```

[Senate Hearing 108-44]
[From the U.S. Government Publishing Office]

                                                         S. Hrg. 108-44

                SEVERE ACUTE RESPIRATORY SYNDROME (SARS)

=======================================================================

                                HEARING

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS
                          UNITED STATES SENATE

                      ONE HUNDRED EIGHTH CONGRESS

                             FIRST SESSION

                                   ON

  EXAMINING THE STATUS OF THE SEVERE ACUTE RESPIRATORY SYNDROME THREAT

                               __________

                             APRIL 29, 2003

                               __________

 Printed for the use of the Committee on Health, Education, Labor, and 
                                Pensions

86-856              U.S. GOVERNMENT PRINTING OFFICE
                            WASHINGTON : 2003
____________________________________________________________________________
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          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

                  JUDD GREGG, New Hampshire, Chairman

BILL FRIST, Tennessee                EDWARD M. KENNEDY, Massachusetts
MICHAEL B. ENZI, Wyoming             CHRISTOPHER J. DODD, Connecticut
LAMAR ALEXANDER, Tennessee           TOM HARKIN, Iowa
CHRISTOPHER S. BOND, Missouri        BARBARA A. MIKULSKI, Maryland
MIKE DeWINE, Ohio                    JAMES M. JEFFORDS (I), Vermont
PAT ROBERTS, Kansas                  JEFF BINGAMAN, New Mexico
JEFF SESSIONS, Alabama               PATTY MURRAY, Washington
JOHN ENSIGN, Nevada                  JACK REED, Rhode Island
LINDSEY O. GRAHAM, South Carolina    JOHN EDWARDS, North Carolina
JOHN W. WARNER, Virginia             HILLARY RODHAM CLINTON, New York

                  Sharon R. Soderstrom, Staff Director

      J. Michael Myers, Minority Staff Director and Chief Counsel

                                  (ii)

  

                            C O N T E N T S

                               __________

                               STATEMENTS

                        Tuesday, April 29, 2003

                                                                   Page
Gregg, Hon. Judd, a U.S. Senator from the State of New Hampshire.     1
Gerberding, Julie, M.D., Director, Centers For Disease Control 
  and Prevention.................................................     3
Gully, Paul, M.D., Senior Director General, Population and Public 
  Health Branch, Health Canada; and James Young, M.D., 
  Commissioner of Public Security, Ministry of Public Safety and 
  Security, Government of Ontario, Canada........................    27

                          ADDITIONAL MATERIAL

Statements, articles, publications, letters, etc.:
    Julie L. Gerberding, M.D.....................................    38
    James G. Young, M.D..........................................    41
    Senator Johnson..............................................    49
    Samuel Wallace...............................................    50

                                 (iii)

  

 
                SEVERE ACUTE RESPIRATORY SYNDROME (SARS)

                              ----------                              

                        TUESDAY, APRIL 29, 2003

                                       U.S. Senate,
       Committee on Health, Education, Labor, and Pensions,
                                                    Washington, DC.
    The committee met, pursuant to notice, in Room SD-106, 
Dirksen Senate Office Building, Senator Gregg (chairman of the 
committee) presiding.
    Present: Senators Gregg, Frist, Kennedy, Dodd, Mikulski, 
Murray, and Reed.

                   Opening Statement of Senator Gregg

    The Chairman. Why don't we get started? I will ask the 
press to wrap up.
    This is our second major hearing on the issue of the SARS 
virus and its implications for the United States and our role 
in trying to abate it as much as possible, certainly here in 
the United States but also internationally.
    Senator Kennedy will be joining us in a few minutes, as I 
understand, but we wish to get started because we have a lot of 
important witnesses who are actively involved in the fight, and 
we want to make sure that they are not taken away from it any 
longer than necessary.
    It is important to get out as much public information as we 
can on this issue so that the American public and to the extent 
we have international viewers, they can appreciate the effort 
that is going into trying to identify and contain this virus 
and be sure that their government is doing what is necessary in 
order to accomplish this with the tools that we have available 
to us.
    Unfortunately, it continues to be a rampant problem 
especially in China. There is, as Dr. Gerberding has said 
before, no vaccine and right now no antibiotics which appear to 
be able to be used to limit its impact, and therefore it is 
important that we identify quickly people who may have symptoms 
of SARS, especially those coming into the United States. If we 
identify those individuals, and people self-police themselves 
as they come back from regions which may have high infection 
rates, and if they have the sense that they have cold symptoms, 
they call their medical provider--call them, hopefully, and not 
go to them--and find out what the next step is. So it is 
important that American citizens understand that that is their 
obligation as good citizens to pursue that course of action.
    Today we are going to hear from Dr. Gerberding, who is head 
of CDC and is doing an extraordinary job for us on this issue 
and many other issues. We are also going to hear from Dr. 
Gully, from Health Canada, which is the national health 
organization in Canada, and Dr. Young, who is with the province 
of Ontario and is involved in the fight there.
    I think the issues before us are many--how far down the 
road are we here in the United States in being ready to handle 
this threat. We have been lucky so far. The super-spreader who 
hit Toronto may have easily landed in Boston or New York or Los 
Angeles or even Manchester, NH.
    We have just been fortunate in not having had the problems 
that Canada has had, and the question is now that we have been 
so fortunate, how can we make sure that we take advantage of 
our good fortune and address the problem aggressively.
    Clearly, China still has a huge problem and does not appear 
to have its arms around that problem yet, in my opinion. But 
other nations such as Vietnam and Canada appear to have taken 
different tacks and have been reasonably successful, and we 
look forward to hearing from those nations, Canada 
specifically, today.
    The border with Canada is, of course, the longest 
undefended border in the world, and we are very proud of that, 
but the issue now is do we need to defend ourselves relative to 
the issue of SARS coming across the border, and if so, how do 
we do that, and how do we do it in a constructive way that 
assists not only our Nation and our people but also our 
neighbors in Canada who are such important and good friends to 
us.
    So we look forward to the testimony today. A number of 
other issues have been raised, and we will proceed to address 
those as we move down the road of the hearing, but first, we 
want to hear from Dr. Gerberding and get her thoughts and input 
on how we should be proceeding, specifically where we are and 
how we should be proceeding.
    Before we begin I have a statement from Senator Dodd.
    [The prepared statement of Senator Dodd follows:]

                   Prepared Statement of Senator Dodd

    Mr. Chairman, thank you for convening this second hearing 
on the continued spread of Severe Acute Respiratory Syndrome 
(SARS). This is an important follow-up to our last hearing, 
which took place two weeks ago. Since that time there have been 
several new developments, some positive and some negative, and 
I would like to understand from our witnesses how we should 
interpret these developments. On the positive side, Vietnam has 
been removed from the World Health Organization's (WHO) list of 
countries with local transmissions of SARS. The WHO has also 
reported that the disease appears to have peaked in Canada, 
Hong Kong, and Singapore. And there still have been only a 
limited number of cases, and no deaths, in the United States. 
However, it is not all good news. The number of cases and 
resulting deaths rises everyday in China, and it is still 
unclear whether all cases are being reported.
    With all of our advances in the field of medicine, it is 
always shocking when an illness suddenly appears that we know 
almost nothing about. In this country, we have been very 
fortunate to have conquered so many of the diseases that have 
threatened us in the past, that we may begin to feel almost 
invincible. However, the development of an illness such as SARS 
reminds us that we must remain vigilant to the threat of new 
and emerging diseases. Especially in a world that is now so 
interconnected, it is virtually impossible to stop disease at 
our borders.
    It is always the unknown that is most frightening, Mr. 
Chairman, and unfortunately we know very little about SARS. 
That is why I believe that today's hearing has the potential to 
be quite useful as a forum to address some of the questions and 
conjecture surrounding SARS. As I am sure all of our witnesses 
here today would agree, we are best prepared to deal 
effectively with an emerging threat only when we know exactly 
what it is that we are confronting. Until we know the true 
nature of SARS, we will not be able to effectively form an 
appropriate response. It is my hope that today's hearing will 
signify a step toward better understanding the threat posed by 
SARS and how we might effectively respond to its emergence.
    More than 300 people have already died as a result of SARS, 
and thousands more are infected worldwide. International 
flights have been cancelled, and businesses are recalling their 
employees from overseas. Photographs in the news media show 
ordinary Chinese citizens walking to work wearing surgical 
masks a disturbing image in this uncertain time. All the while, 
there is very little information about the danger that SARS 
presents to our nation. The American public and I include 
myself here is full of questions about how SARS might affect 
us. Is the danger likely to grow? How can I protect myself and 
my family? How do I recognize the disease? What should I do if 
I begin to feel sick?
    These questions may be an overreaction based on a lack of 
information, which is exactly why this hearing is necessary. I 
am hopeful that today's panelists can answer many of these 
questions, and I thank them for taking the time to be here 
today on such short notice.
    Mr. Chairman, I would again like to thank you for convening 
today's timely hearing. As legislators we have the 
responsibility to help the American public better understand 
emerging threats and the possible impact of these threats on 
their health and well being. We also have the responsibility to 
provide oversight of the development of an effective Federal 
response to the same threats. It is my hope that today's 
session will allow us to do both. I look forward to hearing 
from our witnesses this afternoon.
    The Chairman. Dr. Gerberding?

   STATEMENT OF DR. JULIE GERBERDING, DIRECTOR, CENTERS FOR 
 DISEASE CONTROL AND PREVENTION, U.S. DEPARTMENT OF HEALTH AND 
                         HUMAN SERVICES

    Dr. Gerberding. Chairman Gregg, I appreciate so much the 
opportunity to be here to do this and the interest and 
leadership that you and your committee have shown in this very 
challenging epidemic that we are dealing with.
    We are striving very hard at CDC to maintain transparency 
about the status of the epidemic and the steps that we are 
taking to combat it, and this is really an important 
opportunity for us to update you and get your input but also to 
make this visible to all the people in the country who are 
interested and have a stake in how it is going. So I would just 
really thank you.
    I also thank Health Canada and my colleagues who have been 
working side-by-side with us as we have come to develop 
international strategies for managing SARS and also my 
colleagues from Ontario who are here today to testify as well.
    The concept of collaboration is a word that we use often, 
but I think the spirit and the actualization of this particular 
outbreak response is exemplary of what true international 
collaboration can be; it also illustrates the consequences when 
that kind of international collaboration fails.
    What I thought I would do is give you a brief update on the 
status of the SARS epidemic and then discuss for you the 
current approach that we are taking in the United States as 
well as what some of our long-term strategies may be as we 
begin to transition from the beginning of this problem to the 
ongoing concerns that we need to look forward to and anticipate 
in the future.
    If I can have the first graphic--this is an international 
map. You have seen this kind of information before, but it 
emphasizes the widespread distribution of SARS on a global 
basis. Today WHO is reporting 5,050 cases in 28 countries, and 
321 deaths have been reported. That gives a crude mortality 
rate of about 6.3 percent internationally, but of course that 
mortality rate is very variable from one country to another, 
and it may in fact go up as the time lag between when cases are 
detected and people either recover or die from illness and the 
statistics catch up with the events internationally.
    From a domestic perspective, today we are reporting 220 
suspected cases. These are people who have traveled or who have 
had direct contact with SARS patients and who are ill but do 
not have the full-blown pneumonia. We are also reporting 52 
probably cases. These are individuals who do have the 
pneumonia. And today, shortly following this briefing, CDC will 
be releasing a dispatch from our Morbidity and Mortality Weekly 
Report that will provide for the first time for the U.S. case 
definitions that include laboratory criteria of infection. So 
we are adding to the concept of clinical status of the 
patients, which would be mild illness, moderate illness for 
suspect case definitions and then SARS, the severe illness with 
pneumonia, another dimension which is laboratory-confirmed, 
meaning one of the three testing criteria for laboratory 
results has been positive or laboratory-negative, meaning those 
tests are negative, and then finally, laboratory-indeterminate, 
either because we have not done the test or the test results 
are pending.
    This will add a degree of precision, although at the 
current time, the status of our test is not accurate enough, or 
at least we do not know the accuracy of the test at this point 
to indicate that if someone has a negative test, they do not 
have SARS. We have more to learn about the interpretation. So 
we are putting this out as an additional tool for classifying 
individuals with the suspicion of SARS, but we are continuing 
to cast a very broad net for our isolation precautions because 
we do not want to overlook any potential infectious people who 
could serve as a vector of transmission to others. So we would 
be happy to make that dispatch available to you when it is 
published and disseminated later today.
    We have a current strategy in the United States that 
emphasizes several key components. First and foremost is, 
again, international collaboration, and we are extremely 
fortunate and grateful for the efforts that WHO has made to 
coordinate the overall global response to SARS. Their 
leadership in the investigation as well as the laboratory 
coordination is unprecedented and I think certainly accounts 
for why we were able to learn so much so quickly once the WHO 
alerted the international community to the evolving SARS 
problem.
    But domestically, our first priority is protecting 
travelers, since travelers are the individuals who seem to be 
at greatest risk of SARS right now on the international scale, 
and our protection of travelers consists of information for 
outbound travelers as well as information for inbound 
travelers.
    Outbound travelers are continuing to receive information in 
the form of health alerts, travel alerts, which basically say 
be aware that there is SARS in the country that you are 
planning to visit, do not go to places where SARS is being 
transmitted, and use common sense precautions to protect 
yourself.
    A higher level of precaution is a travel advisory, which 
says there is concern for travelers acquiring this infection in 
the country, and it is important that you not go there unless 
you have absolute reason to be there--in other words, 
nonessential travel to an area should be avoided.
    Right now, mainland China, Hong Kong, Taiwan, and Singapore 
are countries in which we have travel advisories. We had a 
travel advisory in Vietnam as well, but it turns out that they 
have been able to successfully contain the epidemic there, 
there is not evidence of ongoing risk to travelers, so in the 
last 24 hours, we as well as WHO took Vietnam off the list of 
countries where nonessential travel should be avoided.
    Our efforts on behalf of travelers include the mechanisms 
for captains on airliners and other vessels to have the 
requirement of reporting an ill passenger to a Customs official 
as the flight is inbound and then, for CDC, quarantine 
investigators or other Customs officials to intervene, board 
the plane or the boat, and evaluate whether the ill passenger 
is suspicious for SARS and could be posing a risk to other 
passengers.
    Finally, of course, is the ongoing distribution of these 
health alerts. This is one that has been updated since my last 
hearing here, and I can assure you that it is now in Spanish 
and French as well as several other languages, and we are 
making these health alerts available to airplane and vessel 
passengers. In addition, these are being distributed at the 13 
land crossings between Ontario and the United States, where we 
have approximately 5 million travelers cross the Ontario-U.S. 
border every month. So we have had enormous collaboration and 
cooperation with the Canadian Government, with Health Canada, 
and with the Ontario health officials. We have also benefited 
from the interaction with the Department of Homeland Security 
and the Customs inspectors, who have been totally supportive of 
this major step up in our alerting process.
    So international collaboration, protecting travelers, and 
the third component of our current strategy is to detect cases 
of SARS and isolate them as quickly as possible. And the public 
health community and the clinician community in this country 
have done an absolutely outstanding job of early detection but 
also of implementing the kinds of airborne and other 
precautions in the health care setting that will protect our 
health care workers.
    Our observation so far has been that in the countries where 
SARS has really evolved into the community, the weakest link in 
the chain is the health care system and the spread to health 
care personnel. So we are putting huge effort into making sure 
that we have the best possible protection in the health care 
environment from the moment the suspected patient has the 
initial contact with anyone in the system.
    Isolation in our country for SARS cases has been almost 
entirely voluntary. This is a typical pattern of maintaining 
and managing infectious diseases in hospitals, but we also have 
in our State and local health officials the authority to 
require a patient with SARS to be isolated should that ever be 
necessary.
    Finally, the fourth important component of our strategy is 
to protect the contacts of SARS patients. That includes in this 
country a series of efforts. No. 1 is to identify the contacts, 
and our health officials have done a great job of looking for 
potentially-exposed people; second, putting those people in an 
active monitoring program where they are contacted on a regular 
basis to make sure they are not identified as having early 
signs or symptoms of SARS; and then, if the do develop 
anything, to alert the health care delivery system before they 
get there so that those infection control precautions can be in 
place.
    One other important issue here for us is the fact that I 
mentioned early on, that we are working extremely hard to be as 
transparent about what is going on and are putting a strong 
effort into communication. I wanted to give you some impression 
of how active our communication system at CDC has really been.
    We have triaged almost 5,000 press calls. Our hotline has 
answered over 22,000 calls for information from the public and 
about 2,300 emails. We have sent updates about the clinical 
information to the 25,000 clinicians who have signed up for the 
CDC clinician registry, and 67 clinical professional 
organizations are taking our information and redistributing it 
to their memberships, so we are reaching hundreds of thousands 
of clinicians around the country.
    Our website has been accessed by more than 6 million people 
on SARS so far, and we have done a satellite broadcast 
internationally in conjunction with WHO and clinicians in Asia 
that reached more than 40,000 clinicians around the world.
    We have sent 16 health alerts. We are now conducting 
telebriefings with people in the Asian American community 
because we recognize the ongoing concern about fear and 
discrimination that they are having to deal with.
    And last, our website increasingly has more and more 
information that is translated into other languages so the 
international community can benefit from the information.
    This is not an exhaustive list, but I think it helps to 
illustrate that we are making every effort to get information 
out in all the ways that we have at our disposal to do that, 
and we are always open to input or suggestions about how we can 
do that better.
    A couple of quick points on the success of that effort--we 
have been working with collaborators at Harvard and getting 
some information about how the public is really perceiving 
SARS, and some preliminary information from this suggests that 
about 93 percent of the public know about SARS or have heard of 
it, and that is a good thing. It would be hard to miss it, but 
occasionally people do not pay attention.
    Eighty-nine percent of people said that if they became ill 
with a flu-like illness, it would be very important to tell 
their clinicians about recent travel. That is so important to 
us to know that that message is getting through to the average 
person in the community.
    Ninety-four percent said that if they had SARS, they would 
agree to be isolated, and about 92 percent said that if they 
were exposed to someone with SARS and were asked to have 
voluntary quarantine, they would agree to voluntary quarantine 
for a period of 10 days.
    So our public is informed, they are willing to cooperate 
with public health measures, and I think that is a good thing, 
because right now, all the steps that I have described to you 
are primarily a public health strategy which is a tried and 
true old-fashioned way of dealing with an epidemic; but until 
we have a vaccine or we have antiviral treatment, this is the 
best we can do right now, and we will make every use of these 
tools, and if the problem evolves in this country, we are 
prepared to take additional steps to focus on containment.
    We are looking at containment as the primary goal. People 
often ask what is the worst-case scenario. The worst-case 
scenario is ongoing spread such as we anticipate with influenza 
sometime in the future, and we do have a preparedness plan for 
pandemic flu, and we are adopting that plan so that we can be 
prepared for coronavirus or SARS if it did evolve in that 
direction.
    I think the best-case scenario is that the containment 
efforts will uniformly be successful, and this will all go 
away. Increasingly, that seems highly unlikely, as you 
mentioned, given the situation in China and other countries 
where there is ongoing transmission.
    Finally, the most likely scenario, at least as it look from 
our vantage point right now, is that we will have to work hard 
at containment, but I think we have proven that containment can 
be successful in getting a handle on the problem, and we hope 
that this will prove to be a seasonal virus and we can buy some 
time if the weather changes and transmission decreases--but of 
course we cannot count on that, so we need to be prepared to 
continue this effort until, again, we have the other tools.
    I would just make reference to the Institute of Medicine's 
recent report within the last few weeks on ``The Microbial 
Threats to Health,'' which makes the major statement that these 
emerging infectious disease problems are now part of our life 
in the global community, and that the kinds of things we are 
doing for SARS we can anticipate we are going to do again and 
again as our universe becomes smaller in time and geography, 
and we need to learn lessons from SARS and apply them more 
broadly for future preparedness.
    The last point along those lines is the two CDC strategic 
plans for ``Protecting the Nation's Health in an Era of 
Globalization'' and ``Preventing Emerging Infectious 
Diseases,'' which speak to many of the issues that have served 
us well in the current situation.
    So I again just thank you so much for your support and 
leadership and for holding this hearing so that we can provide 
this perspective.
    [The prepared statement of Dr. Gerberding may be found in 
additional material.]
    The Chairman. Thank you, Dr. Gerberding.
    Those numbers which you cited, the polling numbers that 
have been done at Harvard relative to people's receptivity to 
being quarantined, to making sure they contact their provider 
if there is some sort of flu situation, are extraordinarily 
encouraging, and I think they reflect the great work that you 
folks are doing at CDC in this transparency effort of getting 
the message out, making sure people understand what we know and 
how we know it and what we need to do from here. So I 
congratulate you on that.
    In that arena, however, you mentioned that you do not see 
us containing it, essentially, in China, and as a result it is 
continuing to grow as a problem. I am wondering if you can go 
into that a little bit more. I notice that the Philippines now 
has the issue, as well as Taiwan, China, and Hong Kong, 
obviously. What do you see as the game plan for dealing with 
those nations which were behind the curve and as a result 
generated the problem to a large degree? Do you think they can 
get a handle on this? Can they get their arms around it the way 
Vietnam and Canada have, or can they not?
    Dr. Gerberding. I do not know for sure. We are increasingly 
confident that the information that we are getting from China 
is reliable. We do not have teams in all areas of the country 
yet, but the doors are certainly more open now than they were 
in the past several months.
    As part of the WHO effort, we have CDC people on the 
ground, and we are getting information. The best picture of the 
SARS epidemic in China right now would be characterized as 
``variable.'' There are some regions like Beijing that are 
having an extremely difficult time containing this, and other 
cities where the problem does not seem to be widespread or 
present at all. Obviously, that could change. There is a lot of 
travel within China, so they would need to be able to exercise 
the same kind of containment procedures that we are using in 
other parts of the world.
    I wish I had a crystal ball; I would try to project the 
situation there. But I think there is very little suggestion 
right now that it is going to go away any time soon in China. 
The Hong Kong scenario is suggestive that they are making 
strong progress in containment, but there are still 
occasionally new cases being reported there. But we did see a 
remarkable curtailment of transmission in Vietnam even though 
it started there with a very serious outbreak in the hospital. 
That situation, with fairly reliable data, seems to be coming 
under control, and likewise in Thailand, where there was not 
ongoing transmission.
    It is very variable. You made reference to super-spreaders 
or hyper-transmitters, and that is a term that is useful in 
describing clusters of patients and why someone is especially 
associated with a large number of exposed and infected people. 
We do not really know if there is such a thing. It may be that 
people who are ill are infectious because they have a lot of 
virus, and when you take a combination of someone who is 
infectious and a situation where there is inadequate protection 
of the contacts, you end up with that cascade or a cluster that 
sets off the chain of transmission. So we have a lot to learn 
about why some people are transmitting and others are not and 
why some people have severe illness and others do not.
    The Chairman. How far away are we from being able to 
produce a reliable test, that is, you can deliver in a timely 
manner that gives you a pretty good reading as to whether or 
not a person just has the flu or whether he or she has have 
SARS? And isn't that critical to our capacity to contain it?
    Dr. Gerberding. We are certainly at CDC putting a high 
emphasis on that diagnostic testing. By the end of this week, 
we are sending the first kits out to the State labs that have 
the tests. We have two main categories of PCR tests which can 
identify virus RNA in the respiratory tract or the blood of 
some patients. We also have the antibody test which is 
performing as a much better test for discriminating SARS from 
other patients. Unfortunately, we cannot interpret it until 21 
days after the person has become ill.
    These tests are still under evaluation, but FDA is working 
side-by-side with us to get them into a status where we can use 
them for clinical care, and that is an imminent step that we 
will be taking very soon.
    We also have, as you know, posted the RNA genome on the 
website, and I have documentation from numerous private sector 
companies and biomedical or biotech companies who are 
interested in working on diagnostic vaccines. So we are taking 
the steps necessary to make the information and materials 
available to the private sector so they can contribute to this 
effort, and that, in the context of an international community 
that is doing the same thing, putting our collaborators in 
Canada. I think we are very close to a reliable diagnostic 
test--weeks, not months or years--unlike the vaccine or the 
treatment which is a long way away.
    The Chairman. If you could just confirm again that we 
believe this was not manmade and that it came from animals to 
humans, that would be good; and second, to what extent are we 
seeing the disease mutated or do we expect to see it mutate so 
that even those diagnostics might become less than effective?
    Dr. Gerberding. The virus itself is a single piece of RNA. 
It is a single-stranded virus. It is actually probably the 
largest RNA virus that we deal with in humans. And it is in a 
family, the coronavirus family, that is notorious for 
recombination, meaning exchange of pieces of the virus with 
cousins, as well as making mistakes as it replicates.
    We are so early in this epidemic that we have not 
documented any association between changes in the virus and the 
pattern of transmission or the severity of illness, but it 
would not be surprising for this to occur with this particular 
kind of virus, and that is something that we have to be 
monitoring because it could very well at least interfere with 
the PCR test and potentially with the antibody test as well.
    So it is a concern. It will also have implications for 
vaccine treatment. But we have not identified that as a problem 
yet.
    The Chairman. And we still do not feel that it was manmade; 
we feel that it was transferred from an animal to humans?
    Dr. Gerberding. The pattern and onset as we understand it 
in China is really most consistent with a naturally-evolving 
coronavirus. I do not have any evidence to suggest anything 
intentional at all
    The Chairman. And finally, the two prominent leaders on 
this issue in Canada have joined us today, and I would be 
interested in CDC's evaluation of where Canada stands and what 
we can learn from Canada.
    Dr. Gerberding. I look forward to being updated from our 
nearest neighbors, but from our interaction--and we do have a 
CDC employee at Health Canada, and Health Canada has a staff 
member in our operations center at CDC, and we also have a team 
in Ontario working in the health care system, so I think our 
information is reliable--we understand that we need to be 
cautiously optimistic about Canada. They have not had a new 
case in I think 7 days, and there is not evidence of ongoing 
community transmission there. That is why they are not on our 
list of travel advisories. But we are doing the alerting at the 
borders and for outbound passengers and if we are continuing in 
this in trajectory, I think we will work very hard with our 
collaborators in Canada to make sure the rest of the 
international community appreciates that the disease is 
contained there, at least right now.
    The Chairman. So the Red Sox can go there and beat up on 
the Blue Jays.
    Dr. Gerberding. I am not going to get into sports issues.
    The Chairman. Senator Kennedy?
    Senator Kennedy. Thank you very much, Mr. Chairman, and I 
thank you for holding this hearing again. It is enormously 
important.
    And I want to thank Dr. Gerberding and all those at the 
CDC. I think it is important that Americans understand what a 
center of excellence the Centers for Disease Control is and how 
well it is being led. We are enormously appreciate of your 
leadership, Dr. Gerberding.
    It has been 3 weeks since you last testified. The disease 
has spread to 27 countries, affected every continent, claimed 
200 more lives, and sickened 2,000 more patients.
    Although SARS remains a global threat, it has provoked an 
extraordinary global response. Health agencies around the world 
have responded forcefully to SARS. Scientists have labored day 
and night with extraordinary results. They have deciphered the 
complete DNA sequence of the virus. They are developing 
sensitive new tests to spot infection and are testing ways to 
cure the disease and develop the diagnostic test that Senator 
Gregg referred to. Public health agencies have responded 
effectively to prevent local outbreaks from becoming national 
epidemics.
    As has been pointed out, SARS is on the decline in Canada, 
Singapore, and Hong Kong. In Vietnam, the wildfire of SARS has 
been extinguished. Just one hour ago, the World Health 
Organization announced that it is lifting its advisory against 
travel to Toronto. The world owes an enormous debt to the 
dedicated health professionals who have worked tirelessly to 
protect our health from the threat of SARS.
    From Boston to Los Angeles and Seattle to Miami, the story 
is the same. Budgets have been cut to the bone, and there is no 
excess capacity to meet new challenges like SARS. According to 
Dr. Kevin Stevens, the director of the New Orleans Public 
Health Department, ``We have very few resources, and if we 
should have a SARS outbreak, we are very poorly prepared.''
    Dr. Laurene Mascola of Los Angeles County Department of 
Health Services said that, ``In California, about 2,000 people 
die every month from unexplained pneumonia. We have dealt with 
SARS to the detriment of other diseases.''
    One of the most effective ways to fight the spread of SARS 
is quarantine, yet many of the Nation's major health 
departments would be hard-pressed to use even this basic tool 
of disease containment. In Philadelphia, for example, there is 
no city-owned hospital, and the health department has no funds 
to set up a quarantine facility of its own. It would instead 
have to rely on hard-pressed independent hospitals to house 
SARS patients who need to be isolated.
    Seattle has only limited facilities to isolate contagious 
patients. That city is already facing the highest number of TB 
cases it has seen in 30 years. With only two full-time 
infectious disease physicians to serve over a million 
inhabitants, the city would soon be overwhelmed by a major 
epidemic.
    In Boston, the health department is already stretched thin, 
answering over 200 calls a day from people worried about SARS--
and there are no confirmed cases in the city.
    In cities across America, there are gaps in our ability to 
contain a SARS outbreak should one occur, and we need to 
address the deficiencies, and we must address them now. 
Congress has tried to reduce these deficiencies in recent 
years, investing more in our defenses against bioterrorism, and 
these investments are clearly paying dividends now in the fight 
against SARS. But their effectiveness has been undermined by 
cuts in funding for hospitals and health agencies at both the 
Federal and the State levels.
    A survey by the American Public Health Laboratory 
Association found that 30 State health laboratories faced 
budget cuts this year--only seven expected their budgets to 
remain the same, and none expected more funds.
    Our State laboratory in Massachusetts estimates that it 
will need hundreds of thousands more dollars to test tissue 
samples for SARS. With additional funds, they could determine 
whether patients truly have SARS or a sniffle in a fraction of 
the time it takes now; the quicker the decision, the more 
likely we are to keep an outbreak from spreading.
    This is the situation across the country. I have had my 
staff call the major cities in the country and the ports of 
entry, and I have just given you a taste of what is happening 
out there.
    We have had extraordinary success under your leadership of 
CDC. We know the devastating impact that something like this 
can have, let alone if it were a bioterrorism threat.
    What do we say to the people in the local communities about 
what kind of help and assistance they are going to receive in 
terms of trying to deal with this kind of challenge locally? 
What kind of hope can we give them?
    Dr. Gerberding. First of all, let me just say that I am 
aware of the difficulties that State and local health agencies 
are having in this arena and others. As I try to say publicly 
as often as possible, our public health system is suffering 
from decades of neglect, and we cannot fix it with the one-shot 
bolus of resources or even a sustained investment at the level 
that we are making in terrorism without really thoughtfully 
planning and focusing and prioritizing the capabilities to 
respond to these new threats.
    We are very grateful for your leadership and Chairman 
Gregg's leadership, Senator Frist's leadership, and that of the 
full committee, for your support of the improvements in public 
health and public health infrastructure, and we have made 
progress. I really would like to emphasize that we are 
responding as well, I think, to SARS as we are because those 
investments are paying off. But there is a lot more work to do, 
and the appropriation that Congress made, the $16 million that 
was included in the supplemental budget, we obviously need to 
make sure that some of that resource goes to the States to help 
out with the additional burden that this is placing, and we are 
taking a lot of steps now to make sure that we can understand 
and document the true needs as well as the true economic impact 
of what they are trying to do.
    It is a moving target right now, and it is difficult to 
predict what they will need, but we need to take it seriously.
    Senator Kennedy. I appreciate that, and it is not entirely 
fair to ask you about the resources that ought to be necessary, 
but having gone through the SARS period and having seen what 
good preventive work means in terms of getting a handle on 
this, we know that there is still a lot of danger out there. 
But the progress that has been made is enormously important, 
and people should understand that. But we also want to try to 
make sure that we are going to benefit from this kind of 
experience if we are going to be facing other kinds of threats, 
whether it is dealing with smallpox, which is the 
administration's program--we have been able to work out the 
program now; that is costly in terms of implementation--plus 
the potential danger from bioterrorism.
    So this is an enormously important area of need, and at the 
same time, we are facing the further cuts in terms of 
hospitals--about $1.4 billion--at a time when we are returning 
about $450 million that could help and assist them. We are 
trying to prepare them for a surge capacity at a time when the 
roofs are leaking.
    I think we have got to try to make the investments that are 
necessary in terms of protecting our people at the local and 
community level. We see what a difference it makes when it is 
done that way and when we have had strong leadership.
    We thank you very much for all that you have done and all 
that you continue to do.
    My time is up, Mr. Chairman.
    [The prepared statement of Senator Kennedy follows:]

                 Prepared Statement of Senator Kennedy

    I welcome this followup hearing on SARS. And I commend Dr. 
Gerberding and the men and women of the Centers for Disease 
Control for their impressive efforts in addressing this deadly 
virus. We are all enormously grateful for your leadership and 
for the difference you have made in America, and across the 
globe.
    In the three weeks since Dr. Gerberding last testified, the 
disease has spread to 27 countries, affected every continent, 
claimed two hundred more lives, and sickened 2,000 more 
patients.
    Although SARS remains a global threat, it has provoked an 
impressive global response. Health agencies around the world 
have responded forcefully to SARS. Scientists have labored 
day--and night--with extraordinary results. They have 
deciphered the complete DNA sequence of the virus thought to 
cause SARS. They are developing sensitive new tests to spot 
infection and are testing ways to cure the disease.
    Public health agencies have responded effectively to 
prevent local outbreaks from becoming national epidemics. As a 
result, SARS is on the decline in Canada, Singapore and Hong 
Kong. In Vietnam, the wildfire of SARS has been extinguished. 
Just one hour ago, the World Health Organization announced that 
it is lifting its advisory against travel to Toronto. The world 
owes an enormous debt to the dedicated health professionals who 
have worked tirelessly to protect our health from the threat of 
SARS.
    The danger is not over, however. In China, the SARS 
outbreak has intensified, and we must remain on guard in this 
country to respond swiftly and effectively to any SARS 
outbreak.
    And this crisis exposes anew the limited capacity of our 
own public health network. A brief survey of our nation's major 
ports and air hubs conducted by my staff this week shows that 
if CDC had not been able to contain the SARS outbreak in 
America, our local public health agencies lack the resources to 
protect the public from SARS and continue to safeguard 
Americans from other deadly diseases.
    The troops in this new war on disease are doctors and 
nurses, and the front lines are hospitals and health agencies. 
But unlike our military forces; those who fight battles against 
disease are often not given the latest and best equipment. 
Instead, they must do the best they can with outdated equipment 
and too few personnel.
    From Boston to Los Angeles, and from Seattle to Miami, the 
story is the same. Budgets have been cut to the bone, and there 
is no excess capacity to meet new challenges like SARS. 
According to Dr. Kevin Stevens, the Director of the New Orleans 
Public Health Department, ``We have very few resources and if 
we should have a SARS outbreak, we are very poorly prepared.'' 
Dr. Laurene Mascola of the Los Angeles County Department of 
Health Services said that ``In California, about 2000 people 
die each month from unexplained pneumonia. We have dealt with 
SARS to the detriment of other diseases''.
    One of the most effective ways to fight the spread of SARS 
is quarantine--yet many of the nation's major health 
departments would be hard-pressed to use even this basic tool 
of disease containment. In Philadelphia, for example, there is 
no city-owned hospital and the health department has no funds 
to set up a quarantine facility of its own It would instead 
have to rely on hard-pressed independent hospitals to house 
SARS patients who need to be isolated.
    Seattle has only limited facilities to isolate contagious 
patients--and that city is already facing the highest number of 
TB cases it has seen in 30 years. With only two full-time 
infectious disease physicians to serve over a million 
inhabitants, the city would soon be overwhelmed by a major 
epidemic. In Boston, the health department is already stretched 
thin answering over 200 calls a day from people worried about 
SARS--and there are no confirmed cases in the city.
    In cities across America, there are gaps in our ability to 
contain a SARS outbreak should one occur. We need to address 
the deficiencies--and we must address them now.
    Congress has tried to reduce these deficiencies in recent 
years by investing more in our defenses against bioterrorism. 
These investments are clearly paying dividends now in the fight 
against SARS--but their effectiveness has been undermined by 
cuts in funding for hospitals and health agencies at both the 
federal and the state level.
    A survey by the American Public Health Laboratory 
Association found that 30 state health laboratories faced 
budget cuts this year--only 7 expected their budgets to remain 
the same, and none expected more funds.
    These cutbacks come at a time when these state and local 
health agencies are being asked to do more and more to protect 
us against SARS and other diseases. Our state laboratory in 
Massachusetts estimates that it will need hundreds of thousands 
more dollars this year toy test tissue samples for SARS. With 
additional funds; they could determine whether patients truly 
have SARS or a sniffle in a fraction of the time it takes now. 
The quicker the decision, the more likely we are to keep an 
outbreak from spreading.
    Even before now, health agencies and hospitals were already 
reeling under the burden of implementing the nation's smallpox 
inoculation plan. There is no reserve fund for health agencies 
to dip into when they respond to a crisis. To meet new 
responsibilities in one area, they must cut back in others.
    53 percent of local public health agencies say smallpox and 
bioterrorism planning are taking away from other public health 
services. It's not easy to worry--about smallpox and have to 
worry about SARS too.
    The picture is no brighter for hospitals. Although they 
have received $500 million for bioterrorism preparedness this 
year, these funds are dwarfed by cuts in other areas. Graduate 
medical education lost $750 million. Medicaid was slashed by 
$1.3 billion. Recommended increases that were not funded took 
$420 million from hospitals. The result--even with additional 
funds from bioterrorism grants--is that hospitals lost $1.9 
billion last year. And worse is vet to come this year.
    We all have to hope that the SARS epidemic does not make us 
pay too high a price for our failure to equip our hospitals and 
health agencies adequately when we send them into battle.
    That's why everyday--counts now. Dr. Gerberding is a 
familiar and welcome presence in the committee, and we look 
forward to her testimony and her recommendations for action.
    We also welcome Dr. Young and Dr. Gully who will discuss 
the response by Canada to the SARS outbreak in Toronto. The 
World Health Organization this week announced that the worst of 
the outbreak is now over in Canada, and I commend you both for 
your success in dealing with this deadly epidemic.
    Thank you for joining us today and we welcome your 
testimony.
    The Chairman. Thank you, Senator Kennedy.
    We are going to limit the first round to 5 minutes; both 
Senator Kennedy and I took about 5 minutes.
    Senator Reed, did you want to ask some questions?
    Senator Reed. Yes. Thank you, Mr. Chairman, and thank you, 
Dr. Gerberding, for your testimony today and your leadership at 
the CDC.
    Basically, our strategy today is containment, and I think 
consistent with that is monitoring. Could you elaborate on the 
procedures you are taking to monitor particularly outside the 
United States to get an advance notice of potential 
developments?
    Dr. Gerberding. When I mentioned monitoring earlier, I was 
speaking about the monitoring of exposed people within this 
country, and we have asked the State and local health officers 
to implement systems whereby they can contact people who have 
been exposed to SARS patients in the last 10 days and check in 
with them to make sure that they are not developing the early 
systems and helping to triage them to health care if they are.
    Internationally, monitoring is more along the lines of 
surveillance for cases that are occurring there, but we are 
totally supportive of the WHO recommendations that passengers 
be screened for illness at the time of departure so that there 
is not exposure en route. And we are also, of course, 
continuing the ongoing effort to alert returning passengers of 
the need to get medical care if they develop symptoms within 10 
days after their departure from a country where this is 
ongoing.
    Senator Reed. But you do not have a more comprehensive 
surveillance plan, for example--these are just airline 
passengers that you are talking about. What about people 
leaving via ship or moving over land to different countries and 
returning?
    Dr. Gerberding. The health alerting mechanism for returning 
passengers applies to the airline industry, it applies to the 
vessels that come either directly or indirectly to the United 
States, and in Canada, at the Ontario border, it also applies 
to car passengers.
    For direct flights coming into the United States, we have 
very close to 100 percent contact. For indirect flights--for 
example, if a passenger leaves China and goes to another 
country before returning to the United States--we are getting 
close to 98 percent, but we do occasionally miss flights in 
that domain.
    Senator Reed. So I presume, then, you feel that the 
surveillance system in place is adequate to give you fair 
warning as this disease continues in China, certainly?
    Dr. Gerberding. I think the alerting of incoming passengers 
is going very well, and it is working. We know that people are 
responding to this information and getting medical care.
    A broader issue is our capacity to detect these problems 
when they start. And the first cases of SARS were in China in 
November. We got a WHO alert on March 12. That is 5 months down 
the road. That is the kind of system that we need to address in 
collaboration with WHO as well as the ministers of health in 
the global community. That is not acceptable, and this problem 
got started because we did not have an early detection system 
to tell us what it was.
    Senator Reed. And do you have a plan to not only design 
such a system, but to request whatever funding we must make 
available for such a system?
    Dr. Gerberding. We do have a plan for the system, and I 
have to talk with you about the funding and support for it. 
Some of the terrorism dollars from the appropriation have gone 
into a program to create a better sentinel detection system 
internationally. But I think we have a lot of work to do before 
we really have a seamless system that we can rely on fast 
enough and early enough to tell us that there is a new threat.
    A related problem that I specifically struggle with at CDC 
is that we cannot get specimens to the United States. We were 
aware that there was a mysterious pneumonia brewing in China 
and in Asia. We got our first specimen I think on March 13, 
which was one from an American citizen in a hospital in Hanoi--
but it took us a really long time to get all of the patients' 
specimens that we needed to begin to work on this virus because 
the airlines were afraid to fly the specimens to the U.S. We 
have no independent authority to go and get specimens, and that 
is really a factor that has slowed us down in these 
international response efforts time and time again. It happened 
here with SARS. It happened with anthrax where we had anthrax 
specimens in Chile, and we could not get them to the United 
States, even though Department of State and DOD and everybody 
were trying desperately to help us.
    So that is another component of the early warning system 
that we need to resolve.
    Senator Reed. And that would require legislative remedy 
that this committee should consider?
    Dr. Gerberding. I am not sure. We have authorization as I 
understand it to lease aircraft at CDC; that is how we managed 
the stockpile plane. But there may be additional authorities 
that are necessary, and I will certainly be happy to get back 
to you with that specific information.
    Senator Reed. Thank you.
    Let me change the subject slightly. From your comments, it 
seems that this might be the face of things to come, that with 
globalization and with these inadequacies in at least 
surveillance and early alert, we could see other viruses 
following this. And as the chairman pointed out, this virus 
appears to be mutating, which is the stock of all the science 
fiction thrillers--the mutating virus that is detected too 
late.
    Does this give you concern, that we might see a series of 
different viruses or illnesses sweeping across the country?
    Dr. Gerberding. I do not want to be alarmist, but I think 
history is already teaching us that that is the case. We have 
seen the emergence of Nipa virus, we have seen Hanta virus, now 
we see the SARS virus; we had the avian flu virus that 
fortunately did not spread easily from person to person, so we 
were able to attenuate that particular problem. But there is no 
guarantee that the next flu strain to emerge is not going to be 
as transmissible or more transmissible than SARS.
    That is really the message of the Institute of Medicine, 
that these kinds of emerging infectious diseases are a part of 
our life, and we need to scale up and respond to this 
proactively, because we are not going to be able to stop their 
emergence.
    Senator Reed. So deterrence is not working; we have got to 
go into preemptive mode?
    Dr. Gerberding. I think so.
    Senator Reed. Thank you.
    Thank you, Mr. Chairman.
    The Chairman. Senator Mikulski?
    Senator Mikulski. Mr. Chairman, I note that the Majority 
Leader has arrived, and as a Senatorial courtesy, I would defer 
to him.
    The Chairman. If you want to proceed, he said he would 
rather hear from you first.
    Senator Mikulski. Thank you very much, Mr. Chairman, for 
organizing this hearing, and thank you, Dr. Gerberding and all 
the people at CDC who have been working so steadfast and 
persistently on this.
    SARS is a global menace and a local threat. Germs just do 
not know borders. There are three possible cases in my own 
State of Maryland, and Marylanders want me to ask what is the 
Government doing to contain SARS, to find a cure for SARS, and 
also to prevent it from spreading. We also need to be talking 
about a communication strategy about what does the public need 
to know about SARS, and what do they need to know about how to 
protect themselves.
    Another issue is that lessons can be learned from SARS 
about how we can protect ourselves from other epidemics, 
whether they are triggered from who knows where or whether they 
come from a malevolent predator. So my question also goes to 
the whole issue of public health infrastructure and what I call 
``dual use'' to protect us from something like SARS but also 
from something like smallpox.
    Let me go to that, because Senator Kennedy raised the 
issues, and I would like to raise them as well. Some years ago, 
we found that the public health infrastructure was tattered, it 
was worn and in some places, even nonexistent, with local 
health departments not even having fax machines. The Majority 
Leader led this committee and the Public Health Subcommittee, 
and we worked on a bipartisan basis to upgrade it.
    Then, with bioterrorism, we put $1 billion into the CDC 
budget last year for State and local departments. Could you 
tell me, number one, as you are struggling so valiantly with 
SARS, what are the lessons to be learned to protect this 
Nation; number two, what is the status of our public health 
infrastructure--do we have the biosurveillance? Do we have the 
monitoring? Was $1 billion enough, or was it a down payment so 
that we could act again in this year's appropriations?
    Dr. Gerberding. Thank you for your question and also for 
all that you have done to get us started on rebuilding our 
public health infrastructure.
    There are a lot of lessons that I think SARS illustrates. 
The first lesson is that emerging infections are a fact of 
life, and we need to get used to that. I think it is also 
teaching us that the whole public system has to be intact. We 
are only as good as our weakest link, and if we have one failed 
public health system or one failure to be able to take the 
steps necessary to contain a problem like this, the whole 
country could suffer.
    The third lesson is the importance of the continuity of 
public health with the health care delivery system. We have got 
to have both capacities--a viable and vibrant and robust 
medical care system with informed clinicians, but also beds and 
surge space and training--and that has to be immediately linked 
with the public health community.
    For me personally, one of the most important lessons is 
that we have to have public health research to identify what is 
the best way to do all of this. We make it up as we go, and we 
have long experience and some success stories to build on, but 
looking ahead at the public health needs of the future, there 
are a lot of unanswered questions, and we have got to know 
faster how we can deal with these efforts and mitigate the 
consequences of a problem like this.
    Senator Mikulski. But, Doctor, are you satisfied that local 
public health infrastructure, public health agencies, are 
really fit for duty for this new area? In my own city of 
Baltimore, thanks to the great help that came from the State of 
Maryland, we have a vigorous biosurveillance program to be 
ready for homeland security that is now serving us well in 
SARS. Dr. Peter Beilenson, our local health department 
official, was prime time thanks to your alerts and your 
information, right back in the local community. Then, using our 
biosurveillance techniques that were city-wide and even 
metropolitan-wide, we could pick up those SARS cases, and Dr. 
Beilenson himself went to the apartment building where one of 
those cases was, and the information went out. Baltimore is 
calm because we have confidence in Dr. Beilenson and our public 
health network.
    We are in the shadow of Johns Hopkins and the University of 
Maryland; we are a wink away from the NIH--not everyone is. So 
my question is particularly in these large metropolitan areas 
that could be hit so hard, that are so high-risk, do you have 
confidence that they are ready, or do we need to make a greater 
public investment through you--meaning CDC--to really develop 
these essentially combat-ready systems?
    Dr. Gerberding. As you describe, Senator, the public health 
system is tattered, and the investments that have been made so 
far have helped a lot, and we are certainly much better off 
today than we were even a year ago--but there are certainly 
districts and local health communities that do not have the 
kind of capacity that you have in Baltimore. In particular, 
Baltimore has an outstanding biosurveillance network that is 
directly linked to the health care delivery system, and that is 
exceptional, and I would love to see a system like that 
functional across the entire United States, if not the globe. 
So we do have many more steps that can be taken, and I think 
the investments do need to be sustained over time, because it 
is not a one-shot fix.
    Senator Mikulski. Thank you.
    Mr. Chairman, does that mean my time is up?
    The Chairman. Yes.
    Senator Mikulski. OK. I would just like to thank you and, 
really, all of the public health people who have been working 
around the clock to do this at the Federal, State and local 
levels. God bless you. I think you really are saving lives.
    Dr. Gerberding. Thank you.
    I would really like to thank you for making that comment 
and actually, all of the people who have commented on CDC and 
the public health community, because while I may be here 
providing information, there are 400 people in Atlanta and many 
internationally-deployed who are doing the hard work of 
responding to this, and that does not even count all the folks 
in the medical and public health communities--they are the true 
heroes of this.
    The Chairman. The Senate Majority Leader.
    Senator Frist. Thank you, Mr. Chairman, and thanks for 
holding the hearing today at an important time in an evolving 
crisis, that 2 or 3 months ago, none of us would have fully 
anticipated, although we all were aware that emerging 
infectious diseases were on the horizon, would continue to 
occur, and this is, as I have said before, one of many that we 
are likely to see in the future. So the time that we spend with 
it, the dissection of the response in the United States, in 
Canada, in Taiwan, and in Vietnam, is something that is both 
important to do and to dissect it in such a way that we can 
learn. Thus, for the next emerging infection, we will be able 
to respond quickly and appropriately. I am speaking 
internationally as well as domestically.
    Dr. Gerberding, thanks for your leadership. I do have the 
opportunity to tell you that on a regular basis, and I thank 
you for that.
    I had a fascinating experience over the last 2 weeks and 
had talked to Dr. Gerberding and a number of other people 
before going to China, but about 2\1/2\ weeks ago made a very 
conscious decision in part as a physician and in part as 
someone who is familiar with infectious disease. In fact,I 
spent most of my adult life fighting infectious disease in my 
transplant patients before coming to the U.S. Senate. I made a 
conscious decision to go to China, and to Taiwan and South 
Korea as well as Japan, but especially Taiwan and China, 
because it was unclear at that point in time whether accurate 
reporting was underway from that country.
    In fact, the consensus was that there was a coverup, a 
coverup of data from a centralized Communist Party and 
centralized government. And indeed what originated in Guangdong 
Province in January had been covered up, had been covered up 
aggressively, not only in the province there but almost more 
inexcusably, in Beijing itself. For in Beijing, you do have the 
potential of infrastructure and infrastructure support and 
surveillance, probably more so in the provinces at large.
    About 12 days ago, our delegation of eight United States 
Senators arrived in Beijing, and President Hu Jintao and the 
minister of health at that time knew that we were coming, and 
up until about 3 days prior to that, they had simply not been 
willing to release statistics.
    Now we know that over 3,303 probable SARS cases--that is 
the latest statistic as of this morning--and 148 people who 
have died have been reported from the virus in China. But 12 
days ago, those figures, instead of being 3,000 were, several 
hundred, and instead of 148 reported deaths, were in the teens.
    We did have the opportunity 8 or 9 days ago to talk 
directly with the leadership of the Communist Party at the 
highest level, the minister of health, and the acting minister 
of health, and also President Hu Jintao.
    We were very direct in our conversations with them, and 
said that we were well aware that the leadership had been 
withholding data. And their response was that was, ``We have 
not been collecting the data,'' and that ``We have an 
inadequate public health infrastructure''--which they do--``to 
really collect that data.'' It was very clear that they were 
not releasing data nationally within the country but also 
globally as well.
    It gave me a great deal of pride to see the World Health 
Organization arrive--and all of us know the story--that as they 
arrived, SARS patients were put into automobiles, put into 
ambulances, and were actually taken out of hospitals so the 
surveillance could not take place. This happened while we were 
on our Asia trip.
    Again I was very direct, speaking as a physician and as 
someone interested in infectious diseases, but also as a 
political figure here in the United States, that this cannot be 
tolerated.
    Let me say that the response of both the Communist Party as 
well as President Hu Jintao was very positive. The Premier had 
said 2 days before that he recognized that this was a problem. 
President Hu Jintao said this is a disaster not only in China 
but potentially in the entire world--and that was something 
that they had not said before.
    With that, people then asked where are we in terms of the 
evolution in China, and Dr. Gerberding has people on the ground 
there who have had the opportunity to meet at this point. I get 
the feeling that things are progressing well in the sense that 
what is being reported as probable cases and the deaths are 
reasonably accurate. What is clear to me, having been in touch 
on a daily basis with people in the health care community 
there, including this morning and yesterday and every day, is 
that we need more data. We are not really getting the data of 
contacts. We are not getting the dates of onset of illness. And 
I know that we are working hard in that regard.
    Their response is simply: We do not have the public health 
infrastructure. We can set the central policy at the top, but 
by the time you get down to the provincial level itself, there 
is no infrastructure there--there is nobody to collect the 
data, there is nobody to report the data to--there is no 
system.
    I share that only because for me, this should give this 
committee but especially our CDC and our Government something 
that we should feel very good about in that we have begun, with 
the assault on bioterrorism in this committee several years 
ago, to develop, or further develop and support that 
infrastructure in a very positive way.
    My question, after that long introduction, stems from a 
concern of global surveillance. With China, the public health 
officials were generally not supported--nobody listened to 
them, nobody at the provincial level. The head of the Communist 
Party did not listen to them, the president of the country did 
not listen to them--which shows the need for real leadership at 
the top.
    But Dr. Gerberding, how well are we doing in terms of 
global communications? You may have already answered this 
earlier, before I came in But what can we do as a committee to 
facilitate, since these viruses know no boundaries, they cross 
rivers, they cross oceans, they go in airplanes, they go into 
people's nasal passages--what can we do to increase that global 
surveillance to make sure that when the next virus hits, we 
will not have to tolerate such withholding of data which allows 
the virus to explode and to reach a point that is critical and 
allows it to spread around the world?
    Dr. Gerberding. Senator Frist, first of all, we really 
appreciate the efforts that you made in China. I think there 
was a strong association between your visit and the fact that 
the doors became open, and we are now able to get the kind of 
information that we have.
    I would also say that your efforts follow on those of 
Secretary Thompson, who made numerous efforts to intervene and 
connect with health ministers in China. At the World Economic 
Forum in January, I was present when Secretary Thompson tried 
to ask questions about SARS. That was just 2 months into the 
problem, and we were reassured there was not a problem, and 
that it was chlamydia, and so forth. So it has been a very long 
path to get to where we are, and I appreciate the problem of 
infrastructure in China, but unfortunately, many parts of the 
world lack global public health infrastructure, and I think we 
have a lot of work ahead of us if we are going to be able to 
get the kind of global surveillance system that you are talking 
about.
    However, we do have some pieces of it. WHO has a network, 
and various countries have established networks of 
communication, and I think our next step is first of all to 
identify what we have that is working and fill in the gaps 
where it is not working. Easier said than done, but just to 
illustrate what can be done, in China, CDC does have a 
satellite network for training that has been established in the 
various provinces that allows us to put out information into 
the Chinese public health and health care community. Now, that 
is an enormously efficient tool for disseminating information. 
We just have to get it connected in the opposite direction so 
we can have the kind of surveillance and detection capacity 
that we need to find something when it first starts.
    We have plans, and I would be delighted to sit down with 
you and with the Department folks in international health at 
HHS to look at what the priorities really need to be right now 
for filling in the gaps in the global surveillance system. It 
is going to be a big task.
    Senator Frist. In our meetings in China 8 days ago, I very 
specifically offered to the Chinese leaders our support for any 
technical assistance that the United States can provide in 
containing the virus, and I am pleased that representatives 
from across Asia are meeting today to endorse a series of 
measures to both stop the spread of disease but also to reach 
out and be willing to say, Yes, we can use that help as we go 
forward.
    Thank you for your leadership.
    Dr. Gerberding. Thank you.
    The Chairman. Senator Murray?
    Senator Murray. Thank you very much, Mr. Chairman, for 
holding this hearing, and Dr. Gerberding, for being here. You 
have been really good about your time. I have had the 
opportunity to talk with you about this issue several times as 
a member of the Labor-HHS Appropriations Subcommittee, and I 
know you are really working hard to make sure we have all the 
information.
    I especially want to thank our friends from Toronto, Canada 
for being part of this today. I think we have a lot to learn 
from them--and frankly, any of us could be Toronto, so it is 
great for them to share their information and help us learn 
what we need to know as well.
    I just have a couple of questions, Mr. Chairman. I know you 
want to get on to the other witnesses.
    Dr. Gerberding, I continue to be concerned. I know we 
provided $16 million in emergency supplemental to address the 
SARS outbreak, but I am concerned whether that is sufficient 
funding and whether CDC has shifted resources from other 
infectious disease prevention efforts so we can focus on SARS, 
and whether diseases like TB are being underfunded because we 
have this focus now. If you could respond, I would appreciate 
it.
    Dr. Gerberding. When the SARS outbreak started, we were in 
the midst of orange alert in this country because of the war in 
Iraq and other issues then. So from the very onset, we defined 
the goals of the mission but also defined the strategy as being 
one characterized by parsimony, and that means trying to be 
right-sized in the personnel and the amount of engagement in 
SARS that we were committing particularly in the international 
arena, since we had the expectation that we could be called 
upon to deal with a second threat or something related to 
terrorism.
    Since that was the characterization of the response from 
the beginning, I think we have been doing an efficient job of 
managing our human resources as well as our dollars, but 
clearly this is a large effort, and the $16 million 
appropriation was really critical to our success.
    We anticipate that some of the $16 million obviously needs 
to go out to the State and local agencies that are directly 
impacted by this as well, so it is not just there to support 
the CDC infrastructure.
    The impact on other programs at CDC has not been zero, but 
we have mitigated, I think, any major impact by rotating people 
in and out of the SARS effort, not taking somebody from another 
center and keeping them engaged in this over the long haul. So 
our management has been designed to allow a comprehensive set 
of experts from across the agency--because it takes everybody, 
not just the infectious disease people; it takes occupational 
health people, it certainly takes a communications team that 
activates our emergency communication system--but when people 
get detailed to SARS, they are there on a time-limited effort, 
and then they go back to their regular responsibilities so that 
we can minimize the impact. But I certainly could not say that 
there is no impact at all.
    Senator Murray. And I think we have to be really careful 
about that balance as we go through this.
    The other question I have is really one of communication, 
because as Dr. Frist has said, there are no boundaries on 
disease. My home State of Washington has a great public health 
prevention system and public health strategies in place, but 
not all States do. How are you monitoring communication between 
States, because if somebody gets infected in one State, in a 
city right next to another one, it very quickly can progress 
that way--and also internationally. Vancouver, B.C. is very 
close to Bellingham, WA, and there are hundreds of examples 
like that across both borders.
    Are we working internationally with other governments as we 
hear about those cases and communicating back and forth between 
States, localities, and internationally?
    Dr. Gerberding. In terms of the domestic situation, the 
strategy for integrating information across State boundaries 
has relied primarily on the weekly--or daily, sometimes--
conference calls that we have with a group of State health 
officers, and Dr. Siedlecki is obviously a major leader in 
that.
    Senator Murray. Does everybody participate in that?
    Dr. Gerberding. Most of the States participate most of the 
time. At any given time, not all 50 are on a particular call. 
But in addition, that information is posted on the Internet, 
and we have health alerts that go out broadly throughout the 
system whenever there is anything new. We also have a 
connectivity with the public affairs officials in each State 
that link back to CDC and with each other. So we are working 
very hard to maintain that seamless integration.
    Internationally, we have a CDC staff member at Health 
Canada and a Health Canada staff person in our operations 
center at CDC, so that has been a great help to us in having 
free exchange of information back and forth. We are going to do 
this every time because it has made so many problems disappear.
    We have special groups of people looking specifically at 
border issues, because there is the international boundary 
where, for example, planes often fly to Vancouver before they 
come to the U.S. and so forth, so those very specific cases of 
the need for greater integration are handled on a situation-by-
situation basis. But we can always do more, and if you have 
ideas or if there are gaps that come to your attention, we 
definitely want to try to resolve that.
    Senator Murray. Very good. I really appreciate that.
    Thank you very much, Mr. Chairman.
    The Chairman. Senator Dodd?
    Senator Dodd. Thank you, Mr. Chairman, and thank you, Dr. 
Gerberding once again for being here and for your testimony.
    I have two quick health-related questions and then a couple 
of broader questions if I can. First, I just want to get a 
sense--I have read some reports that SARS actually appears to 
have less potency when it comes to children than it does in 
older people. And second, since we have talked, obviously a 
short amount of time has elapsed, but to what extent is the 
work or progress on a vaccine moving along?
    Could you answer those two questions, please?
    Dr. Gerberding. Yes. With respect to children, children are 
not immune. I think we thought early on that this might be most 
severe in the elderly, since the early cases and the deaths 
were weighted in the direction of older people. But as we see 
more of the international picture unfold, we are seeing severe 
infection in all age groups. There is a small number of infants 
born to pregnant women with SARS, and that has been cause for 
concern in Hong Kong and probably in other areas as well.
    Senator Dodd. Is it showing up in the infants?
    Dr. Gerberding. So far, we do not have documentation that 
infants have it or that they acquired it in utero, but they 
were delivered by Cesarean section, and they are premature, and 
they have respiratory difficulties, so they are being watched 
very carefully to make sure that this was not a problem with in 
utero infection.
    So there is a lot to learn. I think that if we can get the 
kind of information that Senator Frist mentioned from China 
about dates of onset and ages and the clinical characteristics 
of the 3,000 cases there, we are going to know a lot more about 
the spectrum of illness and will be able to give you a better 
answer to your question.
    In terms of the vaccine, the short answer is we are not 
going to have a vaccine for at least a year, but the steps are 
well under way. Getting the virus sequenced was a major step. 
NIH has inserted the coronavirus into a certified cell line, 
which is an important step to getting a vaccine product 
started. They are starting by simply killing the virus and 
inoculating it in animals to see whether that protects against 
re-exposure. The first-generation vaccine will probably be 
based on something along those lines.
    The optimism is that our technology should allow us to do 
this very quickly and that there are vaccines for other 
coronaviruses in animals and birds.
    The pessimism is that those vaccines are not always 100 
percent protective in animals and birds, and we do not know yet 
enough about the immunology of the response to coronavirus 
infection to know how likely it is that we will get a strong 
protective response or that the protective response to one 
strain will cross-protect against any evolution that occurs in 
the virus over time.
    So there is a lot of work to be done, but there has been 
good progress, and I think certainly fast out of the starting 
gate compared to many other infectious diseases.
    Senator Dodd. Thank you very much.
    Let me ask two quick questions if I can. I wanted to follow 
up on Senator Murray's question. She asked about the 
communication that goes on with the State health directors. 
What are the requirements today? I have five suspected or 
probable cases in Connecticut--and at some point I would like 
to know the distinction between a ``probable'' and a 
``suspected'' case--but are there requirements that those cases 
be reported to you immediately? Do you know of all cases that 
have been identified as probable or suspected at CDC?
    Dr. Gerberding. We have high confidence in the reporting 
from the States, particularly----
    Senator Dodd. Is it required? Is it required?
    Dr. Gerberding [continuing]. It is not required. CDC has no 
authority to require reporting to CDC.
    Senator Dodd. Could you have that? Would you like to have 
that authority?
    Dr. Gerberding. Well, we have a system that works, and that 
is based on each States develops its own regulations and 
statutes about what is reportable to the State, and because we 
fund----
    Dr. Gerberding [continuing]. Well, it is a little bit 
different because we fund the States to report diseases to us, 
so there is a carrot there, and we do not have to resort to the 
stick. But it is true that overall, there is variability in the 
reporting of many of the reportable conditions. This one, 
because it is new and because we have these outstanding 
relationships, I think we have a high degree of confidence that 
we know about all the cases.
    Senator Dodd. But it is troublesome in a way. I can see why 
people were critical, and rightly so, of the Chinese, 
particularly the province, not reporting for some time--
whatever their motivations may have been. I would be nervous if 
someone at some point in some State, for whatever reason, 
decided they did not want to report the cases. So I would give 
that some thought if you would; I would be interested.
    Second, after 9/11 here, obviously, we have all taken 
different steps and actions to protect our homeland security. 
Tell me what you are thinking now--what happens if we end up 
with a Toronto in Hartford, CT, Baltimore, Seattle? What steps 
have you already planned and thought about that you would take 
in order to deal with that kind of problem in one of our major 
cities--close schools--what are the steps that you have already 
thought about that we would take in this country now as a 
result of this experience?
    Dr. Gerberding. We have a set of step-wise responses that 
we would be able to scale up if the situation evolved to the 
point that Toronto or worse experienced. The first step is to 
initiate the appropriate level of quarantine--and I use the 
word ``quarantine'' very precisely here; quarantine applies to 
the exposed but unaffected people--so we would initiate 
voluntary quarantine if necessary to separate the exposed 
people from the rest of society so that if they were incubating 
the disease, they would have little if any chance of passing it 
on. And most likely the scenario would be that the health care 
personnel are the most vulnerable group--that has been the 
experience in virtually every country--so we could go from the 
system we have now, where exposed people are monitored actively 
by their State and local health officials to a system where 
they are actually quarantined or set aside from others until 
they are out of their incubation period, which is about 10 
days.
    Senator Dodd. Is there existing authority to do that?
    Dr. Gerberding. We have a mosaic of authorities in States 
for taking these kinds of steps, but yes, every State has the 
authority to do that. How they do it is very variable, and one 
of the things that has been going on since 9/11 is an 
evaluation of what the public health laws are on a State-by-
State basis.
    Georgetown and Johns Hopkins have initiated the Model 
Public Health Law Program, and so far, all 50 States have done 
an inventory of the adequacy of their public health laws to 
deal with a situation like this. Thirty-nine States have 
proposed statutory regulatory changes to their State 
legislatures to improve their public law, and so far, I think 
that about 22 States have actually changed statutes or 
regulations to make sure they are up-to-speed.
    Some States do not need to make changes because their 
current laws are adequate, but we are working very hard to 
bring everybody up to the same level--and keep in mind that if 
the State authority fails for whatever reason, there is a 
residual Federal quarantine authority, particularly if it 
pertains to interstate commerce or borders with the 
international community.
    Senator Dodd. I have taken a lot of time, Mr. Chairman, and 
I apologize.
    We might want to think about something along the line--now 
that we have all admitted, obviously, the mobility and 
globalization issue that you have talked about, and Senator 
Kennedy has and the chairman has--we might want to be thinking 
about pulling all this together to some degree and looking for 
a coordinated national approach much along the lines of the 
homeland security issue here in terms of how our States 
interface with the Federal organizations, the World Health 
Organization, and others. I wonder if there could not be some 
stepping back and looking at this thing in its totality in 
light of this experience here, so that we might be better-
prepared structurally, heaven forbid we are confronted with a 
far more serious situation than the one we presently seem to be 
in.
    So I want to suggest, Mr. Chairman, that we might want to 
look at that.
    The Chairman. Thank you, Senator Dodd. I agree 100 percent 
with that assessment, and in fact I have asked our staff to 
start looking at that. I think CDC has its hands full right 
now, so that hopefully when we get this sorted out a bit, we 
will have a chance to take a more comprehensive view and learn 
from this exercise, which is what the next panel is about and 
leads in naturally to the next panel.
    So, Dr. Gerberding, I thank you very much for your time and 
especially for the extraordinary effort--the superb effort, I 
believe--that CDC is pursuing in protecting America's health.
    Thank you.
    Dr. Gerberding. Thank you very much.
    The Chairman. We will ask our next panel to join us now.
    We are fortunate to have the opportunity to hear from two 
of the folks who are on the front lines of this issue in an 
area which has, regrettably, been subject to a significant 
impact, and that is, Canada, specifically, Toronto, and the 
Province of Ontario.
    We have with us Dr. Paul Gully, who is the senior director 
general for the Population and Public Health Branch of Health 
Canada, who is coming to us via videoconference; and also 
joining us is Dr. James Young, the commissioner of public 
security in the Ministry of Public Safety and Security for the 
Government of Ontario.
    We very much appreciate both of these gentlemen being 
willing to testify. They did actually have to get some 
dispensation from their government to testify before a 
congressional committee in the United States, and we very much 
appreciate their willingness to do that and the openness of the 
Canadian Government in allowing this testimony to go forward, 
Canada of course being a good friend and great neighbor.
    Why don't we start with Dr. Gully, and then we will go to 
Dr. Young?
    Senator Kennedy. Could I, Mr. Chairman, just join in the 
welcome as well?
    Dr. Gully, just to join my chairman, the fact that you were 
able to get the lifting by the World Health Organization is a 
real reflection of your leadership as well, so we want to 
recognize that and have the American people understand that we 
are listening to some very expertise from both of our witnesses 
here today, a very important message.
    We are very grateful, and I join the chairman in thanking 
you for taking the time, and your government, for sharing your 
experience with us.
    Thank you.
    The Chairman. Thank you.
    Dr. Gully?

    STATEMENTS OF DR. PAUL GULLY, SENIOR DIRECTOR GENERAL, 
  POPULATION AND PUBLIC HEALTH BRANCH, HEALTH CANADA; AND DR. 
   JAMES YOUNG, COMMISSIONER OF PUBLIC SECURITY, MINISTRY OF 
   PUBLIC SAFETY AND SECURITY, GOVERNMENT OF ONTARIO, CANADA

    Dr. Gully. Thank you very much, Mr. Chairman and Senators.
    We really do appreciate the opportunity to present to you 
this afternoon for Canada, and I certainly would like to 
emphasize and concur with the assessment of the collaboration 
between Canada and the U.S., our branch which is equivalent to 
the CDC in Canada, and the efforts of Dr. Gerberding. I would 
also agree with her in her cautious optimism.
    I would just like to make a point. As I said, our 
Population and Public Health Branch is similar to CDC and also 
has a very similar legislative grounding as does CDC.
    In terms of the context and our history with SARS in China, 
we in Canada were aware of this through our public health 
intelligence network. We were aware of what was going on in 
November and again in February, and then what was happening in 
Hong Kong in February as well as in China.
    We also sent out information from that to our participants 
across the country in February, and I'll make reference to that 
again in just a minute.
    The first Canadian case came to our attention on March 13. 
The first case in Vancouver had in fact been identified on 
March 6. This was an individual who came back from Hong Kong 
and as a result of the prior warnings of what was happening, 
this person experienced respiratory symptoms and, after coming 
back from abroad, was put under respiratory isolation.
    It was unfortunate that the first case in Ontario was a 
woman who came back from Hong Kong, had stayed in the Metropole 
Hotel, became ill, and died at home, and a member of her family 
who acquired SARS came to an emergency room in a hospital and 
spent a number of hours there and transmitted SARS, then, to 
health care workers and other patients.
    Unfortunately, because the person had not arrived back from 
Asia, and in fact had not had any known connection, apparently, 
the possibility of SARS or an atypical pneumonia problem from 
Asia was not identified. I think it is a question of luck in 
terms, therefore, of what happened there, and I think, as I 
have said a number of times, it can easily happen elsewhere 
once it gets into a community.
    From that individual to that hospital and other hospitals 
then came the genesis of the problem in the greater Toronto 
area, and Dr. Young can tell you further about that.
    At the present time, we have 146 probable cases in Canada. 
At the moment, we have just 39 hospitalized cases--all the 
others have left hospitals--and indeed, a number of those are 
getting better, and they are staying in the hospital until they 
are completely recovered.
    We have unfortunately had 21 deaths, which is probably a 
reflection of the transmission to hospital patients and their 
family members, and those hospital patients have tended to be 
older, and therefore, in the vast number of those cases, those 
deaths have occurred in elderly people.
    So the transmission, as I said, occurred to health care 
workers and patients in 92 of those probable cases; home 
contact with health care workers and patients in 43, so close 
contact in the home situation; and then, two specific community 
settings, again traceable back to the original hospital--one 
transmission in a workplace, a worker who worked in a very 
close environment with a colleague transmitted to that 
individual, and then a religious group, a large religious 
gathering of the order to 250 to as many as 500 people, 
transmission to a small number, I believe 4 cases.
    What is interesting is that even in a large group of 
people, there was not a great deal of transmission. It was a 
group meeting that seemed to have a lot of close contact in the 
way that they interacted, but it only gave rise to a very small 
number of people, those people who we believe were in really 
close contact with their fellow believers.
    The last health care worker case occurred in Canada around 
April 20, and I will come back to that a bit later in terms of 
the investigation. The last case occurring in a community 
setting was April 7, and the last imported case, April 1.
    So I think that there are grounds for that cautious 
optimism.
    I just want to say one or two points about investigation, 
because this issue of case definitions has been a challenge 
because of a case definition including contact with a known 
case. But we have developed another case definition of a person 
under investigation geo-linked, i.e., linked to a general area. 
And that will present a challenge to us in terms of especially 
those people who arrive, for example, in the U.S. who have been 
in Toronto, have a fever, have some respiratory symptoms, to 
interpret, if they had no known contact with a case or a 
specific setting, whether they are a SARS case or not. And I 
again will refer to that a bit later.
    But again, we are referring to probable cases in the 
numbers I have referred you to, those who have definite 
disease.
    In terms of laboratory diagnosis, we have carried out 
thousands of tests on now thousands of people--we say thousands 
of people because we have in fact tested as probable suspects 
also those who have traveled with neither and also, then, 
banked specimens. And we have some interesting results. 
Certainly in the probable cases, we only have about 40 percent 
of those who were in fact positive for the coronavirus. And we 
have positive cases in those people who have travel history but 
no symptoms. It is a mystery. It is undoubtedly a challenge in 
terms of interpreting the epidemiology and interpreting the lab 
test for the coronavirus, and we certainly look forward to 
collaborating internationally in answering those questions.
    We have sent out kits for testing to laboratories, but we 
are saying that that is essentially at the moment a research 
tool, because as Dr. Gerberding said, a positive test may be 
indicative of something, a negative test is not.
    We have imposed these actions early on in terms of public 
health management, isolation, or isolation/quarantine of 
probable cases and their contacts. Infection control has been a 
huge issue, as Dr. Young will be able explain to you, in terms 
of the hospitals. We have modified traditional infection 
control procedures, and in fact we are having the benefit of 
three people from CDC with specific expertise who are enabling 
Health Canada to work with Ontario to investigate the 
circumstances around health care worker transmission which 
appears to have occurred even though those individuals have 
implemented the appropriate infection control guidelines. So 
that is being investigated right now, and again it is a 
challenge.
    We have in terms of Health Canada responsibility for 
Federal workers ranging from our staff, quarantine offices, for 
example, but also Customs agents, and giving advice to them has 
been very important.
    We have also given advice on clinical management and 
treatments, and we are watching this very closely because our 
Special Access Program enabling physicians to have access to 
unlicensed drugs--I believe that is the same in the U.S. 
through the APA--that Special Access Program has just issued a 
notice essentially saying to physicians that because there is 
really no evidence that ribavirin, which is the antiviral which 
is being used most widely, little--actually no--evidence that 
that is effective, and we have had numerous reports of adverse 
drug reactions from this drug that, although we, the Special 
Access Program, will not refuse a physician further access to 
ribavirin, they will have to make a very, very strong case in 
the future.
    In terms of other responses, travel advisories, as you have 
done in the United States, and we are indeed looking at those 
travel advisories. Our activities at the borders are not 
dissimilar to those in the U.S. in terms of inbound, and again, 
airlines and ships have responsibility for reporting. We also 
have yellow cards translated very early on into French, 
English, and simplified Chinese, and now we are collecting 
contact information on aircraft from the affected areas in Asia 
so that we can keep those if necessary.
    Outbound, because of the classification of Toronto as an 
affected area, we have had another colored card, a cherry-
colored card, and posters at the Pearson Airport in Toronto. It 
is a challenge; one has to think of how to get information to 
approximately 38,000 people a day, and we are continuing to 
refine that, and we will be enhancing that and we will be 
working with the airlines to ask them to ask passengers about 
what is in the cards.
    We are also working in terms of getting information to 
people who travel by rail, particularly those exiting the 
country, and we are working closely with CDC in terms of the 
issue of cruise ships.
    We will be enhancing outbound screening. We have a number 
of suggested procedures which we will be looking at, and that 
is especially important in terms of the lifting of the travel 
advisory from the World Health Organization. I believe they are 
telling us that to ensure that we take the greater steps to 
ensure that we don't export anymore cases, we do have to give 
an assessment of how many cases we have exported. There may 
have been two in our assessment, and those occurred at least 2 
weeks ago now, which we believe is important.
    The World Health Organization advisory has, as was 
mentioned, been lifted, and lifted as of tomorrow. We lobbied 
heavily the World Health Organization in terms of clarifying 
the information that they used for the travel advisory, and we 
are very appreciative of the close collaboration that has taken 
place over the last few days on a number of videoconferences 
and teleconferences which led to the advisory and also a visit 
from Health Canada staff and the Minister of Health of Ontario 
in Geneva.
    Another issue for us now is how to maintain a sustainable 
response, and I am sure Dr. Young will mention this. We hope we 
have turned the corner in terms of the requirement for 
quarantine and isolation. That has been a huge task of public 
health authorities. The meeting which we are holding tomorrow 
and the next day, which I will mention at the end, will be 
looking at what we should perhaps do in the future in terms of 
isolation, in terms of quarantine, and in terms of further 
infection control. Infection control will be very important 
because, as I have described, the challenge presented once it 
gets into a hospital situation is a real challenge.
    Early detection was mentioned earlier. Early detection by 
physicians is extremely important, and getting information out 
to them. So rapid isolation of a suspect case could be one of 
the hallmarks of how we continue to control this, because we do 
not think it is going away. We hope that certainly transmission 
internally in Canada will go away, but we will continue to have 
to deal with imported cases, I believe, even despite all the 
border controls that we have.
    The other sustainable response we need is in 
communication--the transparency, the explanation of what is 
happening, the reassurance of the public in terms of the fact 
that we have methods to control, we have methods to contain and 
control. And we hope that that message gets out 
internationally, and we hope that the lifting of the WHO travel 
advisory will aid that.
    Another issue is the socioeconomic consequences and, even 
before the WHO travel advisory, economic consequences for 
Toronto and Ontario and Canada as a whole, because a number of 
people outside this country do not appreciate the size of the 
country and the fact that Toronto is a minuscule part of the 
country albeit it has a sizable population.
    In terms of travel, the economic downturn has been tangible 
in Toronto--which again, Dr. Young may refer to. It is a 
challenge for all levels of government in Canada in terms of 
trying, again, to encourage people, say that Toronto is a safe 
place to be, and encourage the Torontonians to be out and 
about. There was a reference to baseball earlier on. The Blue 
Jays are selling tickets for one dollar each tonight to get 
people out and about in Toronto.
    Finally, I would like again to emphasize the importance of 
collaboration within Canada with our provincial territorial 
partners, numerous Federal government departments, and with the 
U.S., as has been mentioned, the liaison with CDC and Health 
Canada and a staff person in Atlanta. We also now have a new 
lay position who is embedded with the Health Canada Emergency 
Operations Center.
    Internationally, there is close collaboration with the 
U.S., the United Kingdom, the Pan-American Health Organization, 
and the WHO.
    I agree with Dr. Gerberding in terms of the support and the 
lead that the WHO has given us in terms of international 
investigation and lab coordination.
    Finally, we hare having an international meeting here 
tomorrow and the next day. We are very pleased that Dr. 
Gerberding will be able to spend at least some time with us, as 
will Dr. David Heymann from the World Health Organization. We 
are going to take stock, look at lessons learned, and move 
forward in terms of border issues, in terms of future 
epidemiology, infection control, public health management, and 
in fact the laboratory work and science leading to a diagnostic 
test and vaccine.
    So again I really do appreciate on behalf of the Government 
of Canada the invitation to present to you, and I look forward 
to any questions that you may have.
    The Chairman. Thank you very much, Dr. Gully. That was a 
really excellent presentation, and not only comprehensive but I 
think it settles out a lot of the issues in its substance and 
reflectiveness of the management of the issues. So we 
congratulate you on it and thank you for it.
    Dr. Young?
    Dr. Young. Thank you, Mr. Chairman.
    I am pleased to be here today to discuss the important 
issue of SARS and to tell you about the effective measures we 
have taken to contain and control this new disease in Ontario.
    I also wish to thank U.S. Consul General Antoinette Marwitc 
and her staff for their strong support of Toronto during our 
SARS outbreak.
    The Centers for Disease Control is also playing a key role 
in our scientific efforts and also in supporting our position 
in regard to the WHO travel advisory against Toronto. I am 
pleased to say that the WHO has accepted out facts and has 
agreed to lift that travel advisory.
    The problem for us in responding to SARS has centered on 
the fact that we know so little about it. What is it? What are 
its characteristics? How is it spreading? When are people 
infectious? How do we test for it? And how do we control and 
treat it?
    In the case of Toronto and the Province of Ontario, we 
faced these questions very early in the known history of SARS 
and only knew that we were facing the challenge after the 
disease was already spreading in a local hospital.
    Our index case, as has been mentioned, was clear. A Toronto 
resident contracted SARS in an elevator in the Metropole Hotel 
in Hong Kong. That person happened to be returning to Toronto, 
became ill and died. The 43-year-old son of that person went to 
the hospital on March 16--and I would note that date because it 
is only 4 days after the initial warning about SARS that was 
mentioned--for treatment of what ultimately turned out to be 
SARS. While in the emergency department and after being 
admitted, this person was not in respiratory isolation. This 
person in retrospect is believed to have been highly 
infectious, and our cluster of cases takes off from this point.
    This person and the next two persons who were infected 
through contact in that emergency department all went on to 
infect large numbers of other patients, health care workers, 
and family members.
    It took us time to recognize the initial hospital case and 
to make the contacts from that case. Once that recognition was 
made, we imposed strict and effective isolation measures. By 
this time, however, because of the highly infectious nature of 
our early cases, enough staff and patients were affected that 
one hospital had to be closed to new admissions, emergency 
cases, and transfers. We also started to alert the entire 
health care system.
    On March 25, we decided that a provincial health emergency 
should be declared in order to mobilize the full resources of 
the Province of Ontario. We decided to act quickly and boldly 
to attempt to eradicate SARS from our community.
    We started by restricting activity in all of the hospitals 
in the province while we put in place stringent infection 
control procedures in all hospitals in the province. These 
included everyone, including staff, being checked for illness 
before entering a hospital. Staff were required to gown, glove, 
and mask in all patient areas of hospitals, and masks were 
provided for all patients entering an emergency department. 
Isolation was required for all respiratory patients in 
emergency departments until their conditions were determined.
    Initially, we also felt it necessary to stop all elective 
surgery; we stopped all visitors and volunteers from coming to 
hospitals, and we organized a new, very strict, system of 
ambulance transfers between hospitals.
    On the community side, we also took strong measures. Public 
health vigorously tracked all contacts of SARS cases and 
imposed a 10-day isolation or quarantine on all contacts. This 
has meant the isolation or quarantine of more than 10,000 
people for a 10-day period. If persons were found to be 
ignoring isolation orders, legal remedies were used.
    The public has also been encouraged not to go to work if 
they show early symptoms of SARS, including headache, malaise, 
or muscle ache, and not to go to work before they develop 
fever.
    Frequent hand-washing has also been encouraged, and we have 
had press conferences each day at 3 o'clock in order to again 
be as transparent as possible with the public, educate the 
public and tell the public everything that we know about SARS. 
This is done in order to foster a calm approach to the problem, 
and these measures continue to this day.
    Before our initial measures had time to take hold, a 
transfer of one of the highly infectious patients occurred to a 
nearby hospital. This patient again was highly infectious, and 
this transfer resulted in more medical staff, their families 
and other patients getting SARS. This hospital was also 
restricted in its activities.
    Our measures have proven effective. Both of the two most 
affected hospitals have now been reopened, and they have been 
through more than two incubation periods, 20 days, without any 
further spread or new cases. All of our known SARS cases are in 
SARS units in our hospitals, and there are currently 37 
patients in hospitals with SARS. There is a small number of 
SARS patients who are finishing their recovery at home.
    March 16 was the critical date for Toronto and our SARS 
outbreak. As well as the patients and staff becoming infected, 
relatives of one patient who took their patriarch to the 
hospital that night also became infected. They subsequently 
visited doctors, a funeral home, and were involved in a 
religious community. This series of unprotected contacts took 
some time to trace and piece together and is referred to as the 
``BLD cluster,'' named after the religious group. There were 31 
cases within this group, and we ultimately isolated and 
quarantined more than 500 people. There have been no new cases 
from this group since April 9. It is important to note that our 
so-called community cases all track back to the original index 
case. We have had no sporadic or unexplained SARS in our 
community.
    Over the Easter weekend, we experienced a setback in our 
efforts. We had some incidents of SARS developing in medical 
staff working in SARS units. In one instance, a very difficult 
and long intubation in a SARS unit infected, we believe, 15 
staff who were in attendance for that medical procedure. We 
immediately rewrote our isolation procedures for SARS units, 
and we invited Health Canada and the CDC to work with us to 
study this unfortunate event and to recommend the best ongoing 
infection control standards for our SARS units. We believe that 
these will become the standard for SARS treatment units around 
the world, and we certainly appreciate the fact that the CDC 
not only agreed to come, but is working diligently and well 
with our people.
    Finally, I will comment on where we are today. As of April 
28, as I mentioned, we have 37 active SARS patients in our 
hospitals--17 fewer than 1 week ago. We have 18 active SARS 
patients at home finishing their recovery. We have had a total 
of 142 probable cases of SARS but have very few cases each day 
now. We have had 20 SARS patients die, but all but one of these 
had significant other medical conditions, and most were 
elderly.
    There has been no spread of SARS through casual community 
contact, and more than 20 days have passed since the last 
transmission among close contacts outside the health care 
setting. And I again emphasize there has been no spread of SARS 
through casual contact at any time in Toronto.
    We continue to work with the CDC on infection control for 
our medical staff who are working in the SARS units and with 
Health Canada. This, along with finding and isolating new 
travel cases as they come into Ontario, is our current 
challenge.
    The streets of Toronto are safe from SARS. They are as safe 
as the streets of London, Paris or Washington. In fact, a BBC 
reporter told me last Saturday that he saw more masks and more 
concern about SARS in London than he did in Toronto. That was 
as we walked through the streets of Toronto, and people were 
out and about on the weekend--and, as Dr. Gully mentioned, 
there will be a full Sky Dome tonight out at the baseball game.
    But the lesson for all of us is that it only takes one case 
to start a new breakout, and therefore, we must be vigilant, 
and we must remember that. We can best, as you asked, Mr. 
Chair, defend the border by working together, by sharing our 
experiences, by sharing scientific data, and by taking common 
approaches.
    Thank you for this opportunity to discus sour experience in 
Ontario.
    [The prepared statement of Dr. Young may be found in 
additional material.]
    The Chairman. Thank you, Dr. Young, and thank you also for 
that excellent presentation--and I think it is a presentation 
that can bring a fair amount of calm to the situation, and that 
is important, because you reflect statistical facts which show 
that the virus can be contained, and I guess that is my first 
question to both doctors.
    Do you feel you have a handle on it in Canada? As you said, 
Dr. Young, there may be somebody else who comes in with the 
disease, but do you feel as of this time that you have it under 
control and have a handle on it?
    Dr. Young. Let me speak to Ontario first, and perhaps Dr. 
Gully can speak for the rest of Canada. We do feel that we have 
a handle on the situation in Ontario. We acknowledge that we 
are working in our SARS units with medical staff. This is an 
age-old problem in infectious situations around the world in 
any unit, and we believe and have reason to be optimistic that 
our new measures are taking hold, but we are prepared to do 
whatever is necessary and whatever is recommended by the study 
group now in order to make our units as safe as is humanly 
possible.
    By going more than two cycles of this disease both in the 
community and within the affected hospitals, we believe that we 
have succeeded in getting it out of our health care system, and 
as far as it went into our community--which I again remind 
people is only by direct contact--it is out of the community, 
and it is out of our general health care system.
    But those remain the risks if a case comes in and it is not 
controlled, but those are the risks for every jurisdiction 
everywhere.
    Dr. Gully?
    Dr. Gully. I agree with Dr. Young that we do have it under 
control. I also echo his words in terms of the fact that from 
now on, we have to ensure that any new cases that arrive are 
dealt with with the utmost care in close contact, but the 
health care setting has not been the case in numerous 
situations in the past with infectious diseases. The hospitals 
have been the ones which are most vulnerable.
    So I think it is important that even though it will be a 
long time before we get a vaccine, maybe it is a question of 
diagnostic test. As described by Dr. Gerberding, we have 
traditional methods of public health--isolation in the 
community, isolation and quarantine, and infection control--and 
these have been applied--through a huge amount of work--but 
have been applied and have worked.
    The Chairman. Do you have a different approach toward 
informing and trying to get the participation of people who are 
coming into your country from China or other areas where there 
is a higher degree of infection than we have? We are giving out 
this yellow card, which was noted by Dr. Gerberding. Is that 
your process? You mentioned that you have an information card, 
but do you do a more aggressive screening than that in light of 
your experience?
    Dr. Gully. We still use the yellow card, but what we did do 
is to put it back onto the airplanes, so that in fact on 
flights from Hong Kong and from China and Taiwan, people on 
those planes get the yellow card on the planes, and in 
addition, we do collect contact information on those flights, 
which is then collected when people disembark.
    We have, in a similar way to you, officers meeting flights 
to take individuals who are obviously sick and also expect the 
airlines to cooperate in terms of informing us of sick people.
    So we have in fact put it back into the system a bit more 
in terms of on the planes, so that people have much longer to 
digest the information and to perhaps ask questions even on the 
flight and perhaps self-identify as being sick, so they can 
then be dealt with when they disembark.
    The Chairman.w are you handling people who are transiting 
through a different country that does not have the issue?
    Dr. Gully. That is a challenge. Certainly in terms of 
individuals transiting through the U.S. we obviously are 
relying on the process which we know the U.S. is undertaking.
    We have taken the opinion that we have to put things in 
place which are--that there is a cost and a benefit to these--
and we feel that because we have not had any reported cases 
since April 1, what we have in place is working. And there have 
certainly been calls for us to do a lot more, and we have to 
decide what is doable, where we feel we should put in the most 
effort, and we believe that we have done that.
    In terms of outgoing, we may be making further enhancements 
of that in particular because of the call from the World Health 
Organization relating to exported cases.
    The Chairman. What would you say are the three or four 
things--or even five, if you have them--off the top of your 
head that we in our country should learn from your experience? 
You have developed protocols, as you said, that you expect to 
be generally acceptable, but if you both could respond to that 
question, I would appreciate it.
    Dr. Gully. The protocols that we have set up with our 
partners obviously in the province in the local health 
departments have worked, and I think it was more the fact that 
it was into the hospital situation in Toronto before we all 
were aware of it. So I think that what you would do in terms of 
public health management and infection control is what we would 
do. I hope now that you do not get in the same situation that 
we did in terms of not identifying a person who actually came 
into the country with obvious symptoms and obvious disease.
    Dr. Young may want to talk about the quarantine/isolation 
experience which is directly related to Toronto.
    The Chairman. Dr. Young?
    Dr. Young. Yes, Mr. Chair. I would advocate several things, 
and some of them you have heard of. Full, open and transparent 
communication is number one, because it keeps the calm in the 
community, and it keeps people doing what we ask them to do, so 
that certainly is very important.
    The actions that need to be taken when there is a problem--
we held the view at the time we declared the provincial 
emergency that we had very little time to act and that we had 
to act properly the first time. So the actions we took were 
firm, they were bold, and in some cases they were described as 
an overreaction. And I make no apology for overreacting; I 
think they have to be when you are faced with this kind of 
problem because you only get sometimes one chance to deal with 
it.
    You then need to mobilize in fact large parts of the 
government, because a problem like this affects much more than 
just public health; it involves the whole health care system, 
doctors' offices, hospitals, and long-term facilities because 
this disease is potentially fatal entering into a nursing home 
or home for the aged or chronic care facility. It means other 
government ministries, because it has such a broad, overarching 
government effect on so many departments.
    And then, you need to use, I believe, the things that have 
worked for us--isolation, close contacts, but isolation has to 
be again lots of people and more people isolated than you would 
think necessary, and there is a big education in that; strict 
infection control within hospitals; and then, reeducation of 
the medical community--they have to approach SARS from the 
point of view of every case that comes in with a respiratory 
problem is SARS until proven otherwise, and a lot more 
isolation until that is proven; and finally, trying to get the 
community to understand that if there is a firm risk in the 
community, people need to stay home when they are sick until 
the issue is sorted out, because that allows people to be 
isolated in relative terms so that you do not have hundreds of 
contacts while somebody is out and sick with a fever.
    The Chairman. That is an excellent set of recommendations, 
and I am sure our folks will be following that closely, as the 
protocols you have developed. I think it is good that you are 
having this meeting--it is tomorrow or the next day?
    Dr. Young. Tomorrow and the next day both.
    The Chairman. Well, we would like to give you some tourism 
and send a few staff folks up from this committee, if that is 
appropriate, to observe and learn, because you obviously have a 
lot to teach us on this.
    Dr. Young. Very much so.
    The Chairman. Just to reiterate, your last case that you 
identified was a public event versus a nonhospital event and 
was on April 9?
    Dr. Young. April the 9th.
    The Chairman. And the incubation period is 10 days?
    Dr. Young. That is correct.
    The Chairman. So you are fairly confident that as far as 
public events are concerned, this is under control?
    Dr. Young. That is correct. We are 20 days out today so 
that we are confident that our community problems are hopefully 
permanently behind us.
    The Chairman. Well, we congratulate you, and again, Dr. 
Gully and Dr. Young, I thank you very much for being willing to 
take the time to participate in this hearing. It means a lot to 
us here in the United States; I know it required some special 
dispensation in Canada to be able to do this. We very much 
appreciate this cooperation, and we look forward to continuing 
it, and if we can be of help, you tell us; you have obviously 
been of great help to us.
    Thank you very much.
    Dr. Young. Thank you, Mr. Chairman.
    The Chairman. This hearing is adjourned.
    [Additional material follows.]

                          ADDITIONAL MATERIAL

            Prepared Statement of Julie L. Gerberding, M.D.

    Good afternoon, Mr. Chairman and Members of the Committee. I am Dr. 
Julie L. Gerberding, Director, Centers for Disease Control and 
Prevention (CDC). Thank you for the invitation to participate today in 
this timely hearing on a critical public health issue: severe acute 
respiratory syndrome (SARS). I will update you on the status of the 
spread of this emerging global microbial threat and on CDC's response 
with the World Health Organization (WHO) and other domestic and 
international partners.
    As we have seen recently, infectious diseases are a continuing 
threat to our nation's health. Although some diseases have been 
conquered by modern advances, such as antibiotics and vaccines, new 
ones are constantly emerging, such as Nipah virus, West Nile Virus, 
vancomycin-resistant Staphylococcus aureus (VRSA), and hantavirus 
pulmonary syndrome. SARS is the most recent reminder that we must 
always be prepared for the unexpected. SARS also highlights that U.S. 
health and global health are inextricably linked and that fulfilling 
CDC's domestic mission to protect the health of the U.S. population 
requires global awareness and collaboration with domestic and 
international partners to prevent the emergence and spread of 
infectious diseases.

                           EMERGENCE OF SARS

    In February, the Chinese Ministry of Health notified WHO that 305 
cases of acute respiratory syndrome of unknown etiology had occurred in 
Guangdong province in southern China since November 2002. In February 
2003, a man who had traveled in mainland China and Hong Kong became ill 
with a respiratory illness and was hospitalized shortly after arriving 
in Hanoi, Vietnam. Health-care providers at the hospital in Hanoi 
subsequently developed a similar illness. During late February, an 
outbreak of a similar respiratory illness was reported in Hong Kong 
among workers at a hospital; this cluster of illnesses was linked to a 
patient who had traveled previously to southern China. On March 12, WHO 
issued a global alert about the outbreak and instituted worldwide 
surveillance for this syndrome, characterized by fever and respiratory 
symptoms.
    Since late February, CDC has been supporting WHO in the 
investigation of a multi-country outbreak of unexplained atypical 
pneumonia now referred to as severe acute respiratory syndrome (SARS). 
On Friday, March 14, CDC activated its Emergency Operations Center 
(EOC) in response to reports of increasing numbers of cases of SARS in 
several countries. On Saturday, March 15, CDC issued an interim 
guidance for state and local health departments to initiate enhanced 
domestic surveillance for SARS; a health alert to hospitals and 
clinicians about SARS; and a travel advisory suggesting that persons 
considering nonessential travel to Hong Kong, Guangdong, or Hanoi 
consider postponing their travel. HHS Secretary Tommy Thompson and I 
conducted a telebriefing to inform the media about SARS developments.
    As of April 23, 2003, a total of 4,288 probable cases of SARS have 
been reported to WHO from 25 countries including the United States, and 
251 of these persons have died. In the United States, there have been 
39 probable SARS cases reported from 18 states. Of U.S. probable cases, 
27 have been hospitalized, and none have died. In addition, 206 suspect 
cases of SARS have been reported and are being followed by state and 
local health departments.

                          CDC RESPONSE TO SARS

    CDC continues to work with WHO and other national and international 
partners to investigate this ongoing emerging global microbial threat. 
We appreciate the continued support of Congress, and of this Committee 
in particular, in our efforts to enhance our nation's capacity to 
detect and respond to emerging disease threats. The recent supplemental 
appropriation of $16 million to address the SARS outbreak will aid our 
identification and response efforts. SARS presents a major challenge, 
but it also serves as an excellent illustration of the intense spirit 
of collaboration among the global scientific community to combat a 
global epidemic.
    CDC is participating on teams assisting in the investigation in 
Canada, mainland China, Hong Kong, Singapore, Taiwan, Thailand, and 
Vietnam. In the United States, we are conducting active surveillance 
and implementing preventive measures, working with numerous clinical 
and public health partners at state and local levels. As part of the 
WHO-led international response thus far, CDC has deployed over 40 
scientists and other public health professionals internationally and 
has assigned over 400 staff in Atlanta and around the United States to 
work on the SARS investigation.
    CDC has organized SARS work teams to manage various aspects of the 
investigation, including providing domestic and international 
assistance and developing evolving guidance documents. These work teams 
have issued interim guidance regarding surveillance and reporting; 
diagnosis; infection control; exposure management in health-care 
settings, the workplace, and schools; biosafety and clean up; specimen 
handling, collection, and shipment; travel advisories and health 
alerts; and information for U.S. citizens living abroad and for 
international adoptions. We have updated our travel advisories and 
alerts for persons considering travel to affected areas of the world. 
We have distributed more than 600,000 health alert notice cards to 
airline passengers entering the United States from China, Hong Kong, 
Singapore, and Vietnam, alerting them that they may have been exposed 
to SARS, should monitor their health for 10 days, and if they develop 
fever or respiratory symptoms, they should contact a physician. We have 
begun distributing health alert notices to airline passengers entering 
the United States from Toronto and at selected sites along the U.S.-
Canada border.
    WHO is coordinating frequent, regular communication between CDC 
laboratory scientists and scientists from laboratories in Asia, Europe, 
and elsewhere to share findings, which they are posting on a secure 
Internet site so that they can all learn from each other's work. They 
are exchanging reagents and sharing specimens and tissues to conduct 
additional testing.
    On April 14, 2003, CDC announced that our laboratorians have 
sequenced the genome for the coronavirus believed to be the cause of 
SARS. Sequence information provided by collaborators at National 
Microbiology Laboratory, Canada, University of California at San 
Francisco, Erasmus University, Rotterdam and Bernhard-Nocht Institute, 
Hamburg facilitated this sequencing effort. The sequence data confirm 
that the SARS coronavirus is a previously unrecognized coronavirus. The 
availability of the sequence data will have an immediate impact on 
efforts to develop new and rapid diagnostic tests, antiviral agents and 
vaccines. This sequence information will also facilitate studies to 
explore the pathogenesis of this new coronavirus. We are also 
developing and refining laboratory testing methods for this novel 
coronavirus, which will allow us to more precisely characterize the 
epidemiology and clinical spectrum of the epidemic. These discoveries 
reflect significant and unprecedented achievements in science, 
technology, and international collaboration.
    In order to better understand the natural history of SARS, CDC is 
investigating aspects of the epidemiologic and clinical manifestations 
of the disease. In collaboration with our partners, we have implemented 
or planned investigations to describe the spectrum of the illness, to 
assess the natural history of the disease, to estimate the risks of 
infection, and to identify risk factors for transmission. These 
investigations are being conducted in concert with ongoing surveillance 
and epidemiologic efforts.
    Rapid and accurate communications are crucial to ensure a prompt 
and coordinated response to any infectious disease outbreak. Thus, 
strengthening communication among clinicians, emergency rooms, 
infection control practitioners, hospitals, pharmaceutical companies, 
and public health personnel has been of paramount importance to CDC for 
some time. CDC has had multiple teleconferences with state health and 
laboratory officials to provide them the latest information on SARS 
spread, implementation of enhanced surveillance, and infection control 
guidelines and to solicit their input in the development of these 
measures and processes. WHO has sponsored, with CDC support, a clinical 
video conference broadcast globally to discuss the latest findings of 
the outbreak and prevention of transmission in healthcare settings. The 
faculty was comprised of representatives from WHO, CDC, and several 
affected countries who reported their experiences with SARS. The video 
cast is now available on-line for download. Secretary Thompson and I, 
as well as other senior scientists and leading experts at CDC, have 
held numerous media telebriefings to provide updated information on 
SARS cases, laboratory and surveillance findings, and prevention 
measures. CDC is keeping its website current, with multiple postings 
daily providing clinical guidelines, prevention recommendations, and 
information for the public.

                          PREVENTION MEASURES

    Currently, CDC is recommending that persons postpone non-essential 
travel to mainland China, Hong Kong, Singapore, and Hanoi, Vietnam. We 
are recommending that U.S. travelers to Toronto observe precautions to 
safeguard their health, including avoiding settings where SARS is most 
likely to be transmitted, such as Toronto health care facilities caring 
for SARS patients. Persons planning travel to Toronto should be aware 
of the current SARS outbreak, stay informed daily about SARS, and 
follow recommended travel advisories and infection control guidance, 
which are available on CDC's website at www.cdc.gov/ncid/sars.
    Persons who have traveled to affected areas and experience fever or 
respiratory symptoms suggestive of SARS should use recommended 
infection control precautions and contact a physician. They should 
inform their healthcare provider about their symptoms in advance so any 
necessary arrangements can be made to prevent potential transmission to 
others. Health care facilities and other institutional settings should 
implement infection control guidelines that are available on CDC's 
website.
    We know that individuals with SARS can be very infectious during 
the symptomatic phase of the illness. However, we do not know how long 
the period of contagion lasts once they recover from the illness, and 
we do not know whether or not they can spread the virus before they 
experience symptoms. The information to date suggests that the period 
of contagion may begin with the onset of the very earliest symptoms of 
a viral infection, so our guidance is based on this assumption. SARS 
patients who are either being cared for in the home or who have been 
released from the hospital or other health care settings and are 
residing at home should limit their activities to the home. They should 
not go to work, school, or other public places until ten days after 
their fever has resolved and respiratory symptoms are absent or 
improving.
    If a SARS patient is coughing or sneezing, he should use common-
sense precautions such as covering his mouth with a tissue, and, if 
possible and medically appropriate, wearing a surgical mask to reduce 
the possibility of droplet transmission to others in the household. It 
is very important for SARS patients and those who come in contact with 
them to use good hand hygiene: washing hands with soap and water or 
using an alcohol-based hand rub frequently and after any contact with 
body fluids.
    For people who are living in a home with SARS patients, and who are 
otherwise well, there is no reason to limit activities currently. The 
experience in the United States has not demonstrated spread of SARS 
from household contacts into the community. Contacts with SARS patients 
must be alert to the earliest symptom of a respiratory illness, 
including fatigue, headache or fever, and the beginnings of an upper 
respiratory tract infection, and they should contact a medical provider 
if they experience any symptoms.

                   EMERGING GLOBAL MICROBIAL THREATS
 
   Since 1994, CDC has been engaged in a nationwide effort to 
revitalize national capacity to protect the public from infectious 
diseases. Progress continues to be made in the areas of disease 
surveillance and outbreak response; applied research; prevention and 
control; and infrastructure-building and training. However, SARS 
provides striking evidence that a disease that emerges or reemerges 
anywhere in the world can spread far and wide. It is not possible to 
adequately protect the health of our nation without addressing 
infectious disease problems that are occurring elsewhere in the world.
    Last month, the Institute of Medicine (IOM) published a report 
describing the spectrum of microbial threats to national and global 
health, factors affecting their emergence or resurgence, and measures 
needed to address them effectively. The report, Microbial Threats to 
Health: Emergence, Detection, and Response, serves as a successor to 
the 1992 landmark IOM report Emerging Infections: Microbial Threats to 
Health in the United States, which provided a wake-up call on the risk 
of infectious diseases to national security and the need to rebuild the 
nation's public health infrastructure. The recommendations in the 1992 
report have served as a framework for CDC's infectious disease programs 
for the last decade, both with respect to its goals and targeted issues 
and populations. Although much progress has been made, especially in 
the areas of strengthened surveillance and laboratory capacity, much 
remains to be done. The new report clearly indicates the need for 
increased capacity of the United States to detect and respond to 
national and global microbial threats, both naturally occurring and 
intentionally inflicted, and provides recommendations for specific 
public health actions to meet these needs. The emergence of SARS, a 
previously unrecognized microbial threat, has provided a strong 
reminder of the threat posed by emerging infectious diseases.

                               CONCLUSION

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

               Prepared Statement of James G. Young, M.D.

    Mr. Chairman, and Members of the Committee: I am pleased to be here 
today to discuss with you the important issue of Severe Acute 
Respiratory Syndrome (SARS), and tell you about the effective measures 
we have taken to contain and control this new disease in Ontario.
    I also wish to thank U.S. Consul General Antoinette Marwitc and her 
staff for their strong support of Toronto during our SARS outbreak.
    The Centres for Disease Control is also playing a key role in our 
efforts, and I will elaborate further on this in my remarks.
    By way of introduction, I am a medical doctor who serves in a 
number of capacities within the Ontario government. I am the Assistant 
Deputy Minister of Public Safety and Security, the Chief Coroner for 
Ontario and Commissioner of Public Security. The public security office 
also coordinates Ontario's approach to terrorism, and manages emergency 
situations within Ontario, including such things as SARS, 9/11, Y2K and 
the Ice Storm of 1998.
    The problem with responding to SARS has centered on the fact that 
we know so little about it. What is it? What are its characteristics? 
How is it spreading? When are people infectious? How do we test for it? 
And how do we control and treat it?
    In the case of Toronto and the province of Ontario, we faced these 
questions very early in the known history of SARS and only knew that we 
were facing the challenge after the disease was already spreading in a 
local hospital.
    Our index case is clear. A Toronto resident contracted SARS in an 
elevator in the Metropole Hotel in Guangdong China. That person 
returned to Toronto, became ill and died. The 43-year old son of that 
person went to hospital on March 16th for treatment of what turned out 
to be SARS, and while in the emergency department and after being 
admitted was not in respiratory isolation. This person in retrospect is 
believed to have been superinfective and our cluster of cases takes off 
from this point. This person and the next two persons who were infected 
through contact in that emergency department all went on to infect 
large numbers of other patients, health care workers and family 
members.
    Initial information about SARS was only beginning to flow around 
March 16th, and it took time to recognize the initial hospital case and 
the other contacts from that case. Once that recognition was made, we 
imposed strict and effective isolation measures.
    By this time, however, because of the highly infectious nature of 
our early cases, enough staff and patients were affected that the 
hospital was closed to new admissions, emergency cases, and transfers. 
We also started to alert the entire health care system.
    On March 25th, we decided that a provincial health emergency should 
be declared in order to mobilize the full resources of the province. We 
decided to act quickly and boldly to attempt to eradicate SARS from our 
community. We started by restricting activity in all of the hospitals 
in the province while we put in place stringent infection control 
procedures. Everyone, including all staff, were checked for illness 
before entering a hospital. Staff were required to gown, glove, and 
mask in patient areas of hospitals; masks were provided for all 
patients entering an emergency department, and isolation was required 
for respiratory patients until their conditions were determined. 
Initially we also stopped all elective surgery, stopped any visitors or 
volunteers from coming to hospitals, and organized a new very strict 
system of ambulance transfers between hospitals.
    On the community side we also took strong measures. Public Health 
vigorously tracked contacts of SARS cases and imposed 10-day isolation 
or quarantines for all contacts. If persons were found to be ignoring 
isolation orders, legal remedies were used. The public has also been 
encouraged not to go to work if they show early symptoms of SARS 
including headache, malaise or muscle ache, and before they develop 
fever. Frequent hand washing has been encouraged and a calm approach to 
the problem advocated. These measures continue to this day.
    Before our initial measures had time to take hold, a transfer of a 
highly infectious patient occurred to a nearby hospital. This patient 
was another superinfectious individual, and this transfer resulted in 
more medical staff, their families and other patients getting SARS. 
This hospital was also closed.
    These measures have proven to be effective. Both hospitals have now 
been through more than two incubation periods (20 days) without any 
further spread or new cases and so both hospitals are in the process of 
reopening. All our known SARS cases are in SARS units in our hospitals 
or, if well enough, at home in isolation finishing recovery.
    March 16th was the critical date for Toronto and our SARS outbreak. 
As well as the patients and staff becoming infected, relatives of one 
patient who took their patriarch to hospital that night also became 
infected. They subsequently visited doctors, and a funeral home, and 
were involved in a religions community. This series of unprotected 
contacts took some time to trace and piece together, and is referred to 
as the BLD Cluster (named after the religious group). There were 31 
cases within this group, and we ultimately isolated more than 500 
people. There have been no new cases from this group since April 9th. 
It is very important to note that all of our so-called ``community'' 
cases track back to the original index case. We have had no sporadic or 
unexplained SARS spread in our community.
    Over the Easter weekend we experienced a setback in our efforts. We 
had some incidents of SARS developing in medical staff working in SARS 
units. In one instance a very difficult and very long intubation in a 
SARS unit infected, we believe, 15 staff who were in attendance. We 
immediately rewrote our procedures, and we have invited Health Canada 
and the CDC to work with us to study this unfortunate event and 
recommend the best ongoing infection control standards for our SARS 
units. We appreciate the fact the CDC agreed to come and are working 
diligently and well with our people.
    The most recent major blow to our efforts was the World Health 
Organization travel advisory issued against Toronto last week. WHO did 
not visit Toronto or discuss our outbreak, or its management, directly 
with us before taking this action; nor did they give us the required 
warning before issuing it. We believe that this advisory was based on 
old data and an incomplete understanding of our situation.
    The WHO advisory unnecessarily and wrongly alarmed our own 
population, has resulted in huge economic loss, and has already 
demonstrated that it wastes valuable health resources in other 
countries such as the US by causing authorities to think they might 
have cases of SARS from Toronto when in fact there is no possible 
epidemic link to our cases. The WHO is currently reviewing its advisory 
and we urge that organization to immediately lift it based on 
scientific facts
    In fact, the CDC doctor currently working with us in Toronto has 
described our efforts as exemplary. The CDC disagrees with the WHO 
position and has correctly, in our view, talked about common sense 
precautions in its travel alert. The director is planning a trip to 
Toronto this week.
    Finally, I will comment on where we are today.
    We have SARS patients who are now well and back in the community. 
As of April 28th, Ontario had:
     37 active SARS patients are in hospitals--17 fewer than 
one week ago
     18 active SARS patients are at home finishing their 
recovery
     20 SARS patients have died, and all but one of these had 
significant other medical conditions and most were elderly.
    There has been no spread of SARS through casual community contact 
more than 20 days have passed since the last transmission among close 
contacts outside health care settings.
    We continue to work with the CDC on infection control for our 
medical staff who are working within SARS units. This, along with 
finding and isolating new travel cases that arrive from outside 
Ontario, is our current challenge.
    The streets of Toronto are as safe from SARS as the streets of 
London, Paris or Washington. In fact, a BBC reporter told me Saturday 
he saw far more masks and concern in London than Toronto. However, the 
lesson for all us that it only takes one case to start the new 
breakout.
    Thank you for this opportunity to discuss our experience in 
Ontario. On behalf of the Ontario government, let me express our 
appreciation for your interest and understanding.

                    SARS AND THE TORONTO EXPERIENCE

A report on what happened, why it happened, and the steps we need to 
        take to manage future outbreaks
    When Severe Acute Respiratory Syndrome (SARS) first appeared on the 
global scene, it took the world by surprise. Less than two months ago, 
SARS was a virtually unknown disease: today it is a household name. 
While more than 40 countries have reported SARS cases, a few countries 
have been affected in an especially dramatic way. Canada is one of 
them. The Toronto area has been particularly affected, largely due to a 
series of unpresentable circumstances during the early days of this 
disease, about which much is still unknown. But the Toronto situation 
is not completely a matter of bad luck; a lack of communication and the 
absence of political leadership were contributing factors. Now that the 
number of SARS cases is on the wane, its evident that the Toronto 
medical community handled the outbreak well (and continues to do so), 
but it's equally evident that that perception did not always reach the 
community at large or the rest of the world. It's essential that clear 
protocols be put in place as soon as possible in order to prepare for 
the next time. And there ,gill be a nest time. Future outbreaks of 
infectious diseases and other medically related crisis, in Canada and 
throughout the world, are a certainty.

                        HOW SARS CAME TO CANADA

    Here is a brief history of the birth, christening and first few 
months of the SARS outbreak.
    Cases of atypical pneumonia are reported in Guangdong Province of 
China in November and December 2002 and January 2003.
    Rumors reach the ``WHO office in Beijing around February 10, 2003.
    When Dr. L. Jianlun, who apparently brought the disease to the 
Metropole Hotel in Hong Kong, dies in February, no one at the hospital 
is infected and his history is not immediately shared with the local or 
international medical community.
    After cases are reported from Canada, China, Hong Kong Special 
Administrative Region of China, Indonesia, Philippines, Singapore, 
Thailand, and Vietnam, an international alert goes out from WHO in 
Geneva on March 15, 2003.
    What was previously described as an atypical pneumonia of unknown 
cause that was initially localized to China becomes known as Severe 
Acute Respiratory Syndrome (SARS).
    Medical and public health officials worldwide are put on official 
alert.

                            TORONTO, CANADA

    A 78-year-old woman (Case A) from Toronto is unknowingly exposed to 
SARS on February 21, apparently near or in the elevator at the 
Metropole Hotel in Hong Kong.
    With a history of heart disease and diabetes, when she dies at home 
on March 5, it was reasonable for the coroner to attribute the death to 
heart attack (what I was told by a public health doctor).
    When her eldest son (Case B) is taken to the emergency department 
of SG Hospital, a peripheral Toronto hospital, on March 7, it was 
reasonable to assume that he was suffering from a local, community-
acquired pneumonia. He has no history of foreign travel. He is 
diabetic. There is no history of contact with a SARS patient, in that 
his mother died of a heart attack.
    Owing to a chronic shortage of in-patient hospital beds. Case B 
spends about 12 hours in a crowded, high-patient-volume emergency 
department. As it is not vet routine to isolate and take respiratory 
precautions yin cases of local community acquired pneumonia, none are 
taken.
    After transfer to the ICU, Case B is thought to have pulmonary 
tuberculosis, which is not uncommon in the ethnic population served by 
the hospital. He is transferred to an isolation area.
    Case C, who acquired SARS from exposure in the emergency department 
on March 7, comes back to hospital by ambulance on March 16. As a 
result of exposure to Case C, two paramedics, a firefighter, four 
emergency staff, one housekeeper and seven visitors who were in the 
emergency department are infected. C's wife and three other family 
members are also infected. When C was intubated, a face shield, mask. 
Gown and gloves were utilized, suggesting performing the procedure 
likely acquired SARS from contact with C's wife. The doctor transmits 
the infection to one member of his family. The seven visitors in the 
emergency spread the disease to live other people. In total, 15 cases 
of SARS can be traced back to C.
    Case D, who was also exposed in emerg on March 7, is re-admitted to 
SG Hospital March 13 with a heart attack. He remains in the CCU with a 
fever, which is not uncommon after heart attach, until March 16, when 
because he requires kidney dialysis he is transferred to YC Hospital. 
(SG Hospital does not do dialysis.) Before leaving, D infects 11 people 
at SG Hospital.
    On arrival at YC Hospital, D is not placed in isolation. D's wife 
is subsequently admitted to hospital for surgery on March 21. D and his 
wife likely spread the infection to nine staff and one patient at YC 
Hospital.
    Case E, who died on April 1, contracted SARS in Emergency on March 
16 from C or his wife. Members of E's family spread SARS on March 28 
and 29 to a church group of some 500 people and during the visitation 
for E on April 3. Contacts of the group are traced and quarantined. 
Thirty-one people are classified as suspect or probable SARS in the 
Case E cluster.
    In all of Ontario, suspect/probable SARS transmission can be traced 
back to a health care facility.
    There were no cases attributed to spread in the general community.
    One person broke quarantine (with the cooperation of his wife, who 
told public health he was at home) and attended his place of work. 
While symptomatic he had contact with a co-worker in a small room, 
resulting in the co-worker's becoming a probable case. The City of York 
MOH subsequently put the entire workplace into quarantine.

                               LEADERSHIP

A. Political
    There did not appear to be much political leadership during this 
crisis. No one politician or community leader was perceived to be 
actively involved and present on the streets. A number of politicians 
organized press conferences at Chinese restaurants, to show that it was 
safe to visit the area known as Chinatown. Or they were pictured 
walking through hospitals wearing gowns. masks and other protective 
equipment. While the intentions were noble, I believe that this further 
drew attention to the Chinese community, who were not particularly 
involved in the spread of the infection beyond the initial cluster. It 
also focused attention on the hospitals, which were in some cases not 
allowing patients to have visitors and in other cases closed to even 
serious trauma and cardiac patients.
    The Toronto mayor's teen of office is soon to end, and he is not 
seeking re-election. Unfortunately, his once-excellent abilities as a 
municipal politician have deteriorated; perhaps owing to the hepatitis 
C he has been battling for several years, resulting recently in his 
being unable successfully to represent Toronto.
    Health is a shared jurisdiction between the provincial and federal 
governments, but both the provincial and federal politicians have 
largely distanced themselves from the crisis. The provincial premier of 
Ontario might have called an election but for the SARS crisis and 
opinion polls, which were not optimal. The Prime Minister of Canada is 
near the completion of his final term of office. Both the premier and 
the prime minister took golfing holidays daring the crisis. Both gave 
the impression that they would not interfere with the health issues and 
that they were powerless to deal, with the financial repercussions that 
they estimated could be in the billions of dollars.
    Neither the federal nor provincial health ministers assumed a 
hands-on role. There is at least one example of information being 
released by a government minister in a manner that potentially 
compromised the confidentiality of an infected individual and 
embarrassed a hospital, for no useful purpose. In another instance, a 
political decision was made to release the name of a housing complex, 
even though public health was certain that a case in another unit was a 
suspected SARS and the incubation period was over.
    The WHO recommended in late March that Canada step up screening 
measures at airports to help prevent SARS from spreading. Vancouver did 
take action, implementing a screening program involving mandatory 
written questionnaires for passengers and reports from flight 
attendants about ill passengers on incoming flights. But WHO felt that 
Canada implemented only the minimum of the recommended airport 
screening measures. In Toronto, signs about SARS were posted at the 
airport and leaflets were available, but mane arriving and departing 
passengers were not screened at all. It's not known how effective 
infrared scanners are in detecting fever in travelers at airports--as 
of April 30. Singapore had screened 75,000 people at its airport 
without detecting a single case of SARS--but Toronto's lack of an 
airport screening policy only served to fuel public concern that the 
situation was not under control. The appearance that something was 
being done might have gone a long way in lessening domestic as well as 
foreign anxiety.
    When the WHO issued a travel advisory for Toronto on April 23, 
political figures appeared to be out of the loop. It was as if the 
advisory was made public without any prior notice to the high levels of 
government, which I expected should have been made as a courtesy.
    A successful leader need not be the primary spokesperson. As we say 
during the Iraq crisis, President George W. Bush and General Tommy 
Franks were clearly the leaders, but each had a high ranking official 
attend the regular briefings. Mr. Bush was seen to be involved publicly 
with troops, civilians and internationally during the crisis. There 
Novas no doubt as to who was in control.
    Anxious people require a reliable, professional, straightforward 
leader. They require reassurance that steps are being taken to protect 
their health and safety.
    We have confidence in leaders who stand front and center, 
surrounded by outstanding professionals skilled in communicating 
confidence that all the appropriate steps have been anticipated and the 
crisis will thus be controlled. At the same time, it is paramount that 
the leader have the courage to act against the advice of his experts 
whenever necessary. Final decision making is more than simply 
understanding the scientific complexities. It must take into account 
the needs of the many as well as the political, economic and social 
consequences.

B. Civil Service
    There needs to be a clear delineation of the roles of the federal, 
provincial and municipal governments. The decision-making 
responsibilities of all levels need to be unambiguous. My perception 
from watching television news conferences and reading the newspapers is 
that various levels had different agendas, which from my perspective 
did not necessarily serve the community as effectively as then might 
have.
    It was apparent that the municipal medical officers of health had 
differing views on matters such as quarantine. This resulted in a 
situation where there were differences in decision making in adjoining 
municipalities. For example, had a business that was essentially closed 
down as a result of quarantine been in Toronto proper as opposed to a 
suburb, it would have remained open.
    Managing a crisis via teleconference from another city is not 
acceptable. While the provincial and federal governments may see 
themselves as being progressively higher up the chain, it is the 
municipal public health department that is responsible for individuals 
at risk as well as those who have contracted the disease.
    Levels that are one or more steps remote should not seek to control 
aspects of the process. A consensus should determine when, what and how 
often reporting back to them should occur. There is an absolute 
necessity for higher levels of government to be in the loop--but not 
predominantly by teleconference. Involvement might best be accomplished 
by providing vital human resources to join the local team, not as 
``spies'' but as contributors providing expertise that may not be part 
of the local team. The exception might be when a toxic environment 
exists, making it unwise for senior people to risk exposure.
    One would think it should normally be possible to establish a sound 
command post where representatives from all levels of government--and, 
when appropriate, the community--could run the campaign. Fixed briefing 
schedules should be possible in all but emergency situations where 
conditions are rapidly changing. Even so, in that scenario, minute-to-
minute decisions would necessarily have to be made on site and not from 
a remote location.

                     PUBLIC SECTOR--COMMUNICATIONS

A. From the Country's Senior Public Health Authority to the 
        International Community
    Seemingly, information to the World Health Organization (WHO) from 
Health Canada was such that WHO published an advisory that was not in 
keeping with what Canadian and some international experts felt was 
based on factual, scientific information. This possibly suggests a 
communication problem between Health Canada and international bodies, 
including WHO. If lines of communication have not been properly 
established, they should be. If there are not clear criteria upon which 
advisories are based, then there should be. Making travel 
recommendations when not necessary and/or when actual risks have not 
been delineated resulted in unnecessary anxiety and significant 
commercial repercussions. After the SARS outbreak, occupancy rates in 
downtown Toronto hotels were down by half, 54,000 room nights were 
cancelled, one-third of hotel staff were laid off or had their hours 
reduced, and four major conventions were cancelled, including the 
American Association for Cancer Research, which alone caused losses of 
upwards of $20 million. People wishing to visit Canada have been unable 
to purchase health insurance. Decreases in travel and tourism have 
affected other areas of Canada thousands of miles from Toronto, where 
no cases of SARS have been reported have been affected. Although the 
WHO travel advisory lasted only six days, from April 23 to April 29, 
it's believed that the Toronto economy will be adversely affected for 
up to two years.

B. Professional--from the Community to the Experts
    Community health workers have a moral and legal responsibility to 
report atypical or novel illness to the appropriate public health 
authority. Public health authorities must investigate in a timely 
manner and report to national and international agencies and bodies.
    Failure to report at either level must be taken seriously.
    Assurances that there be no government interference in the chain of 
reporting, particularly internationally, must be strictly enforced. 
Consideration must be given to creating criminal and/or civil 
repercussions for noncompliance resulting in the unleashing of an 
infectious disease locally or internationally. The international 
community must agree to support reasonable, measures to prevent the 
nurturing, harboring and dissemination--accidental or intentional--of 
infectious disease.

C. Professional--from the experts to the community
    Real-time global communication by email, tele/video conferencing, 
television and print is more available to professionals worldwide than 
ever before. The volume of communication in the Western world is such 
that we are an over-communicated society. There is so much information 
of variable quality and so little time to sort though it that we feel 
as if we're suffocating as we gasp for knowledge.
    In Toronto, the Ontario Medical Association disseminates 
``important or timely'' information to members--essentially all 
practicing physicians--by fax and/or email. There are, I suspect, 
practitioners who do not have a fax in their office and likely the 
majority have no email.
    During the SARS crisis, I received emails from the two teaching 
hospitals that I am affiliated with; the University of Toronto, where I 
have a staff appointment; and the OMA. This is in addition to ProMed 
Mail and to my checking Web sites of WHO, City of Toronto and York 
Public Health Departments, the Ontario Ministry of Health and Long Term 
Care, Health Canada, The U.S. Centers for Disease Control. The Globe 
and Mail newspaper and the Canada Newswire for press releases.
    I suggest that information to front-line health care workers; of an 
urgent/important/timely nature come from a single reliable source to 
avoid the waste of duplicated information. The composition of 
professionals on the single-source committee needs to be established. 
It should include a workable number of people with expertise to 
interpret the basic science and to put it into a form useful to front-
line providers. There should be a clear protocol to determine content 
of all releases.
    Every physician and, when appropriate, every regulated health 
professional must be assured of receiving necessary information. I 
suspect that most clinical settings have a computer utilized for 
billing purposes. Requiring mandatory on-line email capability may be 
an option. Certainly this should be required of every hospital, acute 
and chronic care facility and clinic.
    The method of communication for urgent/important/timely information 
must not be utilized for other purposes. For example, during the SARS 
crisis, I received email from the OMA regarding election of officers 
and other matters.
    Information must contain necessary basic information but must be 
more geared to providing practical advice, assistance and instruction 
to front-line health practitioners. Recommendations should be as simple 
and specific as possible.
    An information/communications professional should be part of the 
releasing source, and all information should be edited and cleared by 
the specialist.
    When information is based on partial knowledge or theories, this 
must be made clear.
    Care should be given with regard to recommendations that may be 
difficult or impossible to follow. For example, a recommendation was 
made to us that staff should wear N95 masks and gowns and that patients 
should use hand sanitizer before entering the office, but materials and 
supplies were not readily available to comply with the recommendation.
    In communities where it is not possible to rely on fax or email, 
alternative methods of communication need to be set up in advance, in 
preparation for the nest crisis.

D. Professional--from the Experts to the Hospitals
    In the Greater Toronto Area (GTA), there are some 22 hospital 
corporations, each with a board of directors, CEO and medical staff. 
There are also chronic care facilities, nursing homes, assisted living 
facilities and other health care institutions.
    Communication has to come from a central leadership to ensure that 
there are uniform policies and procedures.
    In this instance, there was confusion about what precautions 
hospitals would take and in what time course. Early on, hospitals 
outside the GTA were advised to take precautions that were likely not 
necessary. In some hospitals, out- and in-patient services were 
curtailed when there was no medical necessity to do so. Severe 
restrictions were placed on physicians. Sanctions were put in place to 
prevent physicians from working in more than one hospital. Some 
physicians were not permitted to work in private outside of hospital 
offices.
    Conference calls between the 22 hospital CEOs, their senior staff 
and various levels of government are not likely the ideal method of 
communication.
    A system needs to be established to link quickly all health care 
facilities involved in a crisis and to allow for rapid, effective 
communication to the central command. Hospitals require a senior 
administrator on 24/7 calls to respond as required.
    Where necessary, in the case of crisis, legislation should be in 
place to allow a central authority to set hospital policy and 
procedure.

E. From Professionals to the Public
    Ideally, one credible person on the local level should carry out 
communication to the public. This person should be perceived as the 
chief medical officer. The person may have a communications expert 
assist with, or be the primary speaker at press conferences.
    The person should have medical credentials as well as an 
understanding of the health, safety, and community, social, economic 
and global issues. Ideally, the person should also have formal 
communications training.
    Where possible, communication should be in the form of or 
supplemented by regular written media releases approved by a 
communications professional.
    While designating non-government professionals to ``expert'' or 
``leadership'' roles is an excellent idea, these people must have 
formal training or demonstrated ability in communication to the public. 
In this instance, there were people involved who chose unfortunate 
descriptive terms.
    It is essential that accurate information be given to the media, 
since the media rely on the data they receive from those who are 
considered the experts or spokespersons. It is the nature of news that 
dramatic information or events, even when incorrect, gets front-page 
attention; a correction or retraction is much less noticed. For 
example, there was a clear but incorrect message from perhaps the most 
quoted local expert that the SARS virus could live on inanimate objects 
for 24 hours. The information was said to have originated from the U.S. 
Centers for Disease Control with the implication that it was credible, 
when in fact it was not. Likewise, it was worldwide news when three 
Canadian children suspected of having SARS were quarantined upon their 
arrival in Australia, fueling widespread alarm. It was a much smaller 
news story when the children were shown not to have SARS after all.

                               QUARANTINE

    The use of quarantine was seen to be a draconian measure by some 
health care professionals. There was, however, no other effective way 
to control the spread of SARS.
    As quarantine has largely been a procedure of the past, protocols 
need to be revisited. The media referred to ``voluntary'' quarantine, 
when in fact there was or should have nothing voluntary about it. 
Quarantine is mandatory. The medical officer of health has powers to 
detail people against their will. In that we respect rights and 
freedoms, the issue of quarantine needs to be dealt with prior to the 
next ``crisis.'' The use of monetary penalties, involuntary 
confinement, police surveillance, electronic surveillance. etc., need 
to be examined.
    The rights of the state to screen people for disease either 
unobtrusively or without consent requires guidelines and possible 
legislation. The following issues must be debated:
    Should the state in time of urgency/emergency have the right to 
order non-invasive testing, such as estimation of body temperature, or 
invasive testing, such as blood tests, other biological samples or x-
rays?
    What rights should the state have to refuse entry to foreign 
nationals who may be at risk of being infected or spreading infectious 
disease? What criteria would be used to assess risk and classify 
individuals? Currently people with a history of harmful or violent 
behavior in association with a medical or psychiatric impairment 
require a waiver to enter the United States. Likewise, people with 
certain named diseases of public health significance (SARS is not on 
the list) fall into the ``A'' or non-admissible classification.
    In the case of a person at elevated risk of a disease of public 
health significance who may or may not have symptoms, what right should 
the state have to detain the person or prevent the person from leaving 
the jurisdiction? Is there a right or duty to inform the jurisdiction 
to which the person intends to go?
    What if any screening programs or protocols should be legal or 
mandatory at ports of entry?
    What right does a common carrier have to screen or refuse passage 
to a person at elevated risk with or without symptoms? There have been 
reports of healthy Canadians, with no risk factors other than being a 
resident of Toronto, having vacation cruises cancelled.
    Voluntary confinement also requires examination. Voluntary 
confinement is defined as going into isolation because of: 1. risk of 
potential but not confined or likely contact with an infection, or 2. 
manifesting non-specific symptoms with no specific history of contact.
    At one point, when there was concern for the possibility of 
community spread, people were advised to remain off work or school and 
not to venture out in public if they had non-specific symptoms. Health 
professionals were advised to recommend a voluntary confinement of 24 
to 72 hours, during which time it was suggested the individual would 
become sick enough that assessment in a secure facility (SARS 
assessment clinic or emergency department) was indicated.
    The very young, the elderly and people with underlying medical 
conditions could be harmed by a period of voluntary confinement. There 
have been no such reports to date, but considering the varied nature of 
the early symptoms of SARS and the possibility of infection without 
serious respiratory symptoms, voluntary confinement could have resulted 
in serious repercussions.

                            CONFIDENTIALITY

    Every effort must be made to protect the confidentiality of medical 
information. However, when the health and safety of a workplace of the 
community in general may be compromised, by maintaining 
confidentiality, there must be guidelines to allow needed information 
to be utilized in a responsible manner. If in order to determine which 
employees may have reasonably had close contact with an index case and 
thus be at risk to themselves and others, it may be necessary to break 
confidentiality. This should only be done when reasonably necessary and 
only by a regulated (licensed) health professional. It should be done 
with the clear understanding that the information released is 
confidential and that there would be a severe penalty for its further 
release. The media should be legally- bound not to release information 
that would normally be perceived as confidential in any form without 
written permission. I think this should extend to potentially 
identifying information. For example, it was not relevant that a nurse 
from Mt. Sinai Hospital rode the subway and commuter train, when all 
that needed to be said was that ``a woman'' made the journey.

                            HUMAN RESOURCES

    Public Health (PH) Departments perceive themselves to be 
underfunded and understaffed. PH staffs are not accustomed to working 
extended hours, nor are they performing many of the functions required 
in an ``urgency'' or ``emergency'' on a daily or even periodic basis. 
Provision must be made to provide additional trained staff on an 
immediate basis and to ensure that there are adequate staffing levels 
for the necessary period of time.
    Staff may be ``borrowed'' from neighboring jurisdictions, the 
private sector or the military. Preventive preparation should include 
details of the skill sets required for various urgencies and 
emergencies and rosters of professional who meet those qualifications. 
This will make calling up reserves a more seamless process. I am 
uncertain what the Canadian military could offer and what reserves 
exist in the public sector. Consideration should be given to 
establishing an active trained reserve force. Staff will suffer the 
effects of physical and emotional stress as part of the job. Provision 
has to be made in advance to accommodate anticipated needs.
    People on the front lines may, owing to the nature of the 
catastrophe, be deemed contaminated, requiring voluntary confinement or 
quarantine. This may put strains on their families. Some health care 
professionals feel they are invincible and may go through periods of 
denial. Counseling and support will be necessary--in the event of a 
prolonged crisis.

                         INFORMATION TECHNOLOGY

    Computer programs need to be developed for large-scale contact 
tracing. Provision needs to be set up to monitor perhaps tens of 
thousands of people over a course of weeks. In that there will be 
overlapping municipal health units involved, provision needs to be 
built in for sharing of information. People often do not reside in the 
same jurisdiction where they work. Involvement with the private sector 
could result in information transfer, for quarantine and tracking 
purposes to public health. This would save resources and prevent 
inputting errors.

                      SOCIAL SERVICES AND SUPPORT

    Quarantined people may require food, water, thermometers, 
medication, sanitary products, masks, gowns, etc. In addition to having 
a reasonable stockpile of medical supplies, one has to take into 
account all the other requirements that a confined person or family 
would normally require.
    In the Toronto episode, there were logistical problems in 
delivering masks, gowns and other protective equipment to community 
doctors and health facilities. In that the government had made major 
purchases, many of these medical supplies were not commercially 
available.
    Quarantine can also cause financial losses for workers. It is 
against everyone's interest for people in the workplace to spread 
disease to others, but some workers may balk at being quarantined, as 
they would lose pay. It is my strong recommendation that people be 
assured that if they are sent home on voluntary confinement or on 
quarantine by public health, they should not suffer financially. 
Employees' base pay should be maintained as a leave with pay. If they 
were impaired/disabled, they would then be entitled to whatever short-
term absence benefits the business normally had. It would be possible 
to maintain pay as a loan with the employee applying for employment 
insurance benefits and then paying back the loan once employment 
insurance was received. This way, there would be no financial reason 
for a sick person to attend work.
    During the height of the SARS outbreak, the Red Cross and other 
social agencies became overwhelmed, causing delays in the delivery of 
necessities to quarantined people. Logistics experts should likely do 
some contingency plans to more efficiently address these needs for the 
next urgency. Volunteers should be recruited, trained and made part of 
a reserve force. Likewise, hospitals and institutions require 
volunteers to screen people at entry points.
    Methods of transporting infectious or contaminated people on an 
individual basis but in large numbers also need to be addressed. Are 
ambulances the answer for the walking wounded?
    We must also take into consideration the needs of minors, the 
intellectually challenged and the psychiatrically impaired. One couple 
who became seriously ill with SARS and who remain hospitalized have two 
young children. When no relatives or social agencies, including 
Children's Aid, were willing or had facility to care for two 
quarantined children, pediatric hospital admission was the only option. 
One child was subsequently ill but recovered. Both remain in hospital, 
essentially because there is no other place for them at the present 
time.

                               CONCLUSION

    Toronto has borne Canada's largest burden in dealing with the 
illness. But at the same time, it has successfully managed to keep the 
disease from spreading across the country and across the continent. One 
reason that Toronto appears to be a hot spot for SARS is that the 
medical community has quickly become very competent at identifying the 
illness in the first place, and Canada has been very forthcoming about 
making public the numbers of suspected and probable cases.
    Still, the outbreak has served to highlight the weak spots in the 
system. SARS has been a wake-up call not only for Toronto but for the 
world. Infectious diseases will always be with us, and with the speed 
and volume of world travel, outbreaks can happen anywhere and spread 
faster than ever before. There will be other man-made and natural 
events that put great numbers of people at mortal risk. There was a 
time when spread of infection in the community and subsequent death was 
inevitable. We are not willing to accept that today. We expect a high 
level of leadership and an immediate successful response in order to 
prevent potential disaster. This makes it essential that we put systems 
in place now to more fully prepare before the next crisis strikes.

                 Prepared Statement of Senator Johnson

    Mr. Chairman, thank you for allowing me to submit my statement to 
the record for today's hearing on Severe Acute Respiratory Syndrome or 
SARS.
    We live in a time when people can move freely around the globe with 
ease and people can travel from America to virtually every corner of 
the earth in a matter of hours. This convenience provides great 
opportunities for international exploration by all of the world's 
citizens and for partnerships to be developed between countries, 
communities and societies.
    But in this time of great mobility, we must be concerned about the 
ability of newly emerging microbial threats to spread across oceans 
swiftly and quietly. Flu epidemics of the past had the capacity to take 
millions of lives and destroy communities all over the world. And 
today, SARS is impacting the lives of thousands and threatening the 
economic stability of our near neighbors in Toronto and our friends far 
away in China.
    Today we know that over 5000 people all over the world have 
suspected or probable SARS. Hundreds have died at a rate of 6 percent. 
We remain unaware of the period in which infected persons can transmit 
the disease. We remain unsure of the various modes of transmission and 
we are unaware of exactly why people in the U.S. appear healthier than 
those who contract the disease in other nations.
    There are a lot of unanswered questions, but I know that CDC and 
the WHO are working hard, around the clock even, to find these answers 
as quickly as possible and I want to commend Dr. Julie Gerberding and 
CDC for their tireless work to conduct surveillance and provide public 
health information across this country. CDC has also provided extensive 
staff resources to the WHO which I know have been so important in 
helping identify cases quickly across the globe and have made a real 
difference in reducing the spread.
    I also want to commend my colleagues in joining me to support the 
supplemental appropriation
    funds that have provided an additional $16 million dollars for the 
CDC this year to combat this new infectious disease. I know that I and 
other members of the appropriations committee would be interested to 
learn how CDC intends to utilize these funds and whether Dr. Gerberding 
considers this amount sufficient to address all disease control efforts 
including the development of diagnostic tests, antviral drugs and 
vaccines.
    We are aware of at least 41 probable cases of SARS and many 
suspected cases in the United States. Just last week, South Dakota 
reported its first suspected case of SARS, a man recently returning 
home from a trip to Hanoi. Luckily, he has returned home and I 
understand is recovering. Fortunately, the State Health Department was 
able to quickly identify this case and was able to take appropriate 
measures to protect health workers and the broader community from its 
spread. The challenge now for South Dakota and other states is to be 
able to identify all cases in an appropriate and timely manner. I am 
hearing from my state that they are in need of access to diagnostic 
tools as quickly as possible in order to be prepared to protect the 
public health. I hope CDC will continue to communicate with states 
about progress being made on the development of diagnostic tools and 
that CDC will work to disseminate these testing procedures as soon as 
possible.
    As I mentioned earlier, SARS has not hit our country as hard as 
others. We should consider ourselves lucky that our citizens have not 
felt the fear that the people of other nations have experienced. Some 
Americans have however started to express concern. Some have bought 
masks. Some have been hesitant in airports or doctors offices. And 
others have stopped eating in Asian restaurants.
    Actions similar to these may increase if we see more cases in 
America, resulting in economic hardships in our own communities. And 
with more cases, hesitancy can turn to fear, something that I know my 
colleagues and the CDC want to prevent. I encourage CDC and all of my 
colleagues in Congress to examine closely the experiences of other 
countries hard hit by SARS, and how they have handled economic 
hardships and broad fear by citizens and I hope we can work together to 
develop strategic plans to handle such issues, should the outbreak in 
the U.S. worsen. I look forward to working with my colleagues on this 
important issue and I thank the chairman for the opportunity to submit 
this testimony today.

                  Prepared Statement of Samuel Wallace

    A wise man once said that those who do not learn from the lessons 
of the past are doomed to make the same mistakes again. After World War 
II, the entire world experienced an epidemic of the sexually 
transmissible diseases: syphilis and gonorrhea. The two diseases were 
categorized: ``incurable'' and efforts were made to quarantine those 
who had the disease and some people were deliberately infected with the 
disease as ``experiments in the interests of science.'' The epidemic 
continued to spread not only in America, but also world-wide. And it 
was not until those with those diseases were treated with the 
Antibiotic Penicillin in sufficient dosages to cure those diseases that 
the epidemic was finally quelled.
    Prior to the 1960's, Viral Illnesses such as the common cold, viral 
pneumonia, the measles and the mumps were treated and cured with 
Antibiotics. (See Goodman and Gilman's Pharmacology 1955 to 1958, p. 
1388: ``Tetracycline cures Viral Illnesses such as Viral Pneumonia''. 
And in 1962 after Senator Kefauver Amended the FDA Act Requiring the 
use of Safe and Effective Medicines which were usually Antibiotics. The 
new law required the FDA to Tests for effectiveness representative of 
batches of each Antibiotic produced by each manufacturer mandatory. At 
that point the American Health Care System became so efficient that 
President Kennedy was able to reduce taxes and at the same time 
increase government revenues for the only time in American History. In 
the late 1960's President Nixon, announced: War on Cancer and rejected 
Elliot Richardson's nominee for Assistant Secretary of Health, Dr. John 
H Knowles of Mass. General Hospital who was an expert on Public Health 
and who had warned the country that the new trend of not using the 
Antibiotics to treat the sick was resulting in more mortalities and 
much higher medical costs particularly in the Public Health Sector. Had 
he been appointed and allowed to implement his ideas, he would have 
been able to save the country several trillion dollars in Health Care 
Costs up to the present. Today, it is now generally held as dicta that 
``the Antibiotics do not cure Viral Illnesses.'' Even though, I recall 
that the late Dr. Peter Marshall Murray M.D., my Uncle, a Surgeon and 
Officer in the AMA who could operate in any hospital in New York City 
told me that he prescribed the Antibiotics to Cure Viral Illnesses in 
1957. Which can still be verified by prescription records in New York 
City, that fact indicates that it was common practice at the time.

    ACQUIRED IMMUNE DEFICIENCY SYNDROME, (AIDS), like syphilis and 
gonorrhea was initially classified as ``incurable'' and so had an 
enormously high death rate. In recent years the most prevalent and 
mildest form of that disease, HIV 1, which is identical to ``Cat 
Leukemia'' found in medical and nursing students has begun to be cured 
with an ordinary course of Penicillin or Tetracycline and apparently 
many American doctors are curing both forms of the Disease with Empiric 
Antibiotic Therapy just as the American Cancer Society indicates in its 
Text: ``Clinical Oncology'' that it Oncologists now cure ``Neutropenic 
Fever'' in Cancer Patients routinely with Empiric Antibiotic Therapy. 
Which has reduced mortality for Neutropenic Fever by 95% in Cancer 
patients whose immune systems are compromised due to various causes. 
This is similar to the approach of over 51% of American Doctors who use 
similar Antibiotic Therapy to treat Viral Respiratory Diseases such as 
the common cold, influenza and viral pneumonia and perhaps Asthma. 
Though such Antibiotic Therapy is condemned by the NIH and CDC and this 
despite the fact that in 1955-1958 and onwards, the NIH co-authored 
Goodman and Gilman's: ``The Pharmacological Basis of Therapeutics'' 
which on page 1388 indicated that the Antibiotic Tetracycline cured 
such viral illnesses as Viral Pneumonia.
    It appears that at the present time the death rate due to HIV AIDS 
in America has steadily declined. However, it is not certain whether 
this is due to the ``empiric antibiotic therapy'' similar to that used 
to treat medical and nursing students who have ``cat leukemia'' 
acquired by dissecting cats , which is also used by 51% of American 
Physicians to also treat Respiratory Viral Illnesses or whether it is 
due to an increased morality among Americans generally. However, AIDS 
has continued to increase at an alarming rate not only in Africa, but 
also in Eastern Europe and in Asia, particularly in China and Thailand, 
but not in Japan where doctors rely far more heavily on Antibiotic 
Therapy or apparently the Philippines, perhaps for the same reason.
    The countries of Eastern Europe and Russia , at one time had 
excellent Public Health Systems. Those Public Health systems have been 
largely abandoned, as have free medical education. Doctors there no 
longer as a general rule prescribe Antibiotics for the sick. And 
medical costs there have begun to soar and the health of most of their 
people have begun to decline significantly, particularly in Russia.
    India which once had one of the best Public Health Systems of any 
developing country in the world to treat its poor was in the early 70's 
induced by the IMF to privatize its entire Health System and as a 
result with the exception of the Indian States of Bangor, Kerala and 
Madras, there are no longer Public Health Systems in India available 
for the poor. Last year, the President of the World Bank, Mr. Wolfson 
held hearings on this issue and he and his panel recommended that India 
adopt the Public Health Systems and its policies of the three Indian 
states that still have free Public Health for the poor. As a result, 
the Indian State of Kerala whose Public Health System relies heavily on 
Antibiotics has a lower rate of Infant Mortality than the District of 
Columbia where many doctors follow NIH guidelines with respect to 
treating illnesses with Antibiotics. Tragically this is not true for 
the remainder of India for reason just stated above.
    Today, China like Russia has begun to abandon its rural Public 
Health Systems which means as reported by some Reporters the rural poor 
have begun to suffer greatly because they can no longer obtain the 
curative Antibiotic Medicines for their Bacterial and Viral Illnesses 
which were once provided by their Public Health workers, nurses and 
practitioners who delivered Health Care to the poor living in rural 
areas.
    Right next door to the beautiful city of Hong Kong lies Guandong 
where most of Hong Kong`s food animals are raised. It is a poor rural 
area where poor peasants live in poverty in close proximity to poultry 
and live stock without the benefits of good drinking water etc. And 
where in the past once an occasional viral anomaly, such as the Hong 
Kong flue briefly developed, such a virus was defeated by antibiotic 
therapy in a relatively short period of time by Public Health Nurses 
administering antibiotics to people living in the outlying rural areas. 
But today in China the poor in neighboring rural areas can no longer 
expect to obtain such care and either must overcome their disease by 
endurance or else succumb to it.
    Now, in China, as the Public Health System there has begun to 
breakdown in rural China, the Chinese are now faced with a deadly new 
Pneumonia-like Virus, SARS, which is even is deadly to Nurses and 
Doctors who normally have access to the curative Antibiotic Medicines 
and are normally less like to become Infected with such respiratory 
viruses. And so SARS today is raging throughout China and it is not 
even certain whether doctors there today are even prescribing the 
appropriate Antibiotics in the affluent urban areas and hospitals. 
Because so many even there appear to be infected with SARS.
    So the lessons of the 1950's have been forgotten that if you wish 
to stop an epidemic, you must cure the sick generally with the common 
antibiotics such as penicillin or tetracycline which prevents the Virus 
or Bacteria from continuing to spread from one sick person to another.
    And here we are learning once more that If you do not, you may 
experience a devastating epidemic. So far perhaps as many as 6,000 
people are infected with SARS in China. And at least 500 people have 
died from that deadly Virus. And this is because of the deadliness of 
this new Pneumonia like virus and because the Chinese Public Health 
System has begun to fail.
    But here in the United States we have a Public Health System lead 
by our CDC, NIH etc. that experiments with one fad after another in 
treating Viral Illnesses, but consistently denies the Antibiotics cure 
viral illnesses-even though 50% of American doctors prescribe the 
Antibiotics in the treatment of Respiratory Viral Infections such as 
Influenza and Viral Pneumonia.
    In Puerto Rico where its doctors attend American Medical Schools a 
report in the HCFA Journal by a Miss Pagan of Puerto Rico indicated 
that the Puerto Rican Health Care System was 95% more efficient than 
the mainland Public Health System . Which I know as a former Public 
School teacher there was because the Puerto Rican Public Health System 
relies heavily Antibiotics to treat Bacterial and Viral Illnesses.
    It is because of CDC and NIH Policies no longer believes that 
antibiotics cure viral illnesses as they once did that they condemn the 
majority of American doctors who prescribed empirical antibiotic 
therapy to treat Respiratory viral infection while ignoring that as 
many as 15,000 Americans die of Influenza and thousands of Asthma 
because they condemn the doctors use of the very same antibiotic 
medicines that the NIH. once claimed or admitted cured viral illnesses. 
1 /
    Therefore, while the world is witnessing the beginnings of the 
demise of Public Health Systems in Eastern Europe, Russia and now in 
China and other parts of Asia, the United States experiences each year 
15,000 deaths due to the Influenza Virus! Because the NIH and CDC lead 
what is essentially a failed Public Health System here in the United 
States due to their disastrous Public Health Policies condemning 
doctors for prescribing Antibiotic Medicines that they once admitted 
cured the sick. /
    I personally know this is true because I lived for 5 years in 
Brazil from 1969 to 1974, where Antibiotics could be purchased over the 
counter in small quantities without a prescription. I therefore tested 
the Antibiotics against a wide range of viral, bacterial and protozoa 
illnesses. Which I testified about before the Subcommittee of Health of 
the House Ways and Means Committee Dec. 4th, 1975 indicating that the 
times of cure were reduced by 30 to 50% when a Nasal Decongestant Nose 
Drops was combined with one or two grams of Penicillin per ounce of a 
Nasal Decongestant such as Rimidol made by Squibb Industria Brazil of 
Sao Paulo. Which should be applied as Nose Drops three or four times 
per day.
    Such therapy is nonspecific innate therapy where the antibiotics 
activate the macrophage which in turn activates complement and 
immediately begins the curative process. This is scientifically 
demonstrated by observing that as soon as the Antibiotic Nose Drops are 
applied any fever is immediately reduced to normal temperatures. This 
therapy which is so safe that it can be given to infants in reduced 
strength cures most forms of Viral Pneumonia in three days time and is 
such a nonspecific form of Antibiotic Therapy that it was called: 
``Penicillin diversum'' by the Japanese Pharmaceutical Industry in 
Chemical Abstracts, April 15, 1985, Vol. 102, #15:
    130454m:''Production of antitumor agent PD-3. (I) ...[88899-01-8] 
was produced from cultures of [Penicillium diversum]...PD-3, The 
antitumor antibiotic, ``...inhibited growth of Yoshida Sarcoma cells by 
98%'' ...Institute of Physical and Chemical Research. Japan. Kokai, 
Tokyo, Koho, Japan.
    I personally discussed this formula in my testimony 1975 which is 
quite similar to the Nasal Decongestant Rimidol made by Squibb in Sao 
Paulo which is composed of Naphazoline Hcl in .1 of 1% sol. Combined 
with 1 or 2 grams Penicillin k or ampicilin per ounce of Nasal 
Decongestant Nose Drops in Congressional Testimony, Subcommittee of 
Health of the House Ways and Means Committee, Dec. 4th, 1975, Testimony 
Samuel B. Wallace where I emphasized that it could cure Viral 
Respiratory Illnesses such as Influenzas and Viral Pneumonia in three 
days time as well as bacterial infections such as cholera and Protozoa 
Illnesses such as Malaria.
    My Research with the Penicillin Nasal Decongestant Nose Drops 
Rimidol indicates that that formula could cure a wide range of viral 
respiratory illnesses such as SARS in approximately 3 days. And because 
such treatment treats the entire blood and entire glandular system to 
which the Lungs are attached it becomes impossible for the treated 
patient to become a carrier of the disease since the disease is removed 
from the entire system. And this route of administration is important 
in China because it does not use the injection of needles which are 
often reused and sometimes spread the infection. The cost of 
manufacture of Penicillin and the Nasal Decongestant in China is 
relatively low and to make such effective medicines available is far 
cheaper than building new hospitals. Since the Japanese found that the 
same formula was effective against Yoshida sarcoma or bone marrow 
cancer in vitro 98% of the time-the highest rating for any Cancer 
Agent. That means that it would also be effective against less virulent 
virus infections, hence that named the same formula that I had tested 
in Brazil from 1969 to 1974: ``Penicillin diversum'' So in any event, 
the contemporary SARS epidemic does teach us that there is still a need 
for good Public Health Systems as well as good common sense Public 
Health Policy in the world that hopefully still use the low cost safe 
and effective medicines in developing countries where so many poor 
people are unable to afford even ordinary Health Costs.
    The SARS Epidemic in China also teaches us that indifference to the 
poor in Health Care matters does not necessarily allow the more 
affluent areas to escape the consequences of such neglect of the poor. 
And that in order to protect all good Health Care in some reseasonable 
form must be available to all.
    The economic issues are also important. The SARS epidemic has 
already cost the nations of Asia billions of dollars in lost trade and 
tourism. Which is a very high price for poor Public Health and Health 
Policies and Procedures that ignore the value of the low cost safe and 
effective Antibiotic Medicines for panaceas that do not work. 
Particularly where such countries are faced with a Virus readily 
treated and cured with Antibiotics yet powerful enough to even fell 
nurses and doctors in their communities.
    The governments and the Public Health Systems of Japan and 
amazingly Viet Nam, a country much poorer than China and the 
Philippines should be singled out for praise in using the best 
Antibiotics available to them in the treatment of SARS which is a very 
deadly virus, indeed. While the doctors in Hong Kong should be reminded 
that they have a responsibility to treat and cure the sick. And not to 
just posture and ignore the plight of their sick countrymen. And of 
course there should be studies by universities in China directed toward 
improving the plight of the poor including their Health, Nutrition, 
Water and Sanitation in the rural areas of China which produce its 
vital food supplies.
    Another example, of poor Public Health Policy is subsidizing the 
Pharmaceutical Industry by encouraging it to use ``Antiviral Agents'' 
which its manufacturers and numerous studies prove do not cure HIV 
AIDS. Since the low cost safe and effective Antibiotic Medicines that 
have proved effective in Curing HIV I and III Leukemia, cost only 
pennies per patient. The cost of quelling the AIDS epidemic in 
developing countries is much less than the costs of providing medicines 
which do not cure at all. Experience has shown that such epidemics can 
not be stopped until the disease is cured world wide as occurred in the 
1950' when the epidemic of Syphilis and Gonorrhea was quelled when 
finally the antibiotics were administered to patients and there were 
cured. Therefore stopping the AIDS epidemic with ``Antiviral Agents'' 
and weak protease inhibitors is not a solution, but rather is a 
government largess for the richest industry in America-the 
Pharmaceutical Industry. Such a policy promoting the world wide use of 
ineffective panaceas is like fighting fire by pouring oil on the 
flames. Evidence that this is true is seen by the fact that Japan where 
Antibiotics are used to Cure AIDS Japan has a very miniscule incidence 
of AIDS because it is cured almost as soon as it is diagnosed.
    1/ The Pharmacological Basis of Therapeutics, P. 1386, 
Tetracycline's:

    THERAPEUTIC USES (OF TETRACYCLINE) (PARENTHESIS ADDED)
    ``The Tetracyclines are firmly established as extremely valuable 
therapeutic agents in the treatment of a variety of diseases caused by 
microorganisms''. Among the infections for which tetracycline are of 
proved value ``viral diseases''. These Antibiotics are also, of benefit 
in primary viral pneumonia''
    2/ a nonspecific form of Antibiotic Therapy that it is called: 
``Penicillin diversum'' by the Japanese Pharmaceutical Industry in 
Chemical Abstracts, April 15, 1985, Vol. 102, #15:
    130454m:''Production of antitumor agent PD-3. (I) ...[88899-01-8] 
was produced from cultures of [Penicillium diversum]...PD-3, The 
antitumor antibiotic, ``inhibited growth of Yoshida Sarcoma cells by 
98%'' ...Institute of Physical and Chemical Research. Japan. Kokai, 
Tokyo, Koho, Japan.
    3/ Penicillin diversum's 98% effectiveness in vitro is the highest 
rating ever given to any Anticancer Agent in Vitro including Adriamycin 
praised by the American Cancer Society which like Penicillium Diversum 
is a Naphazoline Hcl compound to which is added Streptomycin rather 
than Penicillin.
    However, both Dr. Bonadonna and the late Dr. Hamao Umezawa both 
indicated to me that Penicillin was more effective in treating Cancer 
as did the Japanese Pharmaceutical Industry Immediately above 
discussing [Penicillium Diversum] in Chemical Abstracts 1985.
    I personally discussed a similar formula in my testimony 1975 which 
is a Nasal Decongestant Rimidol made by Squibb in Sao Paulo composed of 
Naphazoline Hcl in .1 of 1% sol. Combined with 1 or 2 grams Penicillin 
k or ampicilin per ounce of Nasal Decongestant Nose Drops in 
Congressional Testimony, Subcommittee of Health of the House Ways and 
Means Committee, Dec. 4th, 1975, Testimony Samuel B. Wallace where I 
emphasized that it could cure Viral Respiratory Illnesses such as 
Influenzas and Viral Pneumonia in three days time as well as bacterial 
infections such as cholera and Protozoa Illnesses such as Malaria.
    My Research with the Penicillin Nasal Decongestant Nose Drops 
Rimidol indicates that that formula could cure a wide range of viral 
respiratory illnesses such as I project SARS in approximately 3 days. 
And because such treatment treats the entire blood and entire glandular 
system to which the Lungs are attached it becomes impossible for the 
treated patient to become a carrier of the disease since the disease is 
removed from the entire system. This route of administration is 
important in China because it does not use the injection of needles 
which are often reused and sometimes spread the infection. The cost of 
manufacture of Penicillin and the Nasal Decongestant in China is 
relatively low and to make such effective medicines available is far 
cheaper than building new hospitals. Since the Japanese found that the 
same formula was effective against Yoshida sarcoma or bone marrow 
cancer in vitro 98% of the time-the highest rating for any Cancer 
Agent. That means that it would also be effective against less virulent 
virus infections, hence that named the same formula that I had tested 
in Brazil from 1969 to 1974: ``Penicillin diversum''
    4/ a Nasal Decongestant Rimidol made by Squibb in Sao Paulo 
composed of Naphazoline Hcl in .1 of 1% sol. Combined with 1 or 2 grams 
Penicillin k or ampicilin per ounce of Nasal Decongestant Nose Drops 
was obliquely described in Goodman and Gilman's, The Pharmacological 
Basis of Therapeutics 1955-1958, on pages 1346 and 1347beginning on 
page 1346::
    P. 1346:4. Penicillin for Inhalation Therapy. Penicillin is 
employed in several forms and by various techniques for inhalation 
therapy of bronchorespiratory tract infections....
    P. 1347: Penicillin is inhaled through the Nose...similar 
bronchodilator drugs can be incorporated in the penicillin solution for 
use in patients requiring both antibiotic and antiasthmatic 
therapy...the usual dosage is 199,999 units of penicillin applied three 
times daily.
    My testimony before the Subcommittee of Health, House Ways and 
Means, Dec. 4, 1975:
    Indicates almost the exact quantity of Penicillin to be applied to 
patients with respiratory illnesses. Which is ten percent of that 
recommended by the Physicians Desk Reference or one gram capsules of 
penicillin for Pneumonia.
    And in addition I indicated in the same Congressional Testimony of 
Dec. 4th, 2003 that a Nasal Decongestant nose Drops such as Rimidol 
combined with Penicillin reduces Viral, Bacterial and Protozoa Fevers 
as soon as it is applied as Nose Drops. (I indicated within one day 
because I did not feel confident that any one would believe me if I 
indicated the precise true time which was within seconds of its 
application as Nose Drops. This can be verified as I suggested 
previously to the NiH in one day pilot tests against any type of fever.
    Dr. Fauci indicated on the Ted Koppel television program that he 
did not believe that a vaccine would be developed for SARS in less than 
three years time. He did express some optimism about finding a new drug 
that cured it because SARS is ``tissue sensitive.'' Thus, it is a virus 
that like Yoshida Sarcoma and Viral Pneumonia can be readily tested in 
Test tube against various medicines, including I suggest Rimidol (or 
Naphazolene Hcl combined with Penicillin K.
    And since it is both Safe and Effective and very quick to cure 
Pneumonia as my Research in Brazil and subsequent testimony in 1975 as 
well as the great research on the very deadly virus: Yoshida Sarcoma by 
the Japanese Institute indicate, I suggest that it should be given 
expedited
    Consideration for testing against the SARS Virus in vitro and in 
vivo. In order to save lives and in order to end this deadly Virus 
before it becomes Endemic everywhere.

    [Whereupon, at 3:58 p.m., the committee was adjourned.]

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