25, all anxious to receive
the latest information.
Congress has provided a down payment on the resources that
will fight this epidemic. Last week the Senate accepted an
amendment that Senator Clinton, Senator Murkowski and I offered
that will add $16 million to the CDC, the Centers for Disease
Control budget to fight SARS, and I understand that the CDC has
assigned over 300 personnel to this outbreak, so more resources
will clearly be needed in the near future. Health departments
across the country are already reeling under the impact of
budget cuts and the burden of implementing the smallpox vaccine
plan, and this new epidemic will strain their capacities yet
further.
SARS is also a wake-up call for another reason. There is no
indication it began as a terrorist attack, but what if it had?
A virus can be just as destructive as a bomb or a missile.
Homeland security means protecting our country against health
threats as vigorously as we protect against military threats.
Yet today we are already stretched to the limit in protecting
the country against bioterrorism. Obviously, we must provide
the resources needed to meet both the manmade threat of
terrorism and the natural threat of SARS.
Senator Frist and I held hearings in the past on possible
threats from bioterrorism. The bioterrorism provisions in the
bill enacted after 9/11 were a key turning point in preparing a
response. We have been worried about the other germ threats as
well such as West Nile virus. We are concerned about the
widespread routine us of antibiotics in agriculture for animal
feed, and the danger that germs will mutate into forms that are
resistant to all forms of antibiotics. Clearly, we need to
strengthen our defenses against these perils.
Health departments and hospitals across the Nation are
taking needed steps to improve preparedness against these
modern disease threats. At a time like this it makes no sense
for either Congress or the states to be cutting reimbursements
to public health agencies and hospitals struggling to face
these challenges.
Today we will hear about SARS from three of our best
experts. Dr. Gerberding has led the CDC through some of its
greatest challenges in its history. She has helped protect the
Nation against the deliberate use of infectious disease as a
weapon, and now the talents of CDC's extraordinary doctors are
being mobilized against SARS. One of the points made at the
forum on Friday was the extraordinary respect by public health
professionals for the job that CDC has done in responding so
far.
We are also pleased that Dr. Fauci is here. He and the NIH
have given extraordinary service to the Nation in their work on
AIDS and many other infectious diseases, and I commend him for
his leadership. We are also honored to have David Heymann from
the World Health Organization joining us by video conference.
He is at the forefront of the emergency international efforts
to combat SARS.
I look forward very much to the testimony of these
impressive witnesses at this extremely important hearing.
I thank you, Mr. Chairman.
[The prepared statement of Senator Kennedy follows:]
Prepared Statement of Senator Kennedy
I commend the Chairman for calling today's hearing on SARS.
It's less than a month since the first reports surfaced of this
dangerous new disease, and it's already spread around the
globe, with thousands of cases and dozens of deaths. We live in
a time when deadly disease can leap oceans and travel the globe
in a matter of hours--as fast as an airline passenger can fly.
It spreads easily from person to person, and there is no
vaccine or miracle cure. The evidence indicates that it is
caused by a virus, and treatments based on how we treat flu-
like diseases are all we can provide so far. The best weapons
in combating this deadly disease are the skill of our health
care workers and the ingenuity of our scientists.
I had the opportunity to hear from some of the nation's
best doctors and scientists at a forum on SARS on Friday in
Boston. We drew on experts from clinical medicine, public
health and basic science to hear the best insights and
recommendations on how to respond to this extraordinary new
health challenge.
Even without a single death so far in the United States,
the impact of SARS has been significant. I heard on Friday that
restaurant bookings in Boston's Chinatown have dropped by over
60 percent because of possible fears of an outbreak there. The
state health department is receiving over 200 calls a day about
the disease. A recent town meeting held by the Boston
Department of Public Health drew over 100 people last week--all
anxious to receive the latest information.
Congress has provided a down-payment on the resources that
will be needed to fight this epidemic. Last week, the Senate
accepted an amendment that Senator Clinton, Senator Murkowski
and I offered that will add $16 million to the CDC budget to
fight SARS. I understand that CDC has assigned over 300
personnel to this outbreak, so more resources will clearly be
needed in the near future. Health departments across the
country are already reeling under the impact of budget cuts and
the burden of implementing the smallpox vaccination plan, and
this new epidemic will strain their capacities yet further.
SARS is also a wake-up call for another reason. There's no
indication it began as a terrorist attack, but what if it had?
A virus can be just as destructive as a bomb or a missile.
Homeland security means protecting our country against
health threats as vigorously as we protect against military
threats. Yet today, we are already stretched to the limit in
protecting the country against bioterrorism. Obviously, we must
provide the resources needed to meet both the man-made threat
of terrorism and the natural threat of SARS.
Senator Frist and I have held hearings in the past on
possible threats from bioterrorism. The bioterrorism provisions
in the legislation enacted after 9/11 were a key turning point
in preparing a response. We've been worried about other germ
threats as well, such as West Nile Virus. We're concerned about
the widespread routine use of antibiotics in agriculture for
animal feed, and the danger that germs will mutate into forms
that are resistant to antibiotics. Clearly, we need to
strengthen our defenses against these perils.
Health departments and hospitals across the nation are
taking needed steps to improve preparedness against these modem
disease threats. At a time like this, it makes no sense for
either Congress or the states to be cutting reimbursements to
public health agencies and hospitals struggling to face these
challenges.
Today we will hear about SARS from three of our best
experts. Dr. Gerberding has led CDC through some of the
greatest challenges in its history. She has helped protect the
nation against the deliberate use of infectious disease as a
weapon, and now the talents of CDC's extraordinary doctors are
being mobilized against SARS. One of the points made at the
forum on Friday was the extraordinary respect by public health
professionals for the job that CDC has done in responding so
far.
We're also pleased that Dr. Fauci is here. He and the NIH
have given extraordinary service to the nation in their work on
AIDS and many other infectious diseases, and I commend him for
his leadership. We are also honored to have Dr. David Heymann
[``HAY-mun''] from the World Health Organization joining us by
video conference. He is at the forefront of the emergency
international effort to combat SARS.
I look forward very much to the testimony of these
impressive witnesses at this important hearing.
The Chairman. Thank you, Senator Kennedy.
The procedure we are going to follow is to hear from Dr.
Gerberding, then Dr. Fauci, and then Dr. Heymann in Geneva, who
we very much appreciate joining us by satellite.
If we could start with you, Dr. Gerberding?
STATEMENTS OF JULIE L. GERBERDING, M.D., M.P.H., DIRECTOR,
CENTERS FOR DISEASE CONTROL AND PREVENTION; ANTHONY S. FAUCI,
M.D., DIRECTOR, NATIONAL INSTITUTE OF ALLERGY AND INFECTIOUS
DISEASES, NATIONAL INSTITUTES OF HEALTH; AND DAVID L. HEYMANN,
M.D., EXECUTIVE DIRECTOR, COMMUNICABLE DISEASES, WORLD HEALTH
ORGANIZATION
Dr. Gerberding. Senator Gregg, Senator Kennedy, we really
appreciate this opportunity to appear here today. I think it is
so important to get this kind of information out to the public
and to Congress as it evolves, so I really am very, very
grateful for this change.
As you know, in November mysterious reports of a severe
respiratory illness emerged from Guangdong Province in China,
and by February there were well-documented reports of some
cases of a new pneumonia in Hong Kong. By March, WHO recognized
that this disease was spreading rapidly in Hong Kong and in
Hanoi, and issued a global health alert on March 12th.
On March 14th, CDC activated its emergency response center
to deal with what we recognize would likely be a complicated
multijurisdictional international outbreak investigation, and
since that time we have been mobilizing our full emergency
response capacity, our communications capacity, as well as our
laboratory science capacity to support the public health
response.
What you can see on this graphic is that this has very
quickly become an international epidemic, starting here in
Asia, but then with foci of cases across the entire globe. We,
today, are aware of 2,301 international cases, plus an
additional 148 cases here in the United States involving 30
states. So we are continuing to aggressively evaluate suspected
cases in the United States. The case definition for SARS is
nonspecific, basically a traveler to an affected area or
someone who has had contact with a SARS patient who develops a
fever and respiratory symptoms. Many of these people have SARS,
some have other common respiratory illnesses. One of our
biggest challenges right now while we are trying to contain
spread through public health and infection control measures is
to get a diagnostic test as quickly as we can.
Let me show you just in a little more detail the situation
of the United States because I think it helps understand how
this disease is being transmitted. On the next graphic I have
what we call the epi curve or the epidemiologic curve, and you
can see that over time, beginning in early February and then
progressing to where we are at the end of March, there are
increasing numbers of cases being detected in the United
States, but all of the cases in blue are cases in people who
have traveled to Asia, Hong Kong, Hanoi, Singapore, areas where
this disease is spreading. The green bars right here represent
contacts of these case patients in the United States. There are
only five individuals right now who have SARS as a consequence
of household exposure in this country. Then here there are two
health care workers who acquired SARS or at least acquired a
disease consistent with SARS from a case patient, and recently
over the weekend, we have a third health care worker who has
been added to the suspected case list.
This is a pattern that is very different from what we are
seeing in other parts of the world, probably because we were
able to get aware of this and implement the appropriate
hospital isolation precautions very quickly to protect health
care workers, and then the home infection control precautions
to protect household contacts. But we are also concerned that
there are some people, the so-called hyper transmitters or
super spreaders, as we have heard it in the press, some
individuals may be especially infectious or especially
contagious. So there is always the chance that we will be
seeing a further spread of the infection here in this country
just as it has been observed in Canada and elsewhere in the
world.
On my final graphic I have a picture of the virus that we
believe is the leading hypothesis as the cause of this illness.
This is a coronavirus. It is called corona because in this
section it looks like a crown, with the spokes of the crown
coming out from the circular virus. Coronaviruses cause
diseases in a whole array of animal and bird species, including
cats, dogs, pigs, cattle and so on and so forth. They are an
important veterinary pathogen, and there are many vaccine
products that have been created to try to protect animals from
coronavirus with various degrees of success, sometimes not all
that successfully. We know a great deal about coronaviruses as
a family.
The laboratories at CDC in Hong Kong first isolated
coronavirus from early patients, and since that time at least
eight other laboratories have found evidence of coronavirus
infection in the patients. What is important to us is, first of
all, this is a new coronavirus. It is not like any others that
we have become aware of, and we expect that our laboratory and
other labs this week will likely have the entire genome of this
virus sequenced. It is one of the largest viral genomes that
exists, and it is a single strand of RNA which means it is very
unfaithful as it reproduces itself, so it can evolve over time,
and that is why there are so many different species of this
virus in animals and so forth.
We do have tests now that can detect evidence of
coronavirus infection. We actually have three tests that we are
using to look at the case patients. Two of them are based on
antibodies that develop in patients over time, and one of them
is a PCR test that can find pieces of the virus genome in
specimens from the case patients. So as we evolve the reagents
and get these tests out into the health community, we will
better understand the spread, but will also be able to help in
individual cases identify patients.
The last thing I wanted to mention is the issue of
treatment. This is a new virus and we do not have things on the
shelf that we know are effective against coronavirus. Many
clinicians around the world have been using ribavirin which is
a drug for other kinds of virus infection. We just do not have
the right kind of clinical information to make any judgment
about whether it is effective or not, although I think
increasingly we are a little pessimistic that it is actually
going to be a useful drug. We are working with the U.S. Army
Medical Institute of Infectious Disease Research to screen drug
compounds, and if anything tests positive, we will be able to
go from there. I think Dr. Fauci is going to give a little more
information on drug screening and what we might see in the
future for vaccine.
To summarize all of this, I would say that what we have
here is an epidemic of new virus or some virus that is causing
problems in virtually every corner of the globe. We are
controlling it primarily by identifying exposed end-case
patients and implementing public health measures to prevent
spread. We do not know where this is going to go. If we are
lucky, it will have a seasonal pattern and it will wane over
the summer months or maybe what we are seeing in the early
stages as this large increase will level off. But we are taking
it very seriously. We have to be prepared for this to continue
to spread, and we are doing everything we can across the public
health system, the scientific system, as well as the research
system, to be out in front of it.
Thank you.
The Chairman. Thank you, doctor.
[The prepared statement of Dr. Gerberding may be found in
additional material.]
The Chairman. Dr. Fauci?
Dr. Fauci. Thank you very much, Chairman Gregg, Senator
Kennedy, Senator Dodd. As Dr. Gerberding mentioned, I truly
appreciate the opportunity to appear before this Committee that
has been in the past so helpful to us in our own endeavors over
the past several years in emerging and reemerging diseases, and
most recently in the arena of biodefense against weapons of
bioterrorism.
I want to start off by echoing the point that Senators
Gregg and Kennedy made regarding the job that the Centers for
Disease Control and Prevention and the World Health
Organization have done on this. As a research scientist
involved in infectious diseases, the degree of competence and
collaboration that the Centers for Disease Control and
Prevention have manifested in this is really quite
extraordinary, and I wanted to take this opportunity to
publicly thank Dr. Gerberding and her colleagues at the CDC for
the most extraordinary job that they have done.
This is a poster that I have shown in this room on more
than one occasion, but I have added something to it, and it is
in some of the hearings that we have had in the past on the
whole concept of emerging and reemerging infectious diseases
which are a threat to our species essentially from the
beginning of mankind and indefinitely. When we talk about a
reemerging disease we talk about something that was a disease
in a place or in a form that we had not seen before. A good
example of one that we have recently encountered is West Nile
virus, which is not a new virus at all, but it is now in a
different place, namely in the United States, when in fact it
had not been before 1999. An emerging infection is one that is
new to our species. A good example of that is HIV/AIDS.
If you look at this rather complicated slide of a number of
emerging and reemerging diseases, some of them every once in a
while evolve into a major public health threat, and others,
relatively speaking, are little blips on the radar screen in
that they stay confined to the time and the place when they
initially emerge. With SARS we know for sure that we are not
dealing with just a blip on the radar screen, but as Dr.
Gerberding says, we are not really sure where it is going to go
because we are truly in the middle of the evolution of an
epidemic. We just do not know whether it is going to peak and
then go down, or whether it will go down and then come back up
at a different season. For that reason we have to take this
very, very seriously.
Dr. Gerberding. mentioned that the prevailing evidence--and
it gets stronger and stronger each day--is that we are dealing
with a coronavirus, and she made some important points about it
so I will not spend much time on it except to say that since
the coronaviruses as a group are a known group of virus, there
has been research going on for years in a number of
laboratories, also several laboratories in the extramural and
intramural program that have been supported by the National
Institutes of Health. As Dr. Gerberding mentioned, it is both a
veterinary and a human infection. There are no adequate
therapies and no adequate vaccines. But we do have people who
have been working on them for several years.
What I would like to do is just spend a minute or so, very
briefly touching some of the areas of research. Dr. Gerberding
mentioned the surveillance and the epidemiology. We have NIH-
funded investigators who are actually very closely aligned in
Hong Kong with looking at the evolution fundamentally of new
influenza viruses from animals, from pigs and fowl, and those
individuals are now currently collaborating with the Hong Kong
group, and have actually isolated a coronavirus in confirmation
of the CDC's activity.
When you talk about basic research one of the things that
is interesting about this is that coronavirus is generally a
fastidious virus that is difficult to grow in culture. We have
found, with the help of the CDC who have given us the material
that they have, that this virus grows quite well on certain
cell lines such as a viro cell line, which is a monkey-derived
line. The reason that is in some respect--in the sober
situation that we have now--good news, is because it would have
been very difficult if we could not grow the microbe. Assuming
this is the microbe, which we feel strongly that it is, this is
a situation where we now have the microbe in hand and we can
actually start producing it for the purpose of testing it
against antivirals, and as I will get to in a second, take a
look at the situation vis-a-vis vaccines.
The pathogenesis means how does this microbe cause its
pathological effect, the genesis of the pathology? That is what
we are going to be studying very intensively now that we have
the virus, because we are not sure at this point whether it is
the virus itself that is causing all the damage in the lungs of
the individuals or if it is the virus together with what would
be a normal immune response, but in some diseases the immune
response itself causes damage. We have certain infections in
which a certain type of an immune response can actually make
the pathological effect worse. We see that in some cases of
respiratory syncytial virus, in some cases of measles. So it is
important for us to nail down the pathogenesis.
The big item is vaccines. Right now again, fortunately, we
have the virus growing in culture, so the step-wise approach to
developing a vaccine, the easiest thing to do quickly is to
take the virus, kill it, and have what is called an inactivated
virus. That research is going on as we speak right now at the
NIH in Bethesda as well as in other areas of the country and
the world.
The first thing you do is you grow it and you determine in
fact if you can get an animal model in a mouse or in a monkey.
The fact that it grown in monkey cells gives us optimism,
though we have not proven it yet, that a primate model might be
a good model to test a vaccine. The other thing you do is you
take the sera from people who are recovering or who have
recovered and find out once you infect an animal if the sera
can block the disease in that animal, then that is a pretty
good indication that a vaccine might work. These are all the
steps that are rapidly going on.
Dr. Gerberding. mentioned the drug screening development
program. We are collaborating with the CDC and USAMRIID in that
regard. We are looking at panels of drugs that already exist.
You might recall that when we developed our first drug against
HIV it was in a screening program of a drug that came off the
shelf. The very first drug was AZT. You remember very well,
Senator Kennedy, we discussed that many, many years ago at this
panel, in which we actually had a drug that came off the shelf.
There are other drugs like interferon that we know work
against certain viral diseases. We use it in hepatitis C. We
are going to be testing it in this particular situation.
Immune-based therapy, namely, when someone recovers can you
isolate from their plasma the immunoglobulins that are directed
against the virus, and therefore perhaps use that in a way for
therapy.
I already mentioned animal models.
Finally, clinical research at the clinical center in
Bethesda. We will be setting up protocols in collaboration with
the CDC and other of our colleagues, that if we have cases that
are actually in the area that we can look at, we would be able
to execute some of the protocols, be they immune-based therapy,
be they treatment protocols or be they understanding the
pathogenesis.
So you see, although this is an extraordinary challenge and
we cannot give any guarantee at this time, the mobilization of
the research endeavor together with the public health endeavors
of the CDC have been extraordinary. So in closing, Dr.
Gerberding has shown how the public health system, in a very,
very difficult situation, is in fact working. What I have shown
you is a very brief example of how the investments that we have
made over many years in the arena of emerging and reemerging
diseases can and will be rapidly applied to address this
situation of SARS as well as the inevitable situations that we
will surely face in the future with other naturally occurring
or deliberately released pathogens.
Thank you very much; would be happy to answer any
questions.
The Chairman. Thank you, Dr. Fauci.
[The prepared statement of Dr. Fauci may be found in
additional material.]
The Chairman. And now we will turn to Dr. David Heymann,
who is in Geneva. He is the Director of Communicable Diseases
with the World Health Organization, and I want to again thank
the World Health Organization for the extraordinary job they
have done in focusing world attention on this and trying to
coordinate an international response, and hopefully they
technology will also work, and we look forward to hearing your
thoughts, doctor.
Dr. Heymann. Thank you, Mr. Chairman. It is a privilege to
speak with you today and speak with our doctor collaborators
from CDC and NIH. As you surely know, WHO depends greatly on
the United States and its facilities, and especially on CDC and
NIH to support our activities worldwide.
WHO implements the International Health Regulations, which
are a set of norms and standards set out for airports, seaports
and other ports entering countries, and also refers reporting
of infectious diseases. These regulations are adhered to by our
192 member countries.
Over the past 5 years WHO has been revising these
regulations to be more in touch with the 21st century, and the
outbreak of SARS has given us the unexpected opportunity to try
out the operational procedures which we have been developing as
we revise the International Health Regulations. And it is under
the authority of the International Health Regulations that on
February 10th, WHO, through its office in Beijing was working
with the Chinese Government to learn more about an epidemic in
Guangdong of acute respiratory infection that had begun on the
16th of November.
On the 17th of February WHO then spread its team into Hong
Kong as well because at that time there were two persons who
had the bird flu or H5N1 virus identified from them. So there
was a heightened concern on respiratory diseases in China and
Hong Kong at the period, when on the 28th of February in
Vietnam there was a case of a very atypical pneumonia which
rapidly progressed to respiratory failure, and which by 5 days
later had infected 22 health workers in that hospital. At the
same time we learned that there were outbreaks of a similar
disease going on in Hong Kong. It was not clear yet whether
this disease was influenza or whether it was some other
disease, but on the 12th of March, because this disease was a
very serious disease involving for the most part at that time
health workers, we went out with a global alert, as Dr.
Gerberding has said, notifying all of our countries in the
world that there was a new unrecognized disease in Asia.
After the 12th of March we were working with countries, and
on the 14th of March, 2 days later, we had a report from Canada
that they had put their health authorities on alert that there
was a similar disease occurring in Canada.
On the 15th of March at 2:00 a.m. in the morning we
received a phone call from Singapore, indicating that a
physician who had been attending a congress in New York was on
his way back to Singapore with a similar disease. We had that
plane diverted to Frankfurt and the patient was isolated in
Frankfurt.
But on the 15th morning here in Geneva we had several
concerns. I will just list those concerns for you. First of
all, the cause of this respiratory syndrome was at that point
unknown. We knew that it was very important to health workers
because health workers were the major people at this time who
had been infected; about 90 percent of all cases were in health
workers. We knew that antibiotics and antiviral drugs that we
were using did not seem to be having effect. At the same time
the disease was spreading international. It had gone to Canada.
It had gone to New York, and it was now in Frankfurt as well.
And it was a serious disease which spread very rapidly in some
instances to respiratory or breathing failure, requiring
respirators. And finally, at that point in time, not knowing
what the disease is, we understood that it was best or easiest
transmitted from person to person by close contact, and we
thought that possibly by raising a global alert, in addition to
preventing many health workers from becoming infected, we might
be able to contain this disease as it was starting up, so that
it would not become still another endemic disease, a disease
such as tuberculosis or malaria which affects human
populations.
We continued with our global surveillance and response,
tracking the disease around the world with our colleagues in
many institutions including CDC, and on this 27th of March it
came to our attention that there had been passengers on
international flights who were sitting adjacent to persons who
now we knew had SARS, who had become infected on those planes.
So on that date we recommended that countries which had this
disease begin screening the passengers leaving to make sure
that if there were passengers with this disease, they would not
fly at that time, but rather be referred to health workers.
Many countries such as Canada and Hong Kong and Singapore,
those countries where there was community level transmission
and the greatest epidemics, did institute these practices.
On the 7th of April though we looked again through our
figures, and we found on that date two different events. We
found that passengers continued to travel out of Hong Kong with
the disease, and in fact 9 passenger had traveled to areas in
Taiwan, in Singapore, and in other countries, with the disease
after the 15th of March when we had put out our alert. So
passengers were still traveling, and at the same time on that
same date we understood that other issues were occurring in
Hong Kong, that this disease appeared not to be close contact
to person to person only, that it had somehow been able to
spread from one person to another through an object of
something in the environment in an apartment complex in Hong
Kong.
With these two understandings we made a recommendation that
passengers postpone voluntarily travel to Hong Kong and also to
China because at that point we did not clearly understand what
was going on in Guangdong in China.
On the 17th of March we began three collaborating groups,
laboratories, epidemiologists, those people who study
infectious diseases, and clinicians, to better understand the
disease, and Dr. Gerberding has given a good summary of what we
understand from those groups.
One issue was a very important issue to us, and that was
China. And as you know, China had not been open with the
information about the disease, as open as we had hoped, despite
our working intensively with them. But gradually over the
period from 10th February until the present they have become a
full global partner in this outbreak investigation. We now have
a team which is in Guangdong Province. We are working in other
cities in China to understand the issue.
Now, the issue that we understand in China was that health
has been delegated to provincial levels, and the Federal and
national government had no authority over those provincial
governments as far as infectious diseases were concerned. That
has changed 1 week ago when China has instituted a national
reporting system for SARS and some other infectious diseases,
requiring provinces to report this information to Beijing, and
this information is now also being made available to us.
So we see this global response, although it has been long
in coming, has included a partner which was reticent at the
start. We hope that as we continue this response and afterward
as we continue the revision of the International Health
Regulations, we will be able to require that all countries work
closely when there is a disease of international importance.
The response has been remarkable to date. Laboratories have
collaborated, sharing information that maybe 5 years ago they
would have kept to themselves, so they public first, and we see
that the world has responded the way we had hoped it would.
Thank you, Mr. Chairman.
The Chairman. Thank you, doctor. I appreciate that
excellent overview. I appreciate the excellent overview of all
three of our superb witnesses here today.
[The prepared statement of Dr. Heymann may be found in
additional material.]
The Chairman. If I could direct my first question to Dr.
Heymann. Can you give us a sense of what you are projecting is
the spread of this disease, number one? And number two, do you
feel that the countries which have the most severe outbreak of
it, specifically China, and you alluded to this, presently are
able to control its spread within their borders, and
communication outside of their borders?
Dr. Heymann. Let me start with Vietnam, which called for
help early. Vietnam called for an international team very
early. The epidemic was well contained and there will be a few
cases, but we believe it is contained in that area.
In Guangdong in China, the epidemic we believe has been
going on from the 16th of November and our team has information
that it continues in the Guangdong Province, and we also have
information that other provinces are affected. China will begin
to work with WHO. We do not know the extent to which they will
work with us, but on that WHO team are the best experts in the
world coming from CDC, coming from Australia, coming from Japan
and many other countries. We will be talking with our WHO
office in Beijing tomorrow, and hope that we will have from
them an idea of how much more reinforcement we can send in, and
we believe that we will have the opportunity to help the
Chinese contain the outbreak there. Hong Kong is a concern. We
will be reinforcing our team in Hong Kong at their request
today also.
So the outbreaks are being contained. We hope that we will
be able to work closely with China to continue what has been an
ongoing and long-term epidemic in China, and we believe that we
will be able to contain at least some of the epidemics.
As far as what will happen internationally, I do not
believe anyone can tell you, Mr. Chairman, what will happen. We
are all waiting to see. We are all doing our best to make sure
that it is contained as it spreads.
The Chairman. What are you recommending that countries do,
relative to movement of citizens across borders, especially
relative to nations which have a high degree of infection?
Dr. Heymann. The decision of what a country will recommend
must be based on many things. No. 1, it is based on a WHO
recommendation, and we have recommended now that travelers
avoid Hong Kong and Guangdong because of the spread of the
disease in those areas. But national governments must also
consider insurance, the possibility of med-evacking their sick
citizens and other issues when they make their recommendations.
So we expect that countries will make recommendations which are
different from ours because of their understanding of what they
can do for their citizens in those countries should they become
sick. So our recommendations are for two areas, Hong Kong and
Singapore--no--and Guangdong. We understand that the U.S. and
other countries have recommendations for other countries as
well, and they fit in with our guidelines.
The Chairman. We have seen these surgical masks being worn
throughout airports in China. I would like anybody on our panel
to describe to us what is the use for these? Do they have a
practical, positive medical use or not?
Dr. Gerberding. Maybe I can put some perspective on the
mask issue. The most important use of masks is for health care
workers in health care settings, to protect themselves from
case patients, and the health care workers are expected to use
a very specific kind of mask that has a better filtration than
the use you have just held up. It is called an N95 respirator,
and it is the kind of mask that we would use for tuberculosis
as part of airborne precautions in health care settings.
The surgical masks that you have raised are useful in
keeping large droplets from disseminating from the mouth or
nose of somebody who is sick. So we recommend that if a SARS
patient is in their home, if they can comfortable wear such a
mask, it will help prevent spread to their household contacts.
If the patient cannot wear the mask, then we are advising the
household contacts to wear the mask so that they do not get
exposed to these droplets that come out when you cough or
sneeze.
Beyond that, we are not recommending masks for anyone at
this point in time. We understand that people are nervous and
that in parts of the world where this really is spreading in
communities, a lot of people are using them as sort of a just-
in-case scenario.
The Chairman. You have identified 148 cases in the United
States or potential cases?
Dr. Gerberding. Potential.
The Chairman. Potential cases. Canada, as I understand, has
the second largest number of cases in the world after China and
Hong Kong. How should we in the western hemisphere be dealing
with this, and are we dealing with it adequately, or what
should average citizens be doing, and is there something else
that our health communities should be doing?
Dr. Gerberding. The most important step is identifying
somebody who may have the condition, and so I think we have
been making extraordinary efforts to alert passengers arriving
on planes from areas where this disease is being transmitted,
and overall, we have actually distributed about 300,000 of
those. You have a little yellow card in front of you which is
an example of a travel alert.
The Chairman. We will have it in front of us soon.
Dr. Gerberding. You will have a little yellow card in front
of you. We have translated this into several languages and they
are being distributed at the ports of entry from flights coming
directly from the affected countries in Asia, but also people
who are traveling indirectly via other ports of entry. This is
an effort to remind people that they have been in an area where
SARS is present, and if they develop a fever or respiratory
illness within 10 days after their last exposure, they should
contact a health authority and let them know that they could be
at risk, so that arrangements can be made for them to come in
and be in the proper infection control precautions when they
are evaluated.
The second most important thing is that when a SARS patient
comes into contact with the health care system that they are
immediately put in the appropriate protective environment for
isolation purposes, so that it does not spread to health care
personnel and others.
The Chairman. My last question before I turn to Senator
Kennedy. I wanted to ask Dr. Heymann, is there anything else
that the United States, either the Government or our health
professionals should be doing to assist the World Health
Organization as it pursues this disease?
Dr. Heymann. We will be identifying our needs as we go
along, and we have a very close relationship with CDC. In fact,
at quarter to 6 Geneva time, just before coming into this
hearing, we were talking with our colleagues at CDC about
certain needs that we need as far as technical support to
countries.
We have also been dealing internationally with IATA which
is a federation of airlines transit authorities, and they are
gearing up to be able to make sure that transmission does not
occur on airplanes, and they have assured us that they are
taking all measures they can to deal with this disease.
So from the U.S. we do need technical support. We are
getting it, and we greatly appreciate that.
The Chairman. Thank you.
Senator Kennedy?
Senator Kennedy. Thank you very much, Mr. Chairman.
We are reminded again about what a small world community we
are when it comes to health care. The steps that have been
taken by the CDC, are enormously important. We see how rapidly
this disease can spread in a very short period of time and
affect families here in the United States.
Just quickly, Dr. Heymann, which countries are doing the
best things? Could you tell us, are all the nations pretty much
following your recommendations that you know of?
Dr. Heymann. Yes. All countries are following our
recommendations, and there has been a great rallying around
this outbreak. In the 21st century there is a new way of
working. I have to say that we did not anticipate the support
that we have had. We only had one ministry of health concern
because they were caught off guard. So it is a solid area
internationally on this. And all countries, including the U.S.
and Canada, are following the recommendations of WHO.
Senator Kennedy. For most of your life has been studying
these kinds of diseases. How does this one rate? How does this
figure in the range of different kinds of virulent viruses or
pathogens that you have studied? Where would you put it in
terms of its danger to mankind?
Dr. Heymann. What is concerning about this disease is that
it is a disease which has probably emerged from nature into
humans, but instead of having a dead end in humans, in other
words, infecting humans and not transmitting on, it continues
to transmit through chains of transmission to health workers
and then to their family and others.
It is not a highly virulent disease. 4 percent is not a
very high case fatality rate, but what is high is the fact that
it is killing health workers who are the pillar of our society.
So it is a very important disease because of that.
If you look at a disease like Ebola that kills between 50
and 80 percent of people, but that disease is so virulent that
it does not have a chance to spread. This disease has spread
very rapidly around the world and continues to transmit from
person to person. So it is a disease which may not be high as
far as mortality, but it certainly is high as concerns
transmission around the world.
Senator Kennedy. Dr. Fauci, do you want to add something to
that?
Dr. Fauci. Yes, Senator Kennedy. I agree with Dr. Heymann.
We are all concerned, but since it is an evolving epidemic, I
think we need to emphasize--because whenever we say
``concerned'' some people say, well then, gee, we should be
panicking, we should be--what should we be doing that we are
not doing? I think that the public health measures that are
being taking internationally under the leadership of WHO and
internationally and domestically under the leadership of the
CDC, are right on, and Dr. Gerberding described some of these.
So I am concerned for the reasons that Dr. Heymann mentioned,
is the transmissibility, the fact that is a new virus.
The point that Dr. Heymann made is an excellent one. When
we had the problem with the bird flu a few years ago and then
just most recently the small number this year, it was a type of
a flu that is involved with chickens and it is called an H5N1.
When it jumped from the chicken to the human, it jumped from
chicken to human with several cases. We dodged a bullet because
it did not then go from human to human to human. The problem
with this one is that it very likely jumped from an animal
species to a human, but now it is spreading in humans, and that
is the thing that is concerning us all.
Senator Kennedy. Dr. Gerberding, I think most Americans
want to know what can they do to prevent getting SARS. What
would you say to people that are watching this and say, what
can I do in order to try and avoid it? What advice would you
give them?
Dr. Gerberding. Right now we have indicated that people
should avoid nonessential travel to the countries where this is
especially problematic and particularly in community
situations. So we are recommending that unless you have to go,
defer your trip and wait until we have a little bit better
handle on containment in these regions.
From the domestic standpoint, we have a very small number
of cases of SARS, but if you are a household contact or a
health care worker, to be alert and use the recommended
precautions. Beyond that I think what people can do right now
is be informed. Stay up to date. Understand where the epidemic
is. Understand what is going on in the community.
Senator Kennedy. Talk to their doctors, get more
information?
Dr. Gerberding. Exactly.
Senator Kennedy. Do you have websites on this?
Dr. Gerberding. Yes. I think we passed--I do not know if we
passed this out----
Senator Kennedy. To people that are reading about this
hearing or watching the hearing, what can they do? Obviously,
we would be interested in telling them about the website, and
then calling their public health department or their doctors to
find out about it?
Dr. Gerberding. Absolutely. We have put a high emphasis on
trying to get all the information out as quickly as we can. As
WHO has something, we turn it around and get it back up. Our
website is a very good resource. It is www.cdc.gov, and you can
find pretty much all of the guidance, all of the information
from WHO and anything else that would offer advice. We have
information there for clinicians which are clearly very
critical in recognizing cases and implementing isolation
precautions.
I should also mention that just Friday, with WHO and CDC
and clinicians in Asia, we were able to do a satellite video
conference to educate clinicians and infection control
professionals globally about how to recognize and isolate SARS
patients. So we got many thousands of people who were able to
get that information on the Web as well as through the
satellite.
Senator Kennedy. As I understand, there are categories of
the communication of various diseases called the R 0 value,
which you are familiar with. The tops is measles which is 16,
and the bottom is smallpox which is 4. Of course we thought we
had eradicated the smallpox. And then there is polio which is
5, and we have made progress. And then there is SARS. The best
estimate is 6, which looks like it is fairly low in terms of
the range, but that could be deceiving, could it not? This
could, if people did not have some form of immunity or
potentially some other kinds of protections, I imagine this
could go very rapidly through the population. Could you comment
on this so that people can understand what we are talking
about? We do not want to unduly alarm people, but we ought to
have the best in terms of science information. What is your
view?
Dr. Gerberding. The R 0 is a number that tells us how
efficiently a disease is being transmitted, and it has to be
greater than 1 for an epidemic to propagate. The estimate of 6
is a very preliminary estimate. One of the things that is
probably going on with this epidemic is that in some patients
have an R 0 that is quite low. They are not transmitting to
very many people at all. And then there may be a few patients
for whom the R 0 is very large, and so that is kind of
confusing the situation in terms of understanding this. We do
not want to alarm people unnecessarily, but we do want to
express the fact that this is the beginning of a problem. We
are learning as we go. It has the potential to spread very
quickly, and we have seen that, and it has the potential to
spread globally. We have seen that. So we have got to work with
our public health agencies and our clinician community to do
everything we can to identify and contain cases when they do
occur here and to be alert to where the threats are
internationally.
Senator Kennedy. You mentioned it is the beginning of the
problem. And I would ask Dr. Heymann too, where are we? Are we
in the first inning? Are we in half time? Are we coming into
the----
The Chairman. They do not do innings in Geneva.
Senator Kennedy. Dr. Heymann is a good American and
understands. Can you tell us where we are? Someone said the
first lines of an opening scene. Where are we?
Dr. Heymann. Let me go back to what Dr. Fauci said earlier.
When a virus emerges from nature into humans, there are many
things it can do. It can emerge; it cannot spread from human to
human. It can emerge and spread from human to human, attenuate
or decrease in its power over time, or it can spread from
person to person, continue to spread and become an endemic
disease in our population.
We are somewhere between the second and the third as far as
our understanding of this disease goes because we have only had
a limited time to study it.
We are now in the third and fourth generations of people
who are infected. We do not know if this virus will continue
with its same power to infect others as we go along, or whether
it will drop off as time goes on and not be so virulent. We
suspect the worst and we have to be ready for the worst, but we
are still between that second part when it transfers from
person to person, and maybe decreasing in virulence over time;
and the third, when it transfers from person to person, remains
a very serious disease. I think probably Dr. Gerberding could
probably supplement that a bit better.
Senator Kennedy. Anything you would add?
Dr. Gerberding. Yes. It is too early to say is the short
answer to your question. We agree with the WHO position that we
can be hopeful, but we need to be prepared for the worst-case
scenario, and actually we are already looking at our influenza
pandemic planning process and seeing if we can translate that
plan to make sense for SARS, just in case. We want to make sure
that if that worse case scenario does happen that we have got
the steps in place to deal with it.
Senator Kennedy. My time is just about up, just the final
two questions. One is, why do there appear to be more deaths in
other countries than there are for the cases that we have had
here so far?
Dr. Gerberding. The main reason for the low death rate here
is probably that we have a much broader case definition in this
country. What WHO is reporting under the probable cases are
people who have the whole pneumonia. Here we are reporting
travelers with fever and respiratory illness, and less than
half of them actually have pneumonia, so we are including
people who are not as sick, to make sure that we know who they
are and that we are doing everything we can to contain the
spread.
Senator Kennedy. I read in your article, you said there is
a possibility we might get a seasonal bounce with this. Can you
comment about that, whether you think with coming into the
warmer weather--I guess when you have an influenza epidemic,
the seasons do not make much of a difference--what do you think
with this? Do you think there is some possibility that when you
get to the warmer weather in the summer it might diminish to
some extent?
Dr. Gerberding. The other human coronaviruses do have a
seasonal pattern, and in fact, most respiratory illnesses are
seasonal. The problem is that what is the winter months here is
the summer months in the southern hemisphere and vice versa. So
a seasonal pattern might allow a specific region to get a head
start on containment, but that does not mean the global problem
will quiet down at any particular point.
Senator Kennedy. One point. You put out your warnings in
English and in Spanish. You might take a look at doing the
other languages. We have a very significant Chinese population
in Boston. The public health department in Boston is
translating it, but it is taking them some time. I do not know
if you have all of these capacities. I mention it because there
is a range of different languages in this country now, and to
the extent that that could be added, give you one more thing to
do.
Dr. Gerberding. I appreciate that. The travel card is in
many languages. But we recognized the same issue, and have put
together an Asian community team at CDC this past week to try
to do a better job with that. So thank you.
Senator Kennedy. This little card here was enormously
important in Massachusetts because we have two known cases,
potentially four cases, but two known cases, one an infant. And
the doctor in Springfield, Massachusetts, a pediatrician, was
able to diagnose it because they had received this kind of a
warning. It just goes to show what it means in terms of
communication, good communication early on. Thank you.
The Chairman. We will recognize people by way of their time
of arrival. We would like to keep the questions to 7 to 10
minutes if possible.
Senator Dodd?
Senator Dodd. Thank you very much, Mr. Chairman. Let me
thank our witnesses. And let me thank you, Dr. Heymann. This is
a--well, we lost him, huh? That is not Dr. Heymann. [Laughter.]
He think he is Dr. Heymann. [Laughter.]
I appreciate it very much, Mr. Chairman. This is tremendous
technology, and listening to you, doctor, talk about the
ability to communicate globally as a result of Internet
services and the like and taking advantage of this technology
for us to be able to talk with someone like Dr. Heymann is
important. He is back.
There you are, doctor. We lost you for a minute. You are
back again. I notice, just to follow Senator Kennedy, just
looking at languages, I do not see Spanish on here. Was this a
particular reason why--there is Spanish? Mine has just Korean
and Vietnamese, Japanese, traditional Chinese, simplified
Chinese. Maybe there are other ones.
Dr. Gerberding. We need to take care of that.
Senator Dodd. It would just seem to me that given the
tremendous number of people in the population.
Mr. Chairman, I am going to ask unanimous consent that an
opening statement be included in the record as well.
The Chairman. Certainly.
[The prepared statement of Senator Dodd follows:]
Prepared Statement of Senator Dodd
Mr. Chairman, thank you for convening this important
hearing on the emergence of Severe Acute Respiratory Syndrome
(SARS). With all of our advances in the field of medicine, it
is always shocking when an illness suddenly appears that we
know almost nothing about. In this country, we have been very
fortunate to have conquered so many of the diseases that have
threatened us in the past, that we may begin to feel almost
invincible. However, the development of an illness such as SARS
reminds us that we must remain vigilant to the threat of new
and emerging diseases. Especially in a world that is now so
interconnected, it is virtually impossible to stop disease at
our borders.
It is always the unknown that is most frightening, Mr.
Chairman, and unfortunately we know very little about SARS.
That is why I believe that today's hearing has the potential to
be quite useful as a forum to address some of the questions and
conjecture surrounding SARS. As I am sure all of our witnesses
here today would agree, we are best prepared to deal
effectively with an emerging threat only when we know exactly
what it is that we are confronting. Until we know the true
nature of Severe Acute Respiratory Syndrome, we will not be
able to effectively form an appropriate response. It is my hope
that today's hearing will signify a step toward better
understanding the threat posed by SARS and how we might
effectively respond to its emergence.
More than 100 people have already died as a result of SARS,
and thousands more are infected worldwide. International
flights have been cancelled, and businesses are recalling their
employees from overseas. Photographs in the news media show
ordinary Asians walking to work wearing surgical masks a
disturbing image in this uncertain time. All the while, there
is very little information about the danger that SARS presents
to our nation. The American public and I include myself here is
full of questions about how SARS might affect us. Is the danger
likely to grow? How can I protect myself and my family? How do
I recognize the disease? What should I do if I begin to feel
sick?
These questions may be an overreaction based on a lack of
information, which is exactly why this hearing is necessary. I
am hopeful that today's panelists can answer many of these
questions. I know that both the Centers for Disease Control and
Prevention (CDC) and the National Institutes of Health (NIH)
are actively pursuing answers, and I thank our witnesses for
taking the time to be here today on such short notice.
Mr. Chairman, I would again like to thank you for convening
today's timely hearing. As legislators we have the
responsibility to help the American public better understand
emerging threats and the possible impact of these threats on
their health and well being. We also have the responsibility to
provide oversight of the development of an effective federal
response to the same threats. It is my hope that today's
session will allow us to do both. I look forward to hearing
from our witnesses this afternoon.
Senator Dodd. Obviously the unknown is what we fear. I will
ask a question of one of you, but if others want to jump in,
please do.
One, Dr. Heymann, I will begin with you. Are there some
lessons that we could be taking--now this is early obviously,
and it is only a few weeks here, but it seems to me, given the
sort of exponential growth that seems to be occurring with
this, and given the point that Dr. Fauci made, and I think you,
doctor as well, Dr. Gerberding did, about the ability for this
to go not only it appeals from animal to human, but then
jumping from human to human rather easily, at least it appears
that way, that we may be looking at a more serious situation
here. But the lessons to be learned regarding how different
countries' health organizations coordinate, that is my question
for you, Dr. Heymann. We are letting changes be made as a
result of what you have determined already on how the WHO
operates. For example, is there anything that could have been
done to encourage the Chinese to open up sooner, and to what
extent have you been able to determine beyond this particular
illness that the Chinese now, given the--at least the stories I
have read about Guangdong Province being a province where you
have large concentrations of population on relatively small
farms with large concentrations of diverse animal populations,
that this has been an area that in the past has produced unique
or almost unique viruses--so to what extent are we now going to
get future cooperation from the Chinese as a result of this
experience?
Dr. Heymann. As you know, WHO has an office in developing
countries, and we have an office in China. So what we were able
to do was to get in immediately when we found out about the
disease in Guangdong, into our office, which we reinforced with
two specialists, one from CDC and one from WHO. Those staff
remained however in the office, and were only after a week
allowed to talk with the authorities at the Beijing or China
CDC.
What we do not have is authority to bypass a State's
sovereignty, and this would never be accepted by any of our
member countries in a regulation such as the International
Health Regulation, because we are not an agency which has the
authority to bypass national sovereignty.
The only we can do and what we are trying to do with the
new International Health Regulations is to create such a
pressure on countries that they feel the obligation to work
with us, and this is what has happened now with China we
believe. There has been an apology actually from the Ministry
of Health that it was so long in coming on board with WHO and
its team. The only thing we can do is make this international
solidarity so that all countries do work together and feel a
pressure from other countries if they do not.
I know the U.S. is very influential in discussing with the
Ministry of Health in China the fact that they should allow our
team in, and this together with what WHO was doing and others,
certainly we had a role to play in the final opening of China.
But we cannot force our presence on countries. We have to force
our presence only through an international understanding that
infectious diseases are security issues to the whole world and
that they know no borders. So hopefully by this lesson we have
made one step forward in our ability to work with countries.
I would just add also that for Chinese, which you were
speaking about earlier, on the WHO website all of our documents
are in Chinese. Thank you, Senator.
Senator Dodd. Let me just take it one step further and ask
our other panelists to comment. What steps, given the
incredible importance of coordinating activities now between
the multiple of nations obviously that have to help respond to
this, what steps do you think we might take? What steps should
the United States take? We are a congressional committee here.
We are going to want to know what we can do, what role can we
play here if any? A very candid answer may be none at this
juncture. What you are doing, by just holding a hearing on this
matter and bringing some public attention is more than
satisfactory at this juncture. And I accept that answer. If
there are some other steps you think we can take, I appreciate,
Dr. Heymann, your point about utilizing whatever rhetorical
kind of encouragement we can to other countries, but I would
find it terribly alarming that as a result of this experience
we did not find a far more higher degree of willingness to
participate and contribute. My mind is already beginning to
think of what steps we might take to encourage, be a little bit
more emphatic than encouragement, for nations to participate,
and I wonder if you have any specific suggestions that we might
consider here as a congressional committee?
Dr. Heymann. I would certainly welcome your ideas as to how
this could proceed, because we only feel that our mandate goes
to creating an international environment where all countries
feel an obligation to participate in such an event. If there
are measures that you could suggest to us that we could try to
work out, we would do that, and perhaps CDC and NIH have some
ideas of what they would like to see us do in the future. We
are restricted by our----
Senator Dodd. I understand that.
Dr. Heymann. --192 member countries, and the regulations we
have.
Senator Dodd. Let me ask you, Dr. Fauci, Dr. Gerberding, do
you have any suggestions you would make to us here, such as,
for instance, putting out a health warning to nations who do
not share this information? I mean just as a generic warning,
to people who travel, for instance?
Dr. Fauci. I think what has been done thus far is on target
for the stage that we are in right now. I think you made the
point earlier that since this is a moving target, we need to
continue communications, communications among the health
agencies, and a very close communication between the Congress
and national and international agencies. That is the reason why
we welcome this hearing, to make this a good start, and maybe
the first in several looks at where we are going.
You made the point regarding that yellow card. I actually
as a health person believe, as you made the example, Senator
Kennedy, that we are in much better shape now because we
actually jumped on that and created a vehicle for people to be
able to understand what they need to do if they get symptoms
when they come from these countries.
I think the recently signed quarantine order that adds SARS
to the diseases that are quarantinable was another step in the
right direction, so I think we need to just follow this very
carefully and make the appropriate moves as things evolve.
Senator Dodd. This morning the New York Times ran a lengthy
piece on this issue, and I read a number of articles over the
weekend. How do you feel that the news media generally is
covering this story? Putting aside the websites. I realize
there have been some websites that have been rather alarmist
and so forth, but as a mainstream media, television, print,
journalism, how well is the story accurately being covered?
Dr. Gerberding. This morning I looked at the CDC clips on
SARS, and it is a stack of newspaper reprints about this big.
That is more coverage than we had for anthrax. So I read
through the major articles. I did not have time to read through
all of them. And it is very impressive, the quality and the
caliber of the reporting that we are seeing. I think people
recognize this as an emerging health threat. They are playing
accurately, not overstating the issues, not understating the
issues. I think recently the emphasis on the business
consequences have helped people prepare and recognize that
there will be other collateral damage from this epidemic, but
we have worked very hard to try to educate the media and to
make ourselves available to them in any way that we can to get
this information out, and we are very impressed with what they
are doing.
Senator Dodd. Last, let me raise an issue. I have often
been told--I believe this is correct--the anecdotal line anyway
that the word for ``crisis'' and ``opportunity'' in Chinese is
the same symbol, and obviously this is at least not a crisis. I
do not think you would use the word ``crisis'' yet, but
certainly one that we are paying a lot of attention to. I
wanted to raise, in addition to the WHO question I asked Dr.
Heymann about what could be done to get more than just
encouragement in participation, I wonder in the research area
as well, Dr. Fauci. This is a wonderful opportunity in many
ways for us to break through some of the resistance that may
exist in certain quarters of the world, to share the kind of
research that is being done at NIH with other leading research
institutions around the globe to develop far more coordination
and better cooperation than exists today. Maybe it exists to a
far greater extent than I am aware, but if it is not, how would
you respond to that?
Dr. Fauci. I think the degree of cooperation thus far,
early on right now, has been quite extraordinary in a very
positive sense. I think that if this serves as an example of
what can be done, not only with other naturally occurring
emerging and reemerging diseases, but in the event of
bioterrorism. This could just as easily have been a microbe
that was deliberately released. We are not 100 percent sure
that it was not. It likely was not. But if it were, the
mechanisms that got put into place to address this at the level
of WHO, and at CDC, and our ability to mobilize the research
enterprise, I think is a very good example. I would not say
this would be a dry run, because it is substantial in and of
itself. It is not a dry run for anything. It is real and it is
serious, but it allows us to be able to show that the apparati
that we have put into place actually can work.
Senator Dodd. Dr. Fauci has said that they are very much
satisfied that this was not bioterrorism in any way. That has
been the news reports I have read as well. Dr. Heymann, do you
agree with that conclusion, there is no evidence that you have
seen that this would be anything other than through natural
causes, if you will?
Dr. Heymann. There is no evidence at present that this is
anything but a naturally occurring infectious disease. But as
Dr. Fauci has said, the mechanisms in place will deal with both
the naturally occurring or deliberately caused infectious
disease. And we have actually, as we have been revising the
International Health Regulations, taken that into account. But
there is no evidence.
Senator Dodd. Mr. Chairman, I thank you immensely for
holding this hearing. I think it is tremendously worthwhile,
and I wonder if we might just keep the record open for a while
here for any sort of recommendations from this hearing that
these witnesses or others might bring to us as how we might
legislatively, if there is such a role for us to respond to
this in some way to encourage greater participation in response
to these kind of situations. But I thank you for doing this.
The Chairman. We will certainly do that, Senator Dodd.
Thank you.
Senator Sessions?
Senator Sessions. Thank you, Mr. Chairman, for this
hearing. It is a fascinating hearing, and I am afraid with our
highly mobile world we will be seeing more of these challenges
in the future.
Dr. Heymann, you indicated that this has provided an
opportunity to try out some of the new procedures I presume
that you have adopted. What is your evaluation? How well has it
worked?
Dr. Heymann. Well, I had to smile when Dr. Gerberding was
telling how many people were working on this from CDC, because
in Geneva we are doing this with 29 people, and it has been
quite a strain on the systems that we have and on the staff
that we have had. We have had some devoted staff working 24
hours a day in some instances to pull this off.
What we need to do now is to strengthen those systems to
make sure that we have the staff available, because this will
not come up every day, but when it does come up, it is time
intensive, it is people intensive, and we need to make sure
that we make the correct changes. We have one person
coordinating all of the information and doing most of the
interviews, a spokesman for WHO. We are very under equipped to
do this type of activity, but we now have the chance to see
where our inadequacies lie and how to move ahead faster because
we want to be able to run the International Health Regulations
proactively rather than passively as has been done in the past.
Senator Sessions. And I would understand that such a
disease as this is not inevitable that it spread and that the
sooner we act and the more vigorously we can act early, could
limit the danger of a widespread epidemic; is that correct?
Dr. Heymann. That is correct. We have seen, after the alert
went out on the 15th of March, the countries that had imported
cases since then, had not the big health care worker and other
epidemics the countries had before the 15th. Canada was the
country which reported on the 14th, which stirred us to the
international alert, and since then countries have been able to
deal with this disease very effectively.
The only caveat that we do not know yet is whether or not
this disease may occur in people who do not have symptoms,
whether they are infected and do not have symptoms, and are
spreading this around the world asymptomatically. That we do
not know yet, but we will know that as diagnostic tests become
available.
Senator Sessions. Would either one of you like to comment
on the questions I asked Dr. Heymann?
Dr. Gerberding. I would just like to agree how important
the lessons we have learned from the past have been in making
this effort happen as quickly as it has. Two years ago I do not
think we could have done this, but the investments that have
been made in the public health infrastructure and the terrorism
preparedness have really paid off. Every time we have an event
like an anthrax attack or a West Nile investigation or a SARS
outbreak, we also learn, and we improve, and I think we have
improved tremendously, internationally as well as domestically
over the last 2 years because of the major, major improvements
in both the CDC's capacity but also the NIH's research capacity
and the whole public health infrastructure. So we really thank
you for your support and input.
Senator Sessions. Dr. Heymann, are you able to call Dr.
Fauci and ask for help on research, for example, when something
like this emerges?
Dr. Heymann. Yes, we are. We understand that there is a
meeting in the U.S. this week on vaccine development, which we
will be following very closely. We are very grateful that the
U.S. takes the steps that they do, that keep the world on the
cutting edge of new diseases.
Senator Sessions. Dr. Fauci, you work with other agencies
and provide the research capability that may be needed to
identify precisely what the disease is and how to fight it?
Dr. Fauci. Yes, Senator Sessions. It is actually an ongoing
collaborative effort. WHO, in fact David visited me in my
office some months ago, talking about the interaction between
WHO and emerging and reemerging diseases. We did not know, have
any idea at the time that this would come up so soon
thereafter. The work that the CDC has done in jumping on this
so rapidly and getting the proposed virus, which we feel
reasonably sure is the virus, not only isolating it but getting
it into the broader research enterprise so that we can do the
kinds of vaccine, therapy and other work. I think it is an
excellent example of how the research enterprise seamlessly
goes back and forth with the public health enterprise. It
should not be looked upon as two separate issues. There is the
public health and then there is the research. They really are
seamless, and there are some public health aspects of the
research and some research aspects of the public health.
Senator Sessions. I agree with that so much, and I think we
need to do a better job in Government of making sure our
various agencies work together. We see it in the Defense
Department. They are doing a lot better. We see it in Homeland
Security, that are going to be working closer together, and it
needs to be done here.
Dr. Fauci, to what extent are you able to positively
identify this virus if a child in Massachusetts, the physician
believes they may have it? Is it diagnosed by symptoms or is it
diagnosed in the laboratory?
Dr. Fauci. Well, I will just make one statement and then
hand it over to Dr. Gerberding because they are working on a
diagnostic test. Right now it is a syndromic diagnosis. Someone
comes in with the fever, the typical physical findings, signs
and symptoms with a epidemiological link to an exposure, that
person is considered to have the syndrome. As we now, having
the capabilities of isolating and identifying with diagnostic
probes not only the virus but a response to the virus, that
diagnosis will be much more definitive, but that is exactly
what the CDC is working on right now.
Senator Sessions. Dr. Gerberding?
Dr. Gerberding. Thank you. We have three tests that can be
used to identify infection with coronavirus. The test that
looks for the piece of the virus RNA in the patient's tissue
specimens would help us diagnose cases early while the
infection is still ongoing, and we are creating the primers for
the molecular tests that need to go out to our laboratory
research network and make that test available in public health
laboratories. So we have got to make the reagents and then we
have got to teach people how to do the test, though they
already know how to do this technology.
The other two tests are based on antibodies that develop
once you are infected. And the problem with that test is that
when you first get sick, the test will be negative because your
body has not had enough time to make an antibody. So we have to
collect serum 3 weeks later after the onset of illness, and see
that the test is positive. So it is helpful in saying, yes,
this was a case of SARS, but it is not helpful up front in
knowing who has it and who does not, or who needs to be
isolated or who does not.
So we are going to be working with FDA to get these tests
into a form where they would be useful diagnostically in
individual patients. Right now they are primarily a tool for
determining where are the cases and what can we learn about
spread and how effective our containment methods are.
I will just say that the fact that this has happened in
just a few weeks period of time, really, 2 weeks since we have
had the virus and begun to work on it are we able to do this
kind of diagnostic testing, is an unbelievable achievement in
science. It would not have, again, have happened without the 11
international laboratories that WHO has put into this
collaborating network. These people have a daily conference
call. They have a secure website, and they truly are exchanging
information in real time. so we have been able to accelerate
the whole process of virus discovery and testing.
Senator Sessions. If someone does contract the virus, what
can you tell us about the normal treatment process, how often
and how long might they expect to be in the hospital, and what
kind of cost would that present the United States, for example,
if it became as widespread as a flu epidemic?
Dr. Gerberding. The data we have right now suggests that
there is a spectrum of illness associated with this virus, and
it is possible that some people have very mild infections that
would not normally require health care, although they could
pose a risk of transmission to others.
The people who get the pneumonia often are quite ill and
require hospitalization, and in some cases mechanical
ventilation. Those are of course people who have the most
serious illness and are most likely to die from the infection,
but the majority of people do recover.
Unfortunately, sometimes it takes many days to a few weeks
to really get back to baseline, and some of the people who have
been the sickest are improving, but they are still not back to
the way they were before they got ill. So a full recovery is
possible, and we hope that ultimately will be the case for
everyone, but it can be a long time in coming.
Senator Sessions. In terms of prevention, prevention is
certainly the best policy financially as well as health care
wise, I am sure.
Dr. Heymann, we had a very interesting hearing here last
week with Dr. Gisselquist who did a study on the transmission
of AIDS in Africa, a very provocative proposal that suggests
that WHO's numbers from health care transmissions, that is by
needles and injections, and HHS's numbers, were below what he
thinks the studies show. Have you had a chance to personally
look at that? And would you give it a study, because it would
make I think a significant difference if he were even partially
correct in how we deal with the transmission of AIDS in Africa?
Dr. Heymann. In the 1990s we did studies in Uganda and in
Zimbabwe, which showed that transmission to midwives, nurse
midwives and others was important, and some of the variables,
some of the reasons were because they stuck their fingers with
needles as they were doing procedures.
From the evidence that we have though in Africa, the
majority of transmission is sexual transmission, and that has
remained constant throughout the studies that have been done.
It is a sexually transmitted disease first and foremost, which
does affect all persons, and then is transmitted unfortunately
from pregnant women to their children in many instances. There
is also transmission by needle and syringe as well.
Senator Sessions. I hope you would just take a look at that
new study, and I would yield.
Dr. Heymann. Be glad to.
Senator Sessions. Good.
The Chairman. Thank you, Senator Sessions.
We will do a second round here. Can you tell us, Dr.
Heymann, whether China has adequately quarantined Guangdong
Province and Hong Kong or whether they need to do more?
Dr. Heymann. It seems that Guangdong was the source of
infection for Hong Kong. Right now on people who are leaving
Guangdong by train or by airplane, they are given a card with
the symptoms of the disease, and they are told that they should
see a health worker if they have that disease. There is not
much more that can be done at present in there except cordoning
the area off. We have done that internationally by asking
travelers not to travel to that area if it is not necessary,
voluntarily, because we do not understand enough about the
disease.
We feel that China is taking the measures now that they
can. If these measures had been taken in November perhaps the
disease would not have spread.
The Chairman. Just generally, what is the death rate that
they are experiencing in China from people that would be
infected; do you know?
Dr. Heymann. The death rate in China is the same as it is
in other countries, between 3.5 and 4 percent of all people who
were infected.
The Chairman. Dr. Fauci, where do we stand with the vaccine
effort, developing a vaccine? Obviously it takes a long time to
develop a vaccine, but you were, as you said, phenomenally
quick in developing identifier capability, diagnostics. And I
am wondering first, what do you see as a time frame for a
potential vaccine? What are the problems with developing
vaccines? Do we have enough of a vaccine industry to do it in
the United States, an issue which we are going to be revisiting
later this week? Do we expect this to mutate? You mentioned
that this may, because of its structure, mutate into an even
more difficult disease to deal with.
Dr. Fauci. With regards to vaccine effort, Senator, for
this particular virus, as you know, vaccines take years and
years, and they are generally generations of vaccine. The point
that I made briefly in my opening statement is that the good
news about this is that the microbe is growing in a cell line,
it is culturable, so you get enough of it if you rev it up and
scale it up to do what would be like a first generation of a
vaccine, namely just take it, kill it, go in an animal model
and see if you vaccinate the animal and then challenge the
animal, first a mouse, then a monkey, and show what we call
proof of concept, that you can actually protect some species
against this with a vaccine.
If we talk about that, that will likely, if we are lucky,
take several months to do that. To get that then translated
into a first generation vaccine for humans, will without a
doubt take longer than a year. I do not think there is any
chance that we are going to have a vaccine this time next year.
Likely within a period a bit longer than a year. And that is if
we are lucky.
But that is not going to be 10 years. The reason we say
that is the concept that, (A) it is growing, (B) there are
coronavirus vaccines that have been successful in animal. When
I say vaccine--and that will get to your second question--that
does not mean we will necessarily have enough of it to give to
everyone, but we would be able to at least get into some human
trials within a period a little bit greater than a year. The
success of showing that that candidate is a usable virus for
distribution, I cannot predict how long that will take.
With regard to industry, this is another example of what we
had discussed several times, is the importance of getting
industry involved early, because we can do those first steps.
We can even take it to the point of pre-advanced development.
But when you get to the point of advanced development in a
vaccine, you need the interested industry involved, because the
killed vaccine that I mentioned is just the first generation.
There is the vector type vaccines, the DNA vaccines, and then
the possibility of live attenuated vaccines, each of which have
the potential for a greater degree of efficacy. So it is a
process the you have to measure over years.
The final question that you mentioned about mutating,
coronaviruses are RNA viruses. They have a very bad what we
call proofreading mechanism when they replicate, so they have
the possibility of naturally being very heterogenous and
variable. Is it possible that this virus that is now in the
community will mutate some more? Sure, there is the possibility
and very likely that it will mutate. Will it mutate to the
point where it changes any of the relevant functions that are
going on right now? Unlikely because it usually takes a longer
period of time interacting among different men, women in the
society before you start seeing mutations that are clinically
relevant. So I think ultimately there is the possibility, given
the nature of the virus, to ultimately start mutating, but at
this early stage of its jumping into humans, it would have to
be a little bit more adapted before you functionally mutate to
the point of having a difference.
The Chairman. Thank you. It just shows we need to pass that
Dodd-Frist Vaccine Bill.
Senator Dodd. I think he calls it Frist-Dodd, but I take
your point.
The Chairman. Senator Kennedy?
Senator Kennedy. Let me ask you, Dr. Gerberding, what are
the symptoms? We tried in the earlier round to ask you what
people might be able to do. But could you tell us about the
symptoms for the people that are watching or hearing this? How
is this different from the flu?
Dr. Gerberding. Well, the short answer is that it does not
differ very much from the flu. It is pretty much the typical
viral like illness when it starts. We have a hint that it kind
of has a biphasic pattern, so you get----
Senator Kennedy. Do you want to just describe that again? I
think most of us know what the flu is about, but just so people
are reminded about it?
Dr. Gerberding. Not everyone starts off with a fever, but
they usually feel tired. They have muscle aches. They have a
sore throat, and then usually a fever develops. Sometimes
headache is a prominent feature. In a few people they have that
early illness and then the fever goes away, and then that is
followed by coughing and sort the pneumonia type symptoms of
the chest pain, the tightness, progressing to the troubled
breathing. But in the very earliest days it looks like any
other kind of common cold or common viral illness. What you
have to know is that you have been either a traveler or you
have been exposed, and if you have those very early symptoms
you need to contact your health care professional.
Senator Kennedy. At present what is the best treatment for
SARS?
Dr. Gerberding. There are nonspecific treatments, which
particularly for the people who have pneumonia include making
sure that they are hydrated, that they have good nutrition,
good nursing care and so forth. But because at the beginning we
often cannot tell it apart from other common causes of
pneumonia, many patients will need to be on antibiotics in case
we are wrong, it is regular old pneumococcal pneumonia or
something. Some patients have been treated with anti-flu,
antiviral medications.
In terms of specific treatment for SARS or for coronavirus
or for other viruses, per se, there is not any. Many clinicians
globally have tried ribavirin. The results are not in, but I do
not think it looks real promising right now for that to be a
solution. Some other things have been tried, and it is just
anecdotal and far too soon. We do have already an
investigational new drug protocol developed to look at
ribavirin treatment more systematically to see if it is
offering anything. The results of the work that is going on in
screening antiviral drugs will help guide future protocols. I
think we will have things to try in the future, but right now
we do not have much on the shelf that makes sense.
Senator Kennedy. Dr. Fauci talked about vaccine
development. What about a diagnostic test? Can you tell us when
you think that might be available?
Dr. Gerberding. Last week we distributed the first test
results to State Health Departments with case patients in the
United States. We cannot sensibly give test results until we
have that second day-21 sample, and since so many of our cases
are just now coming into that epidemiology curve, it is too
soon to interpret anything, especially the negatives at this
point in time. We expect over the next couple of weeks that we
will be getting at least some of the test reagents out broadly.
Senator Kennedy. That is very encouraging and should be to
all public health professionals, that these kinds of tests are
going to be out and available in a very short period of time.
It will be enormously valuable and helpful to them I would
expect.
Dr. Gerberding. We are hoping that will prove to be the
case. Of course we have to test uninfected people and we have
to test really very sick people, and then the kind of mixed
picture in between to really know how sensitive are these
tests, how specific are these tests, and overall, what does a
specific test mean in a given individual? And that is where I
think FDA will help us go through the process of really
validating this for individual patient use.
Senator Kennedy. And they are obviously working with you
now.
Dr. Gerberding. Absolutely. Actually, Secretary Thompson
has pulled together a departmental working group on this with
NIH and FDA and CDC, and we are part of a team pulling together
the reagent development as well as the vaccine product
development.
Senator Kennedy. Let me ask Dr. Heymann, are other
countries working on the diagnostic tests or the vaccines?
Dr. Heymann. On the diagnostic tests, test are being
developed in Hong Kong. Singapore is working on some different
tests, as are laboratories in Germany, and also in other
laboratories around the world. So in these 11 laboratories that
are collaborating, they are also working. The beauty is that
they are exchanging their information so that they are getting
results faster.
Senator Kennedy. That is important. And vaccine, anything
going on in Europe at this time or any of the other----
Dr. Heymann. The only thing with vaccine at this point is
in the United States, as far as we know.
Senator Kennedy. Dr. Fauci, this is, you believe, a
coronavirus? Earlier there was some question about whether it
might be or might not be.
Dr. Fauci. Right.
Senator Kennedy. You believe considering the science to
date is that is what it is?
Dr. Fauci. The virus that the CDC and others have isolated
is unquestionably a coronavirus. The evidence, absolutely 100
percent that this is causing it is almost there, but not 100
percent yet. We are assuming it is. All of the work that I
described is I am confident enough to make the investment to go
ahead with the research that is assuming this.
Senator Kennedy. Well, that is reassuring and I thank you.
Finally, the President signed the Executive Order on
quarantine. What is that going to mean to people? Can you
explain it to us and to the American people, what that might
mean, somebody coming back from China and they have been
interested his area? What are their chances, or if they are
getting the quarantine, what will this mean to them and how
widely do you anticipate that this might be used?
Dr. Gerberding. First of all, right now we are not
quarantining anyone in the United States, and we are not
planning to quarantine anyone, given what we are seeing right
now.
What the Executive Order does, it gives the authority to
quarantine for SARS in the same way that we can quarantine for
other communicable diseases like cholera already. So it is just
simply a matter of adding SARS to a list of diseases that
already, if necessary, we can take action to prevent spread
within the community. So it is a precaution, a just-in-case
kind of Executive Order.
Senator Kennedy. I want to thank you all. This has been
enormously interesting, very helpful.
I must say, Mr. Chairman, I think this is very reassuring
for the American people. As Dr. Gerberding had pointed out, and
in articles about it, there is enormous concern, in my State it
is, and all across this country. And I think the reassurance
that the American people should have with the fact that we have
been on this so quick with the leadership of the World Health
Organization, the NIH already moving with the vaccines, Dr.
Gerberding and the communication of working with public health
groups. The American people ought to understand that this is a
danger, but our leading health research agencies, including the
FDA, are working on this, and we have really the best in the
world that are working on it.
There are going to be others who probably will be infected
and some will lose their lives, but I think the American people
should be very reassured that we have the best working on it
and dealing with it in an important scientific way, and help is
on its way.
I thank you, Mr. Chairman.
The Chairman. That is a very soothing comment.
Senator Dodd, do you have any additional questions?
Senator Dodd. Just a couple of brief ones just to follow up
on that point.
It is always the unknown that is always the most
frightening, and so by sharing with us your thoughts here
today, that does a great deal to help.
Just a couple of quick questions. We had at least a
suspected case in Connecticut, at the University of
Connecticut, a student. It occurred to me reading the articles
again today because they are following up with that, we
received a tremendous number of calls from other universities
just to know how the university handled that particular case.
How difficult is it to identify this based on the
coronavirus cell you had up here with a crowning effect and so
forth? Is it that hard to identify in people? Are there a
number of suspected cases? How does that differ from the known
cases? What are the numbers like here? Is there a great
differential between suspected cases and known cases?
Dr. Gerberding. In the United States we have decided to
lump everybody together in the suspected case under
investigation category because we think that is the best way to
help contain spread from even the less suspicious individuals.
The reason that we cannot get a picture like that for every
patient is that that picture came from an electron microscope,
and it is very difficult to get virus out of tissue through
noninvasive strategy. If we could do a lung biopsy on everyone
early in illness, we would probably be able to find this virus,
but we cannot do that. So mostly we have had to rely on autopsy
tissues, and fortunately we have not had a lot of those to deal
with. So we can see the virus in tissue but not very often.
Senator Dodd. That makes the problem that much more
difficult in a sense then?
Dr. Gerberding. That is why we are relying on these
indirect tests like the antibody test. If someone has a
negative test when they come in and their antibody test becomes
positive, it is really strong evidence that they have been
infected with this agent. We know that the tests are looking
very specific, meaning that we have tested them on 300 or so
people with no illness related to SARS and the test is always
negative in those people. So when we see it coming up in the
course of illness, that is a really strong clue of causality,
and we are just looking at more people to make sure we can say
that with reliability across the board.
Senator Dodd. Is the question that Senator Kennedy raised
about what are you doing at this point with people who you
suspect have SARS, is providing some sort of treatment here in
any way producing its own set of problems in any of these
patients at all that you have been able to identify?
Dr. Gerberding. It is important to appreciate that when
people are sick with pneumonia in hospitals, particularly if
they are on a mechanical ventilator, lots of other
complications can develop in addition to the damage that the
virus is causing per se. One of the reasons why we are very
cautious about recommending treatment when we have no idea
whether it is useful, is that there are side effects. For
example, there are side effects to ribavirin that can be very
serious, such as anemia and other complications. So we want to
do that in a very careful way so that we protect the patients
from the harmful effects of what would really be experimental
treatment at this point.
Senator Dodd. Do you have any idea what the gestation
period is between exposure and coming out with the symptoms,
based on again a limited number? Dr. Heymann, jump in here too
if you have some additional information. But what are we
looking at here between exposure and actually getting symptoms?
Do you have any idea of that at all?
Dr. Gerberding. It has been difficult to say in specific
individual cases. Right now we are operating under the
assumption that it is somewhere between two and 10 days, but
recently there have been a couple of anecdotal reports that
suggest maybe the incubation period could be a day or two
longer than that.
Senator Dodd. And again, any patterns developing here about
age and so forth? I have read where it seems as though some of
the cases of fatalities it was older patients, although I then
saw some information that said even very young patients. I am
wondering if there is anything emerging here that would show at
this point, that you feel confident enough to share with us in
terms of some conclusions? Again, I understand that you want to
be careful, but I wonder if anything that you have been able to
discern at this point leads you to a particular set of
conclusions about this.
Dr. Gerberding. Right now the data suggests that the most
common age of acquiring this infection is sort of middle age,
like around age 50, and men and women seem to be more or less
equally affected, although in health care settings where there
are more women health care workers, there will be potentially
more women cases in those settings. I think Dr. Heymann
probably can give you the global picture on how that pans out.
Senator Dodd. How is that doing, Dr. Heymann, just quickly
on this?
Dr. Heymann. In Singapore there are now three children who
had the disease. But now that we have access to the Chinese
data, which is 4 months worth of data, we will rapidly know
whether or not this disease did remain in adults, who were the
first infected because they are health workers, or if it does
also occur in children. We believe it does because it spreads
from parents to their children, the parents being health
workers. And then we do not know what happens in the community
after that. We believe we will know after we have finally been
able to analyze all of the Chinese data.
Senator Dodd. How much follow up is occurring with those
who have emerged, assumed, suspected they even had SARS, and
then apparently been able to recover fairly quickly from it?
Following those people afterwards to determine, to stick with
them, it seems to me that their immune system or something
about their genetic makeup would be worthwhile to know? Are we
following up? Are we doing that?
Dr. Gerberding. Dr. Gerberding. At CDC we have something
called Team B, which is a group of people we have asked to step
aside from being involved in this day to day and to think about
the kinds of questions that you are bringing up so that we know
that we are asking and being prepared to answer these
scientific questions. We are creating a protocol for the long-
term follow up of people after SARS. Simple things we need to
know. Do they still have the virus; you know, is there a
carrier state? Why do some people get sick and some people do
not get sick? How long does it take for full recovery? How many
people do not have full recovery? There is a lot to learn as we
go forward.
Senator Dodd. And two last questions. One is, you talked
about the group that is organizing here. What about the
companies themselves? It seems to me the pharmaceutical
industry, to what extent are you involving them and their
research activities in what you are doing so that they are very
much a part of this collaborative effort?
Dr. Fauci. We are reaching out to the pharmaceutical
industry in the arenas of not only vaccines but in also in
therapeutics, asking them if they have compounds on their
shelf, some of which are just screened compounds, and some of
which might mechanistically have a possibility of blocking the
virus.
Right from the get-go we made it very clear in our
interactions with industry that we are willing, and want to
very much outreach with them in the areas of vaccines,
therapeutics and also diagnostics.
Senator Dodd. Is that unique in this regard? Because of
this set of circumstances--is this normally something you would
do with a similar kind of situation, other similar situations,
obviously a little different than this, or is this something
that you would be doing that is fairly unique in that regard?
Dr. Fauci. I would not say it is unique, Senator, but I
would say that over the past few years, particularly in the
activity that has now evolved vis-a-vis the need for farmer as
well as biotech companies, in the development of countermeasure
for biodefense, has kind of shook the ground a bit, that we
really do need to have a good collaboration between industry
and academia and Federal law and international organizations.
So although we have done that in the past, the fact that it
is happening now so quickly I think is a testimony to the
realization that no one can really do it alone. We do need
industry there.
Senator Dodd. I understand that. And I wonder if there are
some problems--and you may not be able to answer this right now
just with regard to proprietary information and the
unwillingness of companies sharing the kind of information that
they might feel could end up in the public domain in some way.
Is that a problem?
Dr. Fauci. Well, that sometimes is a problem, but that is a
problem not only with companies. We just have to deal with it.
Senator Dodd. Last, let me ask you this. If you are looking
at this situation--again, everything you have said here, the
important thing about this hearing I think additionally to this
specific information is that the worse thing that could happen
right now is for a panic or an alarmist situation to take over.
But I just want to have a degree of confidence. In light of the
fact that this may become a more serious problem, are you
planning on steps, doctor, to take if this thing emerges over
the next number of weeks, we found an exponential growth? Are
you thinking ahead?
Dr. Gerberding. Yes. We absolutely are thinking ahead. The
kinds of things that Dr. Fauci has been talking about in terms
of antivirals or vaccines are way down the road, and so we have
got to be prepared to do what we can do now. Detection is
critical, and we have made major investments in detection for
terrorism, but we are scaling those up. Getting the tests out,
so we know who has it and who does not, that is a very high
priority for us. If we see ongoing spread, for example, if we
get into a situation like Canada, where there is widespread
transmission within a hospital, we will act quickly to close
the hospitals to new admissions and cohort the health care
workers and patients because we know what will happen if we do
not. We have learned by watching the experience elsewhere.
Similarly, if we saw a situation where there was a danger
to a school or some other kind of scenario, we would take what
is I think very sensible guidance right now, and we will add
steps to help people avoid transmitting to others while they
are sick.
So there is more we can do if we need to.
Senator Dodd. And do you have enough resources at this
juncture, looking ahead, do you think to handle all of that in
personnel?
Dr. Gerberding. Right now I think we are right on target.
Senator Dodd. Dr. Heymann, just curious whether you and the
World Health Organization, the image of 29 people, should this
grow to be a more serious problem, do you have adequate
personnel, resources and so forth to be able to handle this?
Dr. Heymann. Yes. Our Director General has agreed that she
will shift resources to this should we need them. So we are in
the process of looking at how we can shift our budget to deal
with this problem and to keep the people and the staff that we
need.
What we also depend on is people coming in from other
agencies or other countries, and CDC again has helped us in
that respect in detailing people to WHO to work on specific
issues of this outbreak.
Senator Dodd. Thank you.
The Chairman. Thank you very much, Senator Dodd.
Once again, on behalf of myself and the committee, and I
know Senator Kennedy, we certainly appreciate you taking the
time to come here.
We want to thank you, Dr. Heymann, for taking your time
late in the afternoon or maybe early evening in Geneva, and
giving us the time you have, and we especially want to thank
the World Health Organization for the extraordinary job you
have done on this threat to the world community generally.
Dr. Fauci, NIH always does a great job, and Dr. Gerberding,
the same with CDC. We appreciate the fact that you are so
expert and that you give us the confidence that, as Senator
Kennedy said, here in the United States we have a health
community which is on top of the issue and is aggressively
pursuing the protections America needs. So thank you, and we
appreciate your time.
The meeting is adjourned.
[Additional material follows.]
ADDITIONAL MATERIAL
Prepared Statement of Julie L. Gerberding, M.D.
Good morning, 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 Legionnaires' disease, Lyme
disease, 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
international partners to prevent the emergence and spread of
infectious diseases.
EMERGENCE OF SARS
Since late February 2003, CDC has been supporting WHO in the
investigation of a multi-country outbreak of unexplained atypical
pneumonia referred to as severe acute respiratory syndrome (SARS). As
of April 3, 2003, a total of 2300 probable or suspected cases of SARS
have been reported to WHO from 16 countries, and 79 of these patients
have died. This includes 115 suspected cases in the United States, from
29 states. None of the suspected cases in the United States have died.
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.
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.
Of the 115 reported suspected cases among U.S. residents, 109 have
traveled to mainland China, Hong Kong, Singapore, or Hanoi, Vietnam, 4
had household contact with a suspected case, and 2 are healthcare
workers who provided medical care to a suspected case. Cases in the
United States have had relatively less severe manifestations of SARS,
compared to cases reported in other countries. Forty-three cases have
been hospitalized. As of April 3, 12 remain in the hospital, and none
have died. Community transmission of SARS has not been identified
within the United States. Transmission to healthcare workers has only
been observed in one cluster involving two healthcare workers in the
United States, in contrast to the numerous instances of possible
transmission to healthcare workers that have been reported in several
other countries.
Cases of SARS continue to be reported from around the world. The
disease is still primarily limited to travelers to Hong Kong, Hanoi,
Singapore, and mainland China; to health care personnel who have taken
care of SARS patients; and to close contacts of SARS patients. Based on
what we know to date, we believe that the major mode of transmission is
through droplet spread when an infected person coughs or sneezes.
However, we are concerned about the possibility of airborne
transmission and also the possibility that objects that become
contaminated in the environment could serve as modes of spread.
CDC RESPONSE TO SARS
CDC continues to work with WHO and other national and international
partners to investigate this ongoing emerging global microbial threat.
This is a major challenge, but it is also 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
mainland China, Hong Kong, Taiwan, Thailand, and Vietnam. In the United
States, we are conducting active surveillance and implementing
preventive measures, working with numerous clinical and public health
partners at state and local levels. As part of the WHO-led
international response thus far, CDC has deployed approximately 30
scientists and other public health professionals internationally and
has assigned almost 300 staff in Atlanta and around the United States
to work on the SARS investigation.
CDC has issued interim guidance to protect against spread of this
virus for close contacts of SARS patients, including in health care
settings or in the home. We have also issued interim guidance for
management of exposures to SARS and for cleaning airplanes that have
carried a passenger with suspected SARS. We have issued travel
advisories and health alert notices, which are being distributed to
people returning from China, Hong Kong, Singapore, and Vietnam. We have
distributed more than 200,000 health alert notice cards to airline
passengers entering the United States from these areas, alerting
passengers 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.
WHO is coordinating daily 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. Our evidence and that of many of our partners
indicates that a new coronavirus is the leading candidate for the cause
of this infection.
Initial laboratory efforts were focused on a diagnosis based on
clinical symptoms and available epidemiologic information. On the basis
of this initial diagnosis, CDC used classical microbiologic approaches
and molecular diagnostic methods to identify the agent or agents
involved. A broad range of pathogens primarily associated with
respiratory disease and for which respiratory symptoms might be
secondary were targeted for detection in SARS specimens. Various
methods were used for detection, including light and electron
microscopy, immunohistochemistry, cell culture isolation techniques,
serology, and other modern molecular techniques. An apparently new
coronavirus was isolated in cell cultures, and coronavirus nucleotide
sequences specific to this virus were detected in diseased tissues.
This finding, coupled with the increasing reports that many WHO
collaborating laboratories have detected this virus in specimens from
SARS patients, suggests that this coronavirus is involved in the
etiology of the disease. Efforts to further characterize the role of
this coronavirus in SARS are ongoing at CDC and in other laboratories.
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. In the past three weeks, CDC has had multiple
teleconferences with state health 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. On Friday, April 4, WHO
sponsored, with CDC support, a clinical video conference broadcast
globally to discuss the latest findings of the outbreak and prevention
of transmission in healthcare settings. The faculty was comprised of
representatives from WHO, CDC, and several affected countries who
reported their experiences with SARS. The video cast is now available
on-line for download. Secretary Thompson and I, as well as other senior
scientists and leading experts at CDC, have held numerous media
telebriefings to provide updated information on SARS cases, laboratory
and surveillance findings, and prevention measures. CDC is keeping its
website current, with multiple postings daily providing clinical
guidelines, prevention recommendations, and information for the public.
PREVENTION MEASURES
Currently, CDC is recommending that persons postpone non-essential
travel to mainland China, Hong Kong, Singapore, and Hanoi, Vietnam.
Persons who have traveled to affected areas and experience symptoms
characteristic of SARS should contact a physician. 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 our epidemiologists have 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
at least ten days after they are fully asymptomatic.
If a SARS patient is coughing or sneezing, he should use common-
sense precautions such as covering his mouth with a tissue, and, if
possible and medically appropriate, wearing a surgical mask to reduce
the possibility of droplet transmission to others in the household. It
is very important for SARS patients and those who come in contact with
them to use good hand hygiene: washing hands with soap and water or
using an alcohol-based hand rub frequently and after any contact with
body fluids.
For people who are living in a home with SARS patients, and who are
otherwise well, there is no reason to limit activities currently. The
experience in the United States has not demonstrated spread of SARS
from household contacts into the community. Contacts with SARS patients
must be alert to the earliest symptom of a respiratory illness,
including fatigue, headache or fever, and the beginnings of an upper
respiratory tract infection, and they should contact a medical provider
if they experience any symptoms.
EMERGING GLOBAL MICROBIAL THREATS
Since 1994, CDC has been engaged in a nationwide effort to
revitalize national capacity to protect the public from infectious
diseases. Progress continues to be made in the areas of disease
surveillance and outbreak response; applied research; prevention and
control; and infrastructure-building and training. However, SARS
provides striking evidence that a disease that emerges or reemerges
anywhere in the world can spread far and wide. It is not possible to
adequately protect the health of our nation without addressing
infectious disease problems that are occurring elsewhere in the world.
Last month, the Institute of Medicine (IOM) published a report
describing the spectrum of microbial threats to national and global
health, factors affecting their emergence or resurgence, and measures
needed to address them effectively. The report, Microbial Threats to
Health: Emergence, Detection, and Response, serves as a successor to
the 1992 landmark IOM report Emerging Infections: Microbial Threats to
Health in the United States, which provided a wake-up call on the risk
of infectious diseases to national security and the need to rebuild the
nation's public health infrastructure. The recommendations in the 1992
report have served as a framework for CDC's infectious disease programs
for the last decade, both with respect to its goals and targeted issues
and populations. Although much progress has been made, especially in
the areas of strengthened surveillance and laboratory capacity, much
remains to be done. The new report clearly indicates the need for
increased capacity of the United States to detect and respond to
national and global microbial threats, both naturally occurring and
intentionally inflicted, and provides recommendations for specific
public health actions to meet these needs. The emergence of SARS, a
previously unrecognized microbial threat, has provided a strong
reminder of the threat posed by emerging infectious diseases.
CONCLUSION
The SARS experience reinforces the need to strengthen global
surveillance, to have prompt reporting, and to have this reporting
linked to adequate and sophisticated diagnostic laboratory capacity. It
underscores the need for strong global public health systems, robust
health service infrastructures, and expertise that can be mobilized
quickly across national boundaries to mirror disease movements. As CDC
carries out its plans to strengthen the nation's public health
infrastructure, we will collaborate with CDC Response to SARS state and
local health departments, academic centers and other federal agencies,
health care providers and health care networks, international
organizations, and other partners. We have made substantial progress to
date in enhancing the nation's capability to detect and respond to an
infectious disease outbreak; however, the emergence of SARS has
reminded us yet again that we must not become complacent. We must
continue to strengthen the public health systems and improve linkages
with domestic and global colleagues. Priorities include strengthened
public health laboratory capacity; increased surveillance and outbreak
investigation capacity; education and training for clinical and public
health professionals at the federal, state, and local levels; and
communication of health information and prevention strategies to the
public. A strong and flexible public health infrastructure is the best
defense against any disease outbreak.
Thank you very much for your attention. I will be happy to answer
any questions you may have.
Prepared Statement of Anthony S. Fauci, M.D.
Mr. Chairman and Members of the Committee, thank you for the
opportunity to discuss the research activities of the National
Institutes of Health (NIH) that promise to help us better understand
and counter the global outbreak of Severe Acute Respiratory Syndrome,
or SARS. I am pleased to share this table with Dr. Julie Gerberding,
the Director of our sister agency, the Centers for Disease Control and
Prevention (CDC), which has done such an extraordinary job in
responding to the evolving epidemic.
As Dr. Gerberding will discuss in some detail, SARS rapidly has
moved across the globe, becoming a worldwide health emergency that has
resulted in quarantines, travel warnings, and mounting economic damage.
The global tally of SARS cases has grown to more than 2,300 cases in
only six weeks since the apparent emergence of the disease. At this
early stage of the epidemic, it is impossible to predict whether SARS
will become an ongoing, major global health threat, or if the epidemic
will spontaneously burn out or be contained by public health measures.
However, we must be prepared for the worst-case scenario.
Dr. Gerberding and her CDC team, together with the World Health
Organization (WHO) and others, have done a magnificent job in
identifying and tracking this epidemic, illuminating the etiology and
clinical features of SARS, and providing the world with information
about the epidemic in real time. Complementing the efforts of the CDC
and WHO, the National Institute of Allergy and Infectious Diseases
(NIAID), a component of NIH, also has a significant role in the efforts
against SARS, notably by rapidly addressing the issues of vaccine
development, drug screening, and clinical research.
As with Lyme disease, Hepatitis C, HIV/AIDS, Ebola, West Nile virus
and a host of other ``new'' diseases, the SARS outbreak has reminded us
that the emergence or reemergence of infectious diseases is a constant
threat. As has been the case with other emerging diseases, we
anticipate that the strong NIAID research base in disciplines such as
microbiology, immunology and infectious diseases will facilitate the
development of interventions such as diagnostics, therapies, and
vaccines to help counter SARS.
As described by CDC and WHO, evidence is mounting, although not yet
definitive, that SARS is caused by a novel coronavirus that may have
crossed species from an animal to humans. This hypothesis is based on
the detection and isolation of coronaviruses from unrelated patients
from different countries, and on the finding that several SARS patients
have mounted an immunological response to coronavirus as they proceeded
from the acute illness to the recovery or convalescent stage. While
some questions remain--for example, there is some evidence that a
second virus may contribute to the pathogenesis of SARS--the strong
evidence for a causative role for a coronavirus justifies the ongoing
development of diagnostic tools, therapies and vaccines that target
coronaviruses.
Coronaviruses are best known as one of the causes of the ``common
cold,'' which is generally a very benign condition, very rarely
resulting in life-threatening disease. The coronavirus that has been
shown to be associated with SARS is a new type of coronavirus that has
not been previously identified.
I would note that no evidence of genetic ``tampering'' of the virus
implicated in SARS has been detected, based on analyses of the mounting
genomic sequence data of the samples from SARS patients examined so
far. As even more extensive genomic sequence data become available for
the SARS virus, it will be possible to further distinguish natural
origin from the possibility that the SARS agent was created in a
laboratory or even as a bioweapon. Until then, we will keep our minds
open to these possibilities, however remote.
NIAID RESEARCH ON SARS
NIAID maintains a longstanding commitment to conducting and
supporting research on emerging infectious diseases, such as SARS, with
the goal of improving global health. In carrying out its global health
research mission, the Institute supports a myriad of activities,
including intramural and extramural research, and collaborations with
international agencies and organizations. Since the first SARS reports,
NIAID has worked rapidly to identify opportunities for accelerating or
expanding research to improve the diagnosis, treatment, and prevention
of SARS. These areas include:
Surveillance and epidemiology.
NIAID supports a long-standing program for surveillance of
influenza viruses in Hong Kong, led by Dr. Robert Webster of St. Jude's
Children's Research Hospital in Memphis. Dr. Webster and his team in
Hong Kong have collaborated with WHO, CDC and others in helping to
illuminate the SARS, outbreaks in Asia. In addition, at the request of
WHO, NIAID assigned a staff epidemiologist to provide epidemiologic and
logistical assistance during the early stages of the epidemic.
Diagnostics.
As discussed by Dr. Gerberding, significant progress has been made
by the CDC in developing a diagnostic test for SARS. As part of these
efforts, NIAID-sponsored researchers in Hong Kong also devised a
diagnostic test based on PCR technology as well as a diagnostic tool
using the immunofluorescence assay technique. In other research, the
NIAID-funded Respiratory Pathogens Research Unit (RPRU) at Baylor
College of Medicine has developed methods to detect known human
coronaviruses using cell culture and molecular diagnostic tools and can
also assess the host immune response to known coronavirus infections.
In 2003 NIAID will expand this capacity for research on emerging acute
viral respiratory diseases, including pandemic influenza and SARS.
Vaccine Research.
As the SARS epidemic continues, it will be necessary to consider a
broad spectrum of vaccine approaches, as well as immunotherapy. NIAID
is supporting the rapid development of vaccines to prevent SARS through
both our extramural and intramural programs, including the NIAID
Vaccine Research Center. Initially, these efforts are focusing on the
development of an inactivated (or killed) virus vaccine. However, other
approaches will soon follow, including novel approaches such as vector-
based and recombinant vaccines, DNA-based vaccines and live attenuated
vaccines, as more knowledge about the cause of SARS and its etiology
becomes available.
NIAID scientists have received samples of the SARS coronavirus from
CDC and have initiated efforts to develop a vaccine. Fortuitously,
vaccines against common veterinary coronaviruses are routinely used to
prevent serious diseases in young animals, such as a vaccine given to
pigs to prevent serious enteric coronavirus disease. These models could
prove useful as we develop vaccines to protect humans.
To further accelerate SARS vaccine research and development
efforts, NIAID is initiating contracts with companies, institutions and
other organizations who have relevant technologies, cell lines and
containment facilities; supporting the development of reagents needed
for vaccine development; and developing animal models such as mice and
relevant species of monkeys.
Therapeutics Research.
As the nation began its focus on SARS, NIAID responded rapidly to a
request from CDC to evaluate candidate antiviral therapeutic agents
through a collaborative antiviral drug-screening project at the U.S.
Army Medical Research Institute of Infectious Diseases (USAMRIID).
NIAID also has initiated discussions with the pharmaceutical industry
about candidate antiviral drugs, and is reviewing a proposal for a
clinical trial of antiviral therapy to be conducted by investigators of
the NIAID Collaborative Antiviral Study Group and the NIH Clinical
Center.
Clinical Research.
Clinicians treating SARS patients have not yet identified treatment
strategies that consistently improve prognosis, beyond good intensive
and supportive care. Antibiotics do not work, a fact that is consistent
with SARS being a viral disease. However, some improvement has been
noted in certain patients treated with a combination of ribavirin and
corticosteroids, which are given together in an effort to
simultaneously block viral replication and modify the immune system
reaction to the virus.
At the NIH Clinical Center in Bethesda, MD, and through the NIAID
Collaborative Antiviral Study Group, NIH is preparing to admit SARS
patients for evaluation and treatment, should this become necessary.
This will be an opportunity to evaluate the efficacy of antiviral and
immune-based therapies, including interferons, in patients with SARS.
We also plan to evaluate approaches to improve management of patients
with severe forms of the disease, including the passive transfer of
antibodies from SARS patients who have recovered from the disease.
In addition to ensuring state-of-the-art treatment of potential
patients, our clinical experts will be able to study the clinical
characteristics of patients with SARS. We are particularly interested
in answering key questions about the disease mechanisms of SARS. For
example, are acute respiratory distress and mortality entirely caused
by the presence of virus, or could it be that the response of the
immune system is causing the severe outcomes in some patients?
This is a central question to address because it may open up an
avenue for treatment in addition to antiviral drugs.
Basic Research.
NIAID currently is supporting 18 grants on coronavirus research.
Also, the study of patients, as well as specimens in NIAID
laboratories, will facilitate studies of the natural history of the
SARS agent and its potential animal reservoir, and help to illuminate
the risk factors and epidemiology of SARS. NIAID will support and
conduct basic research studies on the pathogenesis of the disease and
viral replication mechanisms, in order to identify targets for
antiviral drugs, diagnostic tests and vaccines. Finally, the Institute
will support and conduct genomic sequencing, proteomics and informatics
of coronaviruses.
Of note, an existing NIAID animal model of a virus infection that
causes a disease in mice very similar to SARS has been identified. The
relevance of this animal model will be evaluated and may prove an
important tool for defining treatment approaches to SARS that involve
modulation of the immune system.
Infrastructure.
A central concern when working with the SARS virus or SARS patients
is the availability of facilities with the required safety level for
the clinicians and staff, as well as for the community. Our ongoing
plans to develop high-level containment facilities will facilitate SARS
research, as well as planned studies of potential bioterror agents and
other emerging diseases.
CONCLUSION
Mr. Chairman, thank you again for allowing me to discuss our
efforts to address SARS. Despite ongoing research efforts and early
successes, we still have much to learn about the disease. As you have
heard, NIAID-sponsored coronavirus research, studies of other viral
diseases, and clinical research already have provided results that are
relevant to our quest for tools to detect, treat and prevent SARS. In
the weeks and months ahead, NIH will continue to collaborate with our
sister agencies the CDC and the Food and Drug Administration, as well
as other relevant agencies to accelerate and expand our research aimed
at improving the diagnosis, prevention, and treatment of SARS.
I would be pleased to answer your questions.
Prepared Statement by David L. Heymann, M.D.
At this moment, public health authorities, physicians and
scientists around the world are struggling to cope with a severe and
rapidly spreading new disease in humans, severe acute respiratory
syndrome, or SARS. This appears to be the first severe and easily
transmissible new disease to emerge in the 21st century. Though much
about the disease remains poorly understood, including the exact
identity of the causative virus, we do know that it has features that
allow it to spread rapidly along international air travel routes.
As of 7 April, 2601 SARS cases, with 98 deaths, have been reported
to WHO from 18 countries on four continents. Some outbreaks have
reassuring features. A high awareness of SARS symptoms among travellers
and the medical and nursing professions has often resulted in good
management of imported cases--prompt isolation of patients and
management according to strict procedures of infection control. As a
result, many countries having only a single or a few imported cases
have experienced no further spread to hospital staff, families of
patients and hospital visitors, or the community at large. However,
other outbreaks, most notably in Toronto, Hong Kong, Hanoi, and
Singapore, give rise to considerable concern.
One of the most alarming features of SARS is its rapid spread in
hospitals, where it has affected a large number of previously healthy
health care workers. Many require intensive care, placing a huge strain
on hospital facilities and staff. In Toronto, SARS is continuing to
spread despite the introduction of strict patient isolation and
excellent infection control. To date, Canada has reported 90 probable
cases and 9 deaths. All cases have occurred in persons who have
travelled to Asia or had close contact with SARS cases in households or
health care facilities. Several Canadian schools and at least two
hospitals are closed.
Hong Kong, with 883 cases and 23 deaths, is presently the hardest
hit area. Health care workers continue to become infected in a growing
number of hospitals. WHO learned today that the chief executive of the
Prince of Wales Hospital--the initial epicentre of the Hong Kong
outbreak--is hospitalized with atypical pneumonia. Hospitals are
overwhelmed. A decision to suspend all primary, secondary, special
schools and kindergartens until 6 April has been extended up to 21
April. Most disturbing is a large cluster of 268 SARS cases linked to
the Amoy Gardens estate of high-rise apartment buildings. The vast
majority of Amoy Gardens cases have been traced to vertically linked
apartments in a single building, Block E. This pattern of transmission
indicates that the disease has moved out of the health care setting and
is now occurring within the community as secondary cases.
Epidemiologists investigating the Amoy Gardens outbreak are considering
the hypothesis that some form of environmental contamination, perhaps
linked to a sewage system, is the source of the large cluster of cases.
Although transmission through the faecal-oral route is being considered
as one possibility, no evidence of airborne transmission has been
demonstrated to date.
In Viet Nam, an epidemiologist from the Hanoi WHO office recognized
the first case of SARS on 28 February at a French hospital in Hanoi.
The number of cases increased rapidly but then stabilized on 24 March
at 58 cases and remained stable for 10 consecutive days. As the maximum
incubation period for SARS is thought to be 10 days. the stable number
of cases over this period raised hope that Viet Nam's outbreak had been
brought under control. However, on 3 April a probable SARS case was
detected in a provincial hospital. Though the case could be linked back
to the French hospital, the absence of isolation and rigorous infection
control at the provincial hospital suggests that many hospital staff,
patients, and visitors may have been exposed, thus possibly seeding
further waves of cases. An additional two probable cases in the
province were reported today.
In Singapore, another of the earliest and hardest hit areas, 106
persons, including 3 children under the age of 18 years, have been
diagnosed with SARS. Most disturbing is a new cluster of 29 suspected
SARS cases among health workers in two interlinked wards at Singapore
General Hospital. Epidemiologists investigating the outbreak are
considering whether some environmental source, as suspected in the Amoy
Gardens outbreak, might account for the unusual clustering of cases.
Through new mechanisms set up by WHO, progress on the research
front has been unprecedented, particularly in the rapid discovery of a
new coronavirus and the rapid development of diagnostic tests. The best
scientists from around the world are working on these problems around
the clock, and in an unprecedented spirit of collaboration against a
threat of, as yet, unknown dimensions. Nonetheless, we still do not
have conclusive proof that the new virus is indeed the cause of SARS.
The results of animal experiments, which are currently being conducted
by a laboratory in a WHO network, will be available soon and may
provide the last pieces of evidence needed for definitive proof that
SARS is caused by the newly discovered coronavirus. Furthermore, the
findings will provide additional evidence to understand the role of
metapneumovirus as a possible ``helper virus'' in persons co-infected
with the new coronavirus. The development of a diagnostic test has also
proved more problematic than hoped. Three diagnostic tests are now
available, but all have limitations as tools for getting this outbreak
quickly under control. The ELISA detects antibodies reliably but only
from about day 20 after the onset of clinical symptoms. It therefore
cannot be used to detect cases at an early stage before they have a
chance to spread the infection to others. The second test, an
immunofluorescence assay (IFA), detects antibodies reliably as of day
10 of infection, but is a demanding and comparatively slow test that
requires the growth of virus in cell culture. The presently available
PCR molecular test for detection of SARS virus genetic material is
useful in the early stages of infection but produces many false
negatives, meaning that many persons who actually carry the virus may
not be detected--creating a dangerous sense of false security for a
virus that is known to spread easily in close person-to-person contact.
Against this background about the dimensions of the SARS outbreak,
the sections below explain why this disease poses a particularly severe
threat to international health, outline the chronology of events as
SARS spread around the world, and discuss lessons, based on strengths
and weaknesses of the global response, for the immediate future. These
lessons are of great importance. The SARS response is the roll out of a
global alert and response activity under the revision of the
International Health Regulations, which provide the legal framework for
the surveillance and reporting of infectious disease and for the use of
measures to prevent their international spread. This roll out is
showing how the alert and response activity works in practice for a
newly identified disease. It also indicates how the system now in
operation could apply to other highly significant infectious disease
events, including the next influenza pandemic, the next emerging
infection, and the deliberate release of a biological agent in an act
of warfare or terrorism. The scientific community is now contending
with an outbreak caused by a new virus. This creates an extra step in
the containment response: identification and characterization of the
causative agent, which then allows development of a diagnostic test,
treatment protocols, and a scientifically sound basis for recommending
control measures. This is a step that would not be needed should a
biological attack occur using a well-known pathogen such as anthrax or
smallpox. The response to an influenza pandemic would likewise not be
dealing with an entirely new and poorly understood virus.
SARS: a particularly serious threat to international health
Although the last decades of the previous century witnessed the
emergence of several new diseases. SARS needs to be regarded as a
particularly serious threat for several reasons. If the SARS virus
maintains its present pathogenicity and transmissibility, SARS could
become the first severe new disease of the 21st century with global
epidemic potential. As such, its clinical and epidemiological features,
though poorly understood, give cause for particular alarm. With the
notable exception of AIDS, most new diseases that emerged during the
last two decades of the previous century or established endemicity in
new geographical areas have features that limit their capacity to pose
a major threat to international public health. Many (avian influenza,
Nipah virus, Hendra virus, Haanta virus) failed to establish efficient
human-to-human transmission. Others (Escherichia coli 0157:H7, variant
Creutzfeldt-Jakob disease) depend on food as a vehicle of transmission.
Diseases such as West Nile Fever and Rift Valley Fever that have spread
to new geographical areas require a vector as part of the transmission
cycle and are associated with low mortality, often in high-risk groups,
such as the elderly, the immunocompromised, or persons with co-
morbidity. Still others (Neisseria meningitidis W 135, and the Ebola,
Marburg, and Crimean-Congo haemorrhagic fevers) have strong
geographical foci. Although outbreaks of Ebola haemorrhagic fever have
been associated with case-fatality rates in the range of 53% (Uganda)
to 88% (Democratic Republic of the Congo), person-to-person
transmission requires close physical exposure to infected blood and
other bodily fluids. Moreover, patients suffering from this disease
during the period of high infectivity are visibly very ill and too
unwell to travel.
In contrast, SARS is emerging in ways that suggest great potential
for rapid international spread under the favourable conditions created
by a highly mobile, closely interconnected world. Anecdotal data
indicate an incubation period of 2 to 10 days (average 2 to 7 days),
allowing the infectious agent to be transported, unsuspected and
undetected, in a symptomless air traveller from one city in the world
to any other city having an international airport. Person-to-person
transmission through close contact with respiratory secretions has been
demonstrated. The initial symptoms are non-specific and common. The
concentration of cases in previously healthy hospital staff and the
proportion of patients requiring intensive care are particularly
alarming. This ``21st century'' disease could have other consequences
as well. Should SARS continue to spread, the economic consequences--
already estimated at around US $6 billion in business losses in the
initial weeks--could be great in a closely interconnected and
interdependent world.
Chronology of events leading to an unprecedented emergency travel
advisory.
Severe Acute Pulmonary Syndrome (SARS) was first identified in Viet
Nam on 28 February, 2003, when Dr. Carlo Urbani, an epidemiologist from
the Hanoi WHO office examined a patient with a severe form of pneumonia
for which no etiology could be found. Two days later, on 10 March 2003
at least 22 hospital workers in Hanoi French Hospital were ill with a
similar acute respiratory syndrome, and by 11 March similar outbreaks
had been reported among hospital workers in Hong Kong.
SARS occurred at a time of heightened surveillance for atypical
respiratory disease. From 10 February the WHO office in Beijing, which
reinforced its staff with two epidemiologists, had been working with
the government of China to learn more about an outbreak of atypical
respiratory disease that affected health workers, their families and
contacts in Guandong Province, with 305 cases and 5 deaths reported
from 16 November 2002 to 7 February 2003. Around 30% of cases were
reported to occur in health care workers. Surveillance was heightened
further when a 33-year-old man who had travelled with his family to
Fujian Province in China died in Hong Kong on 17 February. The next
day, Hong Kong authorities announced that avian influenza A(H5N1)
virus, the cause of ``bird flu'', had been isolated from both the man
and his nine-year-old hospitalized son. Another member of the family,
an eight-year-old daughter, died while in Fujian and was buried there.
On 12 March, after an assessment of the situation in Asia with WHO
teams in Hanoi, Hong Kong and Beijing, a global alert was issued about
cases of severe atypical pneumonia with unknown etiology that appeared
to place health workers at high risk.
Two days later, on 14 March, WHO received a report from the
government of Canada that health authorities had taken steps to alert
hospital workers, ambulance services, and public health units across
the provinces that there were four cases of atypical pneumonia within a
single family in Toronto that had resulted in 2 deaths. At 02h00 Geneva
time on the following day, 15 March, the government of Singapore
notified WHO, by urgent telecommunication, of a similar illness in a
32-year-old physician who had treated hospital workers with a severe
respiratory syndrome in Singapore, including one from the French Hanoi
hospital who had self-evacuated to Singapore. This Singapore physician
had travelled to the United States for a medical conference, and at the
end of the conference boarded a return flight to Singapore in New York.
Before departure he had indicated to a colleague in Singapore by
telephone that he had symptoms similar to the patients he had treated
in Singapore. The colleague notified health authorities. WHO identified
the airline and flight, and the physician and his accompanying family
members were removed from the flight at a stopover in Frankfurt,
Germany, where he was immediately isolated and placed under hospital
care, as were his two accompanying family members when they developed
fever and respiratory symptoms several days later. As a result of this
prompt action, Germany experienced no further spread linked to the
three imported cases.
Later in the morning of 15 March, with this background and
chronology of events, a decision was made by WHO to increase the level
of the global alert issued on 12 March. The decision was based on five
different but related factors. First, the etiology, and therefore the
potential for continued spread, of this new disease were not yet known.
Second, the outbreaks appeared to pose a great risk to health workers
who managed patients, and to the family members and other close
contacts of patients. Third, many different antibiotics and antivirals
had been tried empirically and did not seem to have an effect. Fourth,
though the numbers were initially small, a significant percentage of
patients (25 of 26 hospital staff in Hanoi, and 24 of 39 hospital staff
in Hong Kong) had rapidly progressed to respiratory failure, requiring
intensive care and causing some deaths in previously healthy persons.
Finally, the disease had moved out of its initial focus in Asia and
appeared to have spread to North America and Europe.
At this time, the epidemiology of SARS was poorly understood. A
virulent strain of influenza had not been ruled out as a possible
cause, even though transmission patterns were not characteristic for
influenza. There was also some hope that the new disease, like many
other new diseases of the recent past, would fail to maintain efficient
person-to-person transmission, or that it might attenuate with passage
and eventually self-contain. Despite the lack of understanding about
the disease, its cause, and future evolution, the need was great to
introduce a series of emergency measures to contain SARS outbreaks in
the affected areas and prevent further international spread, thus
reducing opportunities for the new disease to establish endemicity. WHO
thus decided, on 15 March, to issue a rare emergency travel advisory as
a global alert to international travellers, health care professionals,
and health authorities.
The global alert called for increased attention to patients with
atypical pneumonia who fit the following case definition:
High fever (>38 C)
One or more respiratory symptoms including cough, shortness of
breath, difficulty breathing
AND
One or more of the following:
Close contact with a person who has been diagnosed with SARS
Recent history of travel to areas reporting cases of SARS.
At the same time the global alert recommended no change in patterns
of international travel, but that passengers notify their health
authority if they should develop signs and symptoms as described above
and have a history of travel to areas reporting cases of SARS.
Following this alert, awareness increased immediately, and many
potential new outbreaks were prevented by the prompt isolation and
strict management of suspected cases.
By 27 March, however, it was evident that international spread of
SARS had continued after the 15 March advisory at two of the earliest
outbreak sites, namely Viet Nam and Hong Kong, and that persons on the
same aeroplanes as persons with symptoms consistent with SARS, and
sitting in close proximity to them, had developed signs and symptoms
compatible with SARS. On this date it was decided to recommend new
measures related to international travel, still with the intent of
preventing the international spread of the infectious agent. These
recommendations were that SARS-affected areas, where transmission was
known to be occurring in chains of human-to-human transmission,
institute measures to identify international passengers who had signs,
symptoms and history compatible with SARS, and to recommend that such
persons postpone international travel and seek medical advice. These
recommendations were instituted in most of the affected areas shortly
after 27 March.
However, concern continued to mount. An urgent investigation of the
Amoy Gardens outbreak in Hong Kong began on 29 March, and the following
day, health officials announced that 213 Amoy residents were probable
cases of SARS. This followed an unusual cluster of cases, closely
linked in time and place, among guests and visitors who had stayed on
the same floor of a hotel located in the same district (Kowloon) as
Amoy Gardens. By this same date, 9 business travellers and tourists had
returned to Singapore, Beijing and Taiwan from Hong Kong, either sick
or in the incubation period of SARS.
Outbreaks in the hotel and housing estate indicated that SARS was
showing an unusual pattern of transmission in Hong Kong, probably
involving an environmental component, that would place persons at risk
outside the confined health care settings associated with outbreaks in
most other countries. The 9 cases of probable SARS that occurred in
Singapore, Beijing, and Taiwan, and that were associated with travel in
Hong Kong, indicated that the risk of international spread was
continuing. Consultations were made with WHO teams and travel experts.
On 2 April a recommendation for voluntary postponement of all but
essential travel was issued for travellers considering travel to Hong
Kong. At the same time, because the WHO team and government of China
had confirmed that the 4-month long outbreak in Guangdong continued,
and that cases fit the case definition being applied in Viet Nam and
Hong Kong; and because transmission patterns in Guangdong were not yet
available, these same recommendations were made for Guangdong as
maximum security against spread of SARS outside of Guangdong in the
absence of complete understanding of transmission patterns of the
outbreak there.
Cases of possible transmission in aeroplanes continue to be
reported and investigated. As recently as 5 April, notification of a
SARS patient travelling internationally by sea from Hong Kong to
Vladivostak (Russian Federation) was received, opening a possible
second route of international travel for the virus.
WHO travel recommendations are kept under constant review and will
be amended as more data about the evolution of SARS become available.
Lessons: the value of innovation and international collaboration
The knowledge obtained in the three-week period since 15 March has
been remarkable. It demonstrates the value of international cooperation
on emerging infections and the importance of early detection and rapid
introduction of emergency measures to prevent further international
spread and help ensure that imported cases are not allowed to cause
disease in others.
When WHO began to set up emergency plans on 15 March,
identification of the SARS causative agent and the development of a
diagnostic test were given paramount importance in the overall
containment strategy. Detection of the disease in its early stage,
confirmation of cases, understanding modes of transmission, development
of protocols for targeted treatment, vaccine research and development,
and implementation of disease-specific preventive measures would all
depend upon swift progress and results in etiological and diagnostic
research. Sound public health measures would also require understanding
of the presence and concentration of the pathogen in different tissues
and secretions, and patterns of excretion throughout the course of
illness and convalescence. So long as the aetiological agent remained
unknown, specialists in infectious disease control would be forced to
resort to control tools dating back to the ``Middle Ages'' of
microbiology: isolation and quarantine.
On 17 March, a network of 11 leading laboratories around the world
was set up as a mechanism for expediting identification of the SARS
causative agent. Laboratories were selected on the basis of three
criteria: outstanding scientific expertise, facilities at biosafety
level III, and capacity to contribute to the battery of tests and
experiments that would be needed to fulfill Koch's four postulates for
the identification of an infectious agent as the cause of a specific
disease. The network was set up on the model of the influenza network
and provides another important lesson: models and systems set up for
one health emergency can be rapidly adapted to serve others.
Collaboration is virtual. Members of the network confer in daily
teleconferences coordinated by WHO, and use a secure web site to post
electron microscopic pictures of candidate viruses, sequences of
genetic material for virus identification and characterization,
descriptions of experiments, and results. The well-guarded secret
techniques that give each laboratory its competitive edge have been
immediately and openly shared with others. Laboratories also quickly
exchange various samples from patients and postmortem tissues. These
arrangements have allowed the analysis of samples from the same patient
simultaneously in several laboratories specialized in different
approaches, with the results shared in real time. This collaboration
has resulted in the identification of the suspected causative agent,
and the development of three diagnostic tests, with unprecedented
speed.
Virus isolation continues from patients with SARS, and at the same
time virus has been isolated from tears and faeces. Publications on
these various findings are being prepared by members of this
collaborating group, but the need remains for a highly sensitive and
specific PCR test to diagnose acute infections. Although 20% of the
virus has been sequenced. continued around-the-clock collaboration is
taking place to rapidly complete sequencing.
A similar collaborative group on epidemiology, made up of
investigators from all sites with local transmission of SARS, continues
to confirm person-to-person transmission as the major route of
transmission. Today, the group exchanged information about the Hong
Kong investigations to identify a possible environmental source, which
might prove useful in understanding the unusual new cluster of cases in
Singapore. Key questions include the exact points during the course of
incubation and infection when transmission occurs and whether
asymptotic cases are also capable of spreading SARS. These questions
must be answered to better evaluate the extent of spread of SARS, and
the success of containment activities.
A third clinical group, which unites 80 clinicians from 13
countries having SARS cases, has consistently provided anecdotal
information about the lack of efficacy of treatment with specific
antibiotics and antivirals, and has begun to develop systematic
clinical trials of Ribaviran at two sites. Their discussions have shed
light on features of the disease at presentation, treatment and
progression of the disease, prognostic indicators, and discharge
criteria. No therapy has been shown to demonstrate any particular
effectiveness. The clinicians agreed that a subset of SARS patients,
perhaps 10%, decline, usually around day 7, and need mechanical
assistance to breathe. The care of these people is often complicated by
the presence of other diseases. In this group, mortality is high. Age
over 40 years also appears to be associated with a more severe form of
disease.
Countries have made travel recommendations for their citizens,
using the guidance provided by WHO and other considerations such as
feasibility of medical evacuation of their citizens and their insurance
coverage should they become infected.
On 28 March, at the end of the second week of the global response,
China, a reluctant partner in the global alert and response at the
start, became a full partner in the three working groups that were
studying SARS, and concluded that the outbreaks of SARS elsewhere in
Asia were related to the outbreak in Guangdong Province. The Chinese
government has announced that SARS is being given top priority. A
system of alert and response for all emerging and epidemic-prone
diseases is being developed. Daily electronic reporting of new cases
and deaths, by province, has begun. Equally important, health officials
have begun daily televised press conferences, thus taking the important
step of increasing the awareness of the population and hospital staff
of the characteristic symptoms, the need to seek prompt medical
attention, and the need to manage patients according to the principles
of isolation and strict infection control.
The next weeks and months will tell whether the global alert and
response will contain the current SARS outbreaks, preventing SARS from
becoming yet another endemic infectious disease in human populations,
or whether SARS will remain confined to its origins in nature, to re-
emerge at yet another time and place. It is clear that the
responsibility for containing the emergence of any new infectious
disease showing international spread lies on all countries. In a world
where all national borders are porous when confronted by a microbial
threat, it is in the interest of all populations for countries to share
the information they may have as soon as it is available. In so doing,
they will allow both near and distant countries--all neighbours in our
globalized world--to benefit from the understanding they have gained.
[Whereupon, at 1:43 p.m., the committee was adjourned.]