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[Senate Hearing 108-136]
[From the U.S. Government Publishing Office]

                                                        S. Hrg. 108-136
 
                SEVERE ACUTE RESPIRATORY SYNDROME (SARS)
=======================================================================

                                HEARING

                                before a

                          SUBCOMMITTEE OF THE

            COMMITTEE ON APPROPRIATIONS UNITED STATES SENATE

                      ONE HUNDRED EIGHTH CONGRESS

                             FIRST SESSION

                               __________

                            SPECIAL HEARING

                      MAY 2, 2003--WASHINGTON, DC

                               __________

         Printed for the use of the Committee on Appropriations

 Available via the World Wide Web: http://www.access.gpo.gov/congress/
                                 senate

                                 ______

                        U.S. GOVERNMENT PRINTING OFFICE
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                      COMMITTEE ON APPROPRIATIONS

                     TED STEVENS, Alaska, Chairman
THAD COCHRAN, Mississippi            ROBERT C. BYRD, West Virginia
ARLEN SPECTER, Pennsylvania          DANIEL K. INOUYE, Hawaii
PETE V. DOMENICI, New Mexico         ERNEST F. HOLLINGS, South Carolina
CHRISTOPHER S. BOND, Missouri        PATRICK J. LEAHY, Vermont
MITCH McCONNELL, Kentucky            TOM HARKIN, Iowa
CONRAD BURNS, Montana                BARBARA A. MIKULSKI, Maryland
RICHARD C. SHELBY, Alabama           HARRY REID, Nevada
JUDD GREGG, New Hampshire            HERB KOHL, Wisconsin
ROBERT F. BENNETT, Utah              PATTY MURRAY, Washington
BEN NIGHTHORSE CAMPBELL, Colorado    BYRON L. DORGAN, North Dakota
LARRY CRAIG, Idaho                   DIANNE FEINSTEIN, California
KAY BAILEY HUTCHISON, Texas          RICHARD J. DURBIN, Illinois
MIKE DeWINE, Ohio                    TIM JOHNSON, South Dakota
SAM BROWNBACK, Kansas                MARY L. LANDRIEU, Louisiana
                    James W. Morhard, Staff Director
                 Lisa Sutherland, Deputy Staff Director
              Terrence E. Sauvain, Minority Staff Director
                                 ------                                

 Subcommittee on Departments of Labor, Health and Human Services, and 
                    Education, and Related Agencies

                 ARLEN SPECTER, Pennsylvania, Chairman
THAD COCHRAN, Mississippi            TOM HARKIN, Iowa
JUDD GREGG, New Hampshire            ERNEST F. HOLLINGS, South Carolina
LARRY CRAIG, Idaho                   DANIEL K. INOUYE, Hawaii
KAY BAILEY HUTCHISON, Texas          HARRY REID, Nevada
TED STEVENS, Alaska                  HERB KOHL, Wisconsin
MIKE DeWINE, Ohio                    PATTY MURRAY, Washington
RICHARD C. SHELBY, Alabama           MARY L. LANDRIEU, Louisiana
                           Professional Staff
                            Bettilou Taylor
                              Jim Sourwine
                              Mark Laisch
                         Sudip Shrikant Parikh
                             Candice Rogers
                        Ellen Murray (Minority)
                         Erik Fatemi (Minority)
                      Adrienne Hallett (Minority)

                         Administrative Support
                             Carole Geagley

                            C O N T E N T S

                              ----------                              
                                                                   Page

Opening statement of Senator Arlen Specter.......................     1
Statement of Julie Gerberding, M.D., M.P.H., Director, Centers 
  for Disease Control and Prevention, Department of Health and 
  Human Services.................................................     2
Statement of Luther V. Rhodes, M.D., chief, Division of 
  Infectious Disease, Department of Medicine, Lehigh Valley 
  Hospital and Health Network....................................     7
Statement of Anthony S. Fauci, M.D., Director, National Institute 
  of Allergy and Infectious Diseases, National Institutes of 
  Health, Department of Health and Human Services................    16
Statement of Dr. John Combes, Senior Medical Adviser, Hospital 
  and Health System Association of Pennsylvania..................    23
Questions submitted by Senator Arlen Specter.....................    32

                SEVERE ACUTE RESPIRATORY SYNDROME (SARS)

                              ----------                              

                          FRIDAY, MAY 2, 2003

                           U.S. Senate,    
    Subcommittee on Labor, Health and Human
     Services, and Education, and Related Agencies,
                               Committee on Appropriations,
                                                    Harrisburg, PA.
    The subcommittee met at 9:29 a.m., room 140, Pennsylvania 
State Capitol, Hon. Arlen Specter (chairman) presiding.
    Present: Senator Specter.

               opening statement of senator arlen specter

    Senator Specter. Good morning, ladies and gentlemen. The 
hour of 9:30 having arrived, we will begin our hearing promptly 
on time.
    This is a hearing of the Appropriations Subcommittee on 
Labor, Health and Human Services and Education, and this 
subcommittee has jurisdiction over the budget of the Department 
of Health and Human Services which includes the National 
Institutes of Health and the Centers for Disease Control and 
Prevention.
    The world is now suffering from an enormous problem of 
SARS, originated in China, has been a problem in many parts of 
the world, recently in Toronto and also in the Lehigh Valley in 
Pennsylvania.
    The subcommittee has taken up the subject on two occasions. 
Once when the Secretary of Health and Human Services, Tommy 
Thompson, testified earlier this year about the budget for NIH, 
CDC and his entire department.
    Then we had a hearing a few weeks ago where Dr. Gerberding 
and Dr. Fauci testified, and in light of the continuing problem 
and a great deal of public concern, really public worry, about 
what is happening here, it seemed to us that it would be useful 
to convene a hearing and to have an update.
    In the world of Washington activities so much happens that 
it is hard to focus on any one subject when we are battling the 
problems of Iraq and North Korea, economy and the tax cuts, et 
cetera, so it seemed a good idea to come to a local setting.
    I very much appreciate Dr. Fauci's being here and Dr. 
Gerberding's being here. And I asked them not once, but several 
times if it was an unduly imposition on their time to come and 
testify.
    We can find very much concern that they spend their time on 
the substance of the problem, but a very big issue here is 
informing the public with the current threat, and I hear it 
from many, many constituents, what is the problem, what is 
happening, what is the risk to my family, what will be the 
risks this summer when more people are outdoors?
    Then we also have the issue of adequacy of funding which is 
a very grave concern of the subcommittee. And I have already 
expressed these concerns in Washington, but they bear 
repeating.
    We are calling upon the Centers for Disease Control to 
undertake enormous new responsibilities to prepare for 
potential bioterrorism, and SARS is an unexpected problem; but 
when we take a look at the funding for the Centers for Disease 
Control, it is really totally inadequate not to use other 
language which might be more expressive or more emphatic, but 
the Centers for Disease Control was cut by some $175 million 
this year.
    For fiscal year 2003, the Centers for Disease Control was 
funded at $4.49 billion, and this year it is at $4.32 billion 
which is a $175 million cut, and it is hard to see how the 
Centers can function with all of its increased responsibilities 
on bioterrorism, to say nothing of a unique problem like SARS.
    It is difficult to say this, but the Centers for Disease 
Control is in a dilapidated state, something that Senator 
Harkin and I, the Ranking Member of this committee, we found 
out and revisited Atlanta several years ago and undertook an 
expansion program, but this year that expansion program has 
been curtailed with a reduction of the planned funding by $152 
million.
    I think it is important for people everywhere to know what 
is happening, because this is a matter of public concern, and 
candidly, public pressure on the Congress and on the 
administration to provide the funding necessary to do the job. 
That is by way of a very brief introduction on the overall 
issues of the funding. And now we come to the substantive 
problem. Today we will take up what is happening now on the 
containment of SARS, what is happening with the problem posed 
in China, which is really, as I understand, it is out of 
control; but there have been limitations as to where people can 
travel and quarantines, and we have had some good results which 
will be detailed by our witnesses here today and they will be 
taking a look at what is going to happen in the future and what 
we need to do to have an adequate system to deal with problems 
like this one.
    Then in the local scene we will be hearing from Dr. Luther 
Rhodes, who is chief of the Division of Infectious Disease at 
Lehigh Valley Hospital and Health Network, where they recently 
treated a man with SARS.
    We will be hearing from Dr. John Combes, senior medical 
adviser for the Hospital and Health System Association of 
Pennsylvania, to get some insights as to Pennsylvania's ability 
to handle the problem and really perhaps illustrative of what 
is happening nationally.
STATEMENT OF JULIE GERBERDING, M.D., M.P.H., DIRECTOR, 
            CENTERS FOR DISEASE CONTROL AND PREVENTION, 
            DEPARTMENT OF HEALTH AND HUMAN SERVICES
    Senator Specter. Our first witness is the celebrated Dr. 
Julie Gerberding. She has been celebrating since she has become 
the star of television in the course of the past few weeks. 
Something I think she did not desire.
    That is one of the facts of life. She is the director of 
the Centers for Disease Control and Prevention. She has a 
bachelor's and M.D. from Case Western Reserve, and a master's 
in public health from the University of California, Berkeley.
    Dr. Gerberding, thank you for joining us, and we look 
forward to your testimony.
    Dr. Gerberding. Thank you. It is great to be here and 
especially in this excellent, gorgeous building. This is an 
extraordinary architectural design here and it is filled with 
history; so I am especially pleased to be here, participate in 
this hearing with you and I thank you for your leadership and 
your interests. You have been a great friend of CDC's and 
Public Health and I think we really respect and appreciate that 
you are taking time to focus in on SARS, especially at the 
local level where so much of our efforts really do have to come 
to fruition.
    I want to give you a brief recap of where we are right now 
with the epidemic. We recognize that there was a problem in 
China last November, and it took about 4 or 5 months before the 
WHO could get information about the details of the evolving 
problem in that part of the world.
    Senator Specter. As a matter of format we are going to run 
this hearing a little differently than we run hearings where 
there is a great distance between Senators and the witnesses.
    I wanted to set this up in a very informal way. And you and 
I have discussed this matter on a number of occasions, so I am 
familiar with where you are going, and I think we would have a 
better description if I do kind of a conversation with you as 
opposed to a regular type of testimony procedure.
    Why did it take so long for CDC to find out about the China 
problem?
    Dr. Gerberding. Well, the Chinese Government was unwilling 
to provide the information to the global health communities for 
quite some time. I think initially they misunderstood the 
problem as being caused by chlamydia infection or some other 
infectious disease.
    We could not access information, we do not have people 
there on the ground who can independently assess or provide 
technical assistance----
    Senator Specter. Dr. Gerberding, the Chinese authorities 
have been criticized for really stonewalling this issue, and I 
think that is one point which needs to be made, not to attach 
political blame, that is not our interest in criticizing 
Chinese officials, but to make the point that when a Nation 
faces a health problem that they do not understand, that they 
need to communicate that to people who do understand it.
    Is there any agency in the world which compares to the 
Centers for Disease Control in the United States and experience 
and understanding of this kind of a problem?
    Dr. Gerberding. I think we have tremendous experience and 
laboratory support and technical support and we work very well 
with the World Health Organization that has the international 
jurisdiction for being the first point of contact for many 
health problems. So we certainly would have wanted to help if 
we had been asked.
    Senator Specter. We are going to circulate this transcript 
far and wide. I think that is the first point to be made, and 
that is when a country faces a health problem, they ought to 
communicate it to the World Health Organization, Centers for 
Disease Control, so you can start to get some assistance.
    On a communications level, in our prior discussions you 
have commented to me about the lack of communications and the 
difficulty in correlating materials.
    Could you expand upon that issue?
    Dr. Gerberding. We need a global system for detecting and 
diagnosing and responding to emerging infectious disease 
threats. In fact, the Institute of Medicine just issued a 
report which said exactly that, that CDC and the Department of 
Defense and the USDA need to come up with a coordinated global 
interface for identifying these emerging threats.
    We have some capacity to do this in some parts of the 
world, but the network is not complete, the laboratory 
capability is inadequate in many regions such as China, and we 
have a lot to do before we really get that network to encompass 
the entire global community.
    Senator Specter. Before coming to the steps which are 
necessary to correct those kinds of problems, let us focus at 
the outset on the problem posed to the United States by SARS.
    Dr. Gerberding. At the moment we have 56 cases of probable 
size in the United States and we have not had any transmission 
from those individuals to contact their healthcare workers for 
more than 20 days, which means we have contained the problem 
here, at least for the time being.
    We are continuing to alert travelers to the hot spots, and 
the hot spots right now are China, Hong Kong and Taiwan, where 
there is very active transmission and new cases being reported 
every day.
    We are also alerting travelers to other parts of the world 
that have recently had problems with SARS--which is Canada and 
Vietnam--but we do not have travel advisories to those areas 
that have brought the disease under containment.
    So the threat in the United States right now is primarily 
from travelers returning from the hot spots, and we have to 
continue to be vigilant and identify people at the earliest 
possible moment so that we can prevent spread.
    Senator Specter. What is being done when people do come 
back from China, Hong Kong or Taiwan, the so-called hot spots?
    Dr. Gerberding. Well, first of all, we advise them not to 
go to those hot spots unless they have essential business 
there, and when they come home they would see the travel alert 
card at the airport.
    I just got one yesterday coming home from Toronto, as a 
matter of fact, and it advises if they develop any illness in 
the next 10 days that they should contact their physician so 
that the healthcare system can initiate the infection control 
precautions before they even arrive in the doctor's office.
    When they arrive at the doorstep they will have the mask 
protection and the air protection necessary----
    Senator Specter. If they start to show some signs that they 
might have something?
    Dr. Gerberding. Symptoms, exactly.
    Senator Specter. And what are those symptoms so that people 
will be able to recognize them perhaps if they or their 
children are afflicted?
    Dr. Gerberding. The most common symptom is fever. But some 
people do not start out with a fever, they start out with aches 
and pains or coughing. Sometimes they have diarrhea. And mostly 
they just feel exhausted and weak like we all do when we are 
coming down with a virus infection.
    It is not specific, and that is why we are trying to cast 
this broad net. If you do not feel well, make contact and let 
the doctor help you sort it out if there is anything to be 
concerned about.
    Senator Specter. Is that sufficient if somebody is coming 
back from China, they have essential business as you 
characterize it, and they come back and they are given a 
warning as to what to look for, but they are obviously in a 
position to have contact with a lot of other people and the 
disease is spread in an infectious way on person-to-person 
contact.
    So what risks does the community run by having somebody 
back from China or Taiwan or Hong Kong that are mingling in the 
community?
    Dr. Gerberding. So far, our science tells us that you are 
not at risk to the community until you get sick. So if you are 
incubating it, you are not likely to be infectious.
    But once you start developing the symptoms of your own 
infection, and probably when you start coughing, and you are 
having the illness, then you become an efficient transmitter to 
other people around you.
    Senator Specter. So it depends upon the individual then 
being responsive at that early moment to report to a hospital 
so that person can be effectively isolated or quarantined?
    Dr. Gerberding. Exactly. We do one additional thing in this 
country, and that is, if you are a traveler and you have been 
evaluated for SARS or admitted to the hospital for SARS, we are 
asking anybody who has been recently exposed to you, such as 
the people who live in your house with you, to participate in 
an active monitoring program. So the health department will 
make contact with these individuals on a daily basis to make 
sure that they are not developing early SARS so they can 
capture them before they pose a risk to additional people.
    Senator Specter. What has the experience been on this 
approach? Do people make the reports in time or is there some 
SARS transmitted from people that have traveled and do not 
recognize the symptoms early enough or take precautions to 
notify public health authorities to not come in contact with 
other people?
    Dr. Gerberding. We have had good, but not perfect success 
with this. We have had some people such as an individual 
admitted to the hospital here in Pennsylvania who was not 
recognized as being at risk for SARS at the first point of 
contact in the healthcare system.
    We have had 1 of the 56 SARS patients, who was a healthcare 
worker exposed to another patient, and one was a household 
contact of another patient. So kind of two transmissions 
outside of the travelers, per se.
    Senator Specter. Is that in the Pennsylvania situation?
    Dr. Gerberding. No, not in Pennsylvania. The containment 
here seems to be completely successful at this point in time 
and we are not aware if there has been any change since their 
most recent update, but the health department and the 
clinicians here were very aggressive about monitoring the 
exposed people and have a very good system for isolating the 
patient in the hospital. They actually evaluated the healthcare 
workers who were exposed and requested that they voluntarily 
quarantine themselves for ten days just to be absolutely sure 
that they did not pose a risk.
    One of the frightening things that we have seen over and 
over again in China, in Vietnam, in Taiwan and in Canada, is 
that the threat starts with the healthcare workers.
    The healthcare workers are the people who are at most risk 
for getting this in-country, and so our highest priority is the 
protection of the healthcare workers and the other patients in 
the healthcare system. That is why an aggressive approach, such 
as was taken here, is something that we would totally support.
    Senator Specter. Has there been any consideration given to 
the more extreme measures, such as quarantining the people who 
are returning back from the hot spots?
    Dr. Gerberding. We have not needed to do that in this 
country yet. It would be a very challenging task to quarantine 
everybody because we are talking about hundreds of thousands of 
people who are still traveling.
    Senator Specter. Hundreds of thousands of people are coming 
back----
    Dr. Gerberding. Over time, yes.
    Senator Specter [continuing]. From China and Taiwan and 
Hong Kong?
    Dr. Gerberding. We still have a large volume of 
international travel. You know, some people who are traveling 
to other areas have to pass through Hong Kong to get back to 
the United States, but right now the pattern of transmission 
does not indicate that that step is necessary.
    We have seen in other countries that containment can be 
achieved without quarantining incoming travelers.
    Senator Specter. What countries have you seen that 
containment can be achieved without quarantining?
    Dr. Gerberding. Vietnam has been able to achieve 
containment, and that is very important because they started 
out with a very bad healthcare outbreak, and that is where Dr. 
Urbani, the physician scientist who first recognized the 
problem there, he himself acquired SARS and died from it.
    So there was a cascading epidemic in Vietnam. By using the 
same kinds of high level protection for the healthcare workers, 
we sent CDC experts there to help get the precautions in the 
hospital organized and implemented.
    They had to close the hospital temporarily and they had to 
do some steps that we have not had to take here, but they have 
had no new cases in Vietnam for more than 20 days, which means 
that they are two incubation periods away from the last case, 
and that by definition is containment.
    Senator Specter. But they had to close the hospital?
    Dr. Gerberding. They did have to close the hospital and 
they did have to quarantine some of the healthcare workers 
because they did not get the transmission stopped without 
taking the next step.
    I was in Toronto yesterday. One of the specific things that 
I was interested in learning about was in Ontario what steps 
were taken in the hospitals there when they were involved in 
this outbreak and could not get it under containment with the 
basic steps, what enhancements did they use, and quarantining, 
expressed healthcare workers, was an important aspect of their 
plan and it works.
STATEMENT OF LUTHER V. RHODES, M.D., CHIEF, DIVISION OF 
            INFECTIOUS DISEASE, DEPARTMENT OF MEDICINE, 
            LEHIGH VALLEY HOSPITAL AND HEALTH NETWORK
    Senator Specter. Let us turn to Dr. Rhodes just to 
interrupt your testimony for a few minutes here, Dr. 
Gerberding, with the Urbani issue, to Pennsylvania where we do 
have it. Your testimony is up to this point.
    So I would like to turn to Dr. Rhodes, who is the Chief of 
the Division of Infectious Disease for the Department of 
Medicine at Lehigh Valley Hospital and Health Network.
    He has his M.D. from Loyola University. Thank you for 
joining us, Dr. Rhodes, we are very interested, anxious to hear 
what your experience has been and what the status is of the 
Pennsylvanian who had contracted SARS.
    Dr. Rhodes. Thank you. Senator Specter, members of the 
community, my name is Luther Rhodes. I was a native of 
Lewistown, Pennsylvania, right up the street, so to speak. I am 
an infectious disease clinician.
    I have been in the private practice of infectious diseases 
for about 27 years, all in the Allentown, Lehigh Valley area. 
Most of that time I have been chief of a very dynamic--and 
blessed to have an excellent division of infectious diseases 
and infectious control. We are unusually well-supported by our 
health network.
    I would like to summarize for this community today what 
happened with our two cases, actually, that were reported 
through appropriate channels, and I will discuss both 
separately to show you the different kinds of things that can 
happen at the community level.
    I am honored to be in the presence of the esteemed national 
experts, Dr. Gerberding and Dr. Fauci, and our State is 
represented by Dr. Combes and myself, but I am basically the 
local doc trying to present the situation on SARS as it runs 
forward in our community.
    About March 11 of this year Hong Kong officials published 
on an Internet site known as Pronet, at least if I watch them, 
any other infectious disease folks read. They described at that 
time an outbreak in Hong Kong of a pneumonia which had not yet 
been called SARS, but which was, and what riveted my attention 
was involving healthcare workers in large numbers, and I would 
say Dr. Gerberding and Dr. Fauci will tell you, that gets your 
attention right away because of the large number of healthcare 
workers and my experience is twofold; one, that is a problem 
medically for the people involved; the other is, we positively 
have to ensure that healthcare workers themselves are proven, 
effectively proven, prepared, otherwise there is an eminent and 
present danger of the healthcare system collapsing on itself.
    The cases initially described I think 3 days later by the 
WHO as cases of pneumonia which I think on March 14 were being 
called SARS for the first time.
    What attracted my attention was they were now in Canada, 
Indonesia, Philippines, Singapore, Thailand, and Vietnam; and a 
worldwide alert was issued, that was a Saturday, the 15th of 
March.
    Because again of the Internet and access to that 
information, we put the five emergency rooms in our area on 
alert by direct phone calls and faxes, et cetera, to say much 
of travelers from Asia, if they come in with fever and cough, 
put a mask on them and put a mask on yourself.
    Senator Specter. So you did this before when the incident 
occurred with the man who had SARS?
    Dr. Rhodes. Yes, Senator. The WHO, at least in my reading, 
I have not seen worldwide alerts come out like that, and I also 
could not get beyond the very compelling information on the 
large numbers of healthcare workers.
    I envision my own institution, you know, your own world 
where you work and spend your time, and I hearken back to when 
I was 2 months out of my fellowship, brand new, wet behind the 
ears, I showed up in Allentown the summer of 1976, and about my 
second month there the City of Allentown and the State of 
Pennsylvania was paralyzed with fear about a mystery pneumonia.
    We had several dozen American Legionnaires who died a great 
mystery. There was hints about terrorism in the air. That was 
all new to me. The observation was----
    Senator Specter. What year was that?
    Dr. Rhodes. That was August 1976.
    Senator Specter. That is when the Legionnaire's Disease hit 
Philadelphia and Bellevue and----
    Dr. Rhodes. Absolutely. Absolutely. The Legionnaire's 
outbreak or Legionnaire disease was a mystery pneumonia that 
affected Pennsylvania American Legionnaires because it was a 
statewide convention.
    At that time all we knew in Allentown was we had seven 
people in Allentown Hospital with mystery pneumonia that was 
killing people throughout the State.
    Of course everybody and their brother and their sister had 
an opinion as to what was causing it, and the hospital's 
ability to go to their healthcare was impacted severely.
    That is a lesson that sticks in my mind, and when I see 
things like SARS where the healthcare workers are directly 
threatened, I see a couple of problems.
    One is the patient themselves. Two, the healthcare team. 
Three, the ability of my community to deliver healthcare. 
People still have heart disease, diabetes, diabetic 
repercussions and the like, they need healthcare.
    What I see in Toronto, and it is compelling information, 
the greater Toronto area appears to be in disarray, getting 
better, but in disarray; and I translate that to my own 
community, and it is painful, it is threatening.
    It requires not panic, but a focus and continued 
notification of people in the township as to what is going on. 
Fortunately we have first-rate quality national resources.
    The CDC, if anything, provides us so much information, you 
have to go there two or three times a day. And national 
response from my perspective is superb. Our statewide response 
and capabilities are getting better by the hour and are very, 
very good.
    My concern is how do we incent and how do we prepare people 
at the community level, and by that I mean how do we strengthen 
the private practice of the health infrastructure in a 
meaningful way so that we can respond and respond promptly to 
that world class information.
    This tremendous information is coming out from the Centers 
for Disease Control, WHO. I mean I have tons of record-setting 
information available at my fingertips.
    When I go to my peers in those five or six area hospitals 
in Allentown, I have got to be able to put that into a 
meaningful package, because one case coming through where you 
have unrecognized, and goes through the institution, is 
catastrophic.
    Senator Specter. Dr. Rhodes, come to your case. The one 
case that did come through, tell us exactly what happened.
    Dr. Rhodes. Yes. First of all, the very first case, about 2 
weeks after we put our prevent preparation in the ER, just shy 
of 2 weeks, a 42-year-old businessman from Lehigh Valley 
returned on March 19--within 1 week I should say, on March 19 a 
42-year-old businessman from Lehigh County returned from China, 
directly from China, where within the past week he had had 
fever, cough, shortness of breath.
    He came back to Lehigh Valley and came to our emergency 
room, and because of a couple things, preventative preparation 
allowed us to give his family a mask. They took a mask out and 
met him at the tarmac, basically at the airport, put a mask on 
him. He was left in our emergency area, and the entire time he 
was there, there was essentially no exposure to the healthcare 
workers, so we could do our job in safety.
    Senator Specter. He was given a mask?
    Dr. Rhodes. He was met at the terminal, at the airport with 
a mask, and so that went unusually well. He fortunately has 
done very well. He is home. In fact, his testing to date has 
not confirmed SARS, but we reported him as a suspect case----
    Senator Specter. Did he come directly from the airport to 
the hospital?
    Dr. Rhodes. Yes. His family gave us a heads-up that there 
was a family member who had possible--this mystery pneumonia--
was coming back, and what to do.
    Senator Specter. Coming back from Toronto?
    Dr. Rhodes. Coming back actually from China, right around 
China. The second case is the Toronto connection. Two different 
situations that occurred. First occurs, like you say, 
flawlessly, or as close to that as you can get, the gentleman 
is doing well, fine and dandy.
    Senator Specter. Did the first man coming back from China, 
was he diagnosed with SARS?
    Dr. Rhodes. He was tested for and considered a suspect 
case. His testing to date has not confirmed, is not completely 
finished, but does not confirm, so he remains a suspect case 
with final testing pending. He has done excellently and he is 
already back to work.
    That was the first experience we----
    Senator Specter. You were able to intercept him after 
notice from the family, you met him coming in from the airport 
with the mask so that it is an illustration of an excellent 
move on your part having been aware of the generalized problem, 
the cooperation from the family, and taking it right into a 
situation where you could minimize exposure.
    Dr. Rhodes. Again, we translated the information to WHO and 
CDC provided to us to have those prevent preparations in place, 
and that on the surface you would say, well, okay, we are ready 
for this, bring it on, so to speak, but that was very resource 
consumption. Despite our precautions, our employees were 
nervous for several days after that.
    They still wanted to know because every day they pick up 
their paper they read healthcare workers--there was more dying 
in other countries and so on, so if there is not----
    Senator Specter. I want to say for the record, Dr. Rhodes, 
we are not mentioning names because names are confidential.
    Dr. Rhodes. The second case is on April 14, a 52-year-old 
resident of Pennsylvania, gentleman presented to the emergency 
department at one of the three LVH campuses, this is the 
Bethlehem campus, for cough, shortness of breath and recent 
fever.
    Now, this gentleman, in the 11 days prior to coming to the 
hospital, no airplane travel, no travel to Asia, he had set out 
to care for himself at one other hospital and a doctor's office 
during that 11-day time he was ill.
    They actually looked at the thought of, both places, could 
this be SARS? And discounted it because at that time the 
diagnosis or the definition did not include travel to Toronto. 
And he persisted with his symptoms and presented on the 14 to 
the Middleburg campus in Bethlehem, Pennsylvania, Lehigh Valley 
Hospital.
    Even then when he came in with that history of having been 
checked, got so-called ruled out, and having another chest x 
ray, our emergency room physicians, after about a 2\1/2\ hours 
period of time, increasingly escalated their concerns, 
increasingly escalated their precautions--point of fact, 2\1/2\ 
hours he was put in the full precaution that they put the other 
patient in on day one.
    Same institution, same prevent preparation, a little more 
experience, so to speak, about why the difference. Well, the 
definition changed. That is my concern, and I think that is the 
concern of all of us here is this clinical definition we use 
now, whether it has traveled to this, this, this, this and 
this, is a phony definition. It will change with time. It has a 
purpose. It is like the Legionnaire disease.
    The definition of Legionnaire disease in 1976 was you had 
to have spent a week in the Middle East effort. Imagine in 
retrospect how silly those folks felt that diagnosed 
Legionnaire's with a history of having been in a hotel in 
Philadelphia.
    So things changed, and if nothing else they must translate 
this world-class rapid development of information by Dr. 
Gerberding and Dr. Fauci and the Federal Government, what are 
they provided with, and translate that. That takes time, effort 
and energy and commitment. And I would say the private sector 
has to do this in partnership with public health. Public health 
infrastructure in my opinion is fragile, fragile at best at the 
local level.
    Senator Specter. Is patient number 2 isolated at the 
present time?
    Dr. Rhodes. Patient number 2 went through a hospital stay 
for pneumonia. He was Pennsylvania's first and only case.
    Senator Specter. You said Pennsylvania's first case. I 
believe it is the only Pennsylvania case.
    Is that correct, Dr. Gerberding?
    Dr. Gerberding. The first patient is on the suspect case 
list and has not had positive virology. The patient that was 
the second individual here has a probable diagnosis and our 
laboratory test is positive, so he is now being considered a 
probable case with laboratory confirmation.
    Senator Specter. But are there any other Pennsylvania 
cases?
    Dr. Gerberding. Not at this time.
    Dr. Rhodes. Fortunately this gentleman is home now 
recovering, but because of that 2\1/2\ hours, we had six 
healthcare workers who had not been protected at the time of 
their initial encounter.
    We furloughed those individuals and monitored their health 
for 10 days at home as an extra precaution. They are doing very 
well.
    Senator Specter. Dr. Rhodes, are they doing well enough so 
that you can rule out SARS having been contracted by them?
    Dr. Rhodes. The entire amount is close to 100 percent at 
this point because of the number of days that have gone by, and 
again----
    Senator Specter. When you say close to 100 percent, there 
is still some risk, however minimal, existing?
    Dr. Rhodes. Current CDC guidelines recommended our final 
testing 21 days after the original exposure and I do not 
think----
    Senator Specter. And they are still being isolated at this 
time?
    Dr. Rhodes. Well, their 10 days of incubation or quarantine 
is over. So they are actually now back to work and doing well.
    Senator Specter. Why are they permitted to be back at work 
after 10 days if it requires 21 days to be absolutely sure?
    Dr. Rhodes. The testing, if you go to Version 10 of testing 
in a new disease, that is the testing is--without question the 
testing is getting more and more sophisticated such that I am 
reasonably certain we will be able to do as they do now for 
strep throat and emergencies.
    It is something that you vote, vote out, and say you have 
SARS or you do not have SARS. That level of testing will 
improve expeditiously. We are weeks to months into this 
diagnostic testing, so it is an imperfect test and I think 
caution is proper at this point, and the CDC has decided 21 
days for reasons I am sure that they have great sense. It is 
new information that I suspect will be really nice.
    Senator Specter. Dr. Gerberding, let us hear from you on 
that point. If you are not absolutely sure until 21 days, what 
is your evaluation, that there is sufficient assurances after 
ten days to take the minimal risk?
    Dr. Gerberding. We are really talking about two different 
things. One is, at what point do we determine that people are 
not going to develop the disease SARS and that incubation 
period is ten days.
    So if you were exposed, you would wait 10 days, and if 
nothing happened to you in those 10 days, you would be assured 
that you are not going to develop the illness SARS.
    The 21 days comes in as an antibody test. If you have SARS, 
it takes 21 days for your antibody test to become positive. So 
if we want to diagnose someone or we want to see whether or not 
they actually have the coronavirus infection, when we test them 
at the beginning of their illness it is usually negative 
because the antibodies take time to develop. But we repeat the 
test after 21 days. It will be positive then. And that will 
tell us for sure, yes, there was coronavirus infection or, no, 
there was no coronavirus infection.
    So you are asking both questions with your patients. One 
is, are the healthcare workers who are exposed safe, and if it 
has gone 10 days without infection, they are safe.
    But if you are asking, does the patient have the infection 
or did they develop an asymptomatic infection, you would have 
to test them 21 days after exposure to be absolutely sure.
    Senator Specter. So it is a determination that a patient 
with a 21-day test as opposed to the 10-day incubation period?
    Dr. Gerberding. Correct.
    Senator Specter. But there is no possibility of 
transmission between the 10th day and the 21st day?
    Dr. Gerberding. We have not seen any evidence of 
transmission after 10 days here, but obviously we are still new 
in this and we have probably looked at 56 probable cases here, 
so we do have an open mind and we are not abandoning the 
follow-up of individuals who have been exposed.
    Senator Specter. In some of the commentaries there is an 
issue raised as to recurrence. What is the scientific thinking 
that SARS can recur in an individual even after there is some 
judgment that he or she is safe to be around others, Dr. 
Gerberding?
    Dr. Gerberding. I spoke with Dr. Heyman from the World 
Health Organization about this yesterday, we have more than 
5,000 probable cases of SARS internationally, and so just this 
week there were no reports of recurrence in any country.
    The only country that is reporting recurrence right now is 
Hong Kong, in 12 patients. What is unique in Hong Kong is that 
when the patients are in the hospital with the severe 
pneumonia, they get started on steroids to cut down their 
inflammation.
    What they think they are seeing is that the steroids are 
artificially disguising the inflammation in the lungs, and when 
they stop the steroids, the patients get sick again. So it may 
not be an infection recurrence. It may be an unmasking of the 
problem that was really there and that the steroids were 
artificially covering it up, and also the steroids were 
preventing the sick person from developing immunity to the 
infection and it was delaying their recovery.
    That is just a speculation right now, but that is the kind 
of question that is being asked there. We can answer the 
questions with some laboratory testing and some better clinical 
observation of the patients. We do not treat our patients here, 
typically, with steroids, in part because most of them have not 
been that ill, and in part because we have no evidence that 
steroids are particularly effective.
    Now with this new information there is some concern they 
could even be harmful. But in this country and in Canada and 
the other countries that we have good, quality information, we 
have not seen evidence of recurrence.
    Senator Specter. Dr. Gerberding, you said in response to my 
question only two of these instances in Pennsylvania and you 
said nothing else ``at this time.''
    Do I detect some concern in your answer not at this time 
that it is an open question as to further problems in 
Pennsylvania?
    Dr. Gerberding. Can I just have the last graphic there? We 
all like to think that we have successfully contained this 
here, but I think this graphic that your staff kindly prepared 
for us illustrates the situation in Canada where----
    Senator Specter. Dr. Gerberding, bring the graphic up here.
    Dr. Gerberding. Can you bring that up here?
    There was just one person----
    Senator Specter. It was not for me, Dr. Gerberding, it was 
for the television camera.
    Dr. Gerberding. This was reprinted from a newspaper 
article. There was just one person in Toronto who came back 
from Hong Kong with SARS, and that individual infected members 
of the family, they went to the hospital, all of these people 
in the hospital became infected, patients were admitted to 
other hospitals.
    That one patient created this whole cascade of SARS 
patients in Canada, and it is this cascade of transmission that 
resulted in the closure of hospitals, the travel advisory by 
the WHO that had a terrible impact on the Canadian economy and 
great fear and concern on the part of the healthcare workers. 
Many hundreds of people needed to be quarantined and so forth. 
So you can see what happens when just one patient slips through 
the cracks of the system and the terrible consequences that can 
result from that.
    We know we have to continue to be vigilant because there is 
no reason why this patient could not have arrived in the United 
States instead of Canada. And so the kinds of things that Dr. 
Rhodes talked about have to go on in every single emergency 
room and every single physician's clinic around our country 
right now. It is a big challenge and we just cannot relax.
    Senator Specter. I do not want to be unduly provincial with 
respect to Pennsylvania, but are there SARS problems in any of 
the surrounding areas, Ohio, New York, West Virginia, Maryland, 
New Jersey?
    Dr. Gerberding. There have been, and I did not bring my 
State-by-State list with me this morning, but I can certainly 
provide to you that information.
    Senator Specter. That is very interesting. You tell me what 
it means.
    Dr. Gerberding. This is just simply a list of today's 
updated information and the number of probable cases, in places 
across the United States. You asked about Ohio. There is one 
probable case of SARS in Ohio. You asked about----
    Senator Specter. Where in Ohio? The Indiana border?
    Dr. Gerberding. I do not know the answer to that and I hope 
it is not close to Pennsylvania.
    Senator Specter. Why do you say that? You are a national 
officer.
    Dr. Gerberding. I am trying to be thorough. The States that 
have the largest number of cases right now are California, 
Illinois, Massachusetts, New York, and Pennsylvania.
    Senator Specter. How many does New York have?
    Dr. Gerberding. New York has a listing of 26 suspect cases 
and 7 probable cases. Pennsylvania is listing one probable 
case, so that presumably would be the individual we are talking 
about, and has evaluated over time a total of 10 suspect 
patients here throughout the State.
    Senator Specter. Where are the other non-suspect cases, if 
you know?
    Dr. Gerberding. I can find out for you and let you know.
    Senator Specter. How about New Jersey?
    Dr. Gerberding. New Jersey is demonstrating three suspect 
patients and one probable patient today.
    Senator Specter. And West Virginia?
    Dr. Gerberding. West Virginia is not reporting any probable 
or suspect patients at the present time.
    Senator Specter. Maryland?
    Dr. Gerberding. Maryland is reporting three suspect and no 
probable cases.
    Senator Specter. Do you know what precautions are being 
taken as to the other eight suspect cases in Pennsylvania?
    Dr. Gerberding. The precautions that are being taken are as 
we described. The other patients in Pennsylvania are not 
necessarily in the hospital.
    When we say suspect patient, this has been a very difficult 
thing to explain. We wanted to cast the widest net we possibly 
could so that every patient was included in the catchment, even 
if we did not have a strong suspicion that they had SARS.
    So if a patient has traveled to any of the countries I have 
mentioned and they have any respiratory illness--they could 
have the common cold--they get included in the suspect case 
list until they have a chance to be evaluated and ruled out.
    Senator Specter. What precautions are being taken as to 
those suspect cases?
    Dr. Gerberding. It depends on how ill they are, but they 
are not in the hospital. Most of them are over the period----
    Senator Specter. Who is following them?
    Dr. Gerberding. Local clinicians and the local public 
health agencies.
    Senator Specter. Do you keep track of those?
    Dr. Gerberding. We have a State team and we have a specific 
person who is responsible for tracking each State.
    Senator Specter. And how many people from CDC do you have 
in Pennsylvania?
    Dr. Gerberding. We had a team of three people assisting Dr. 
Rhodes in the investigation of this particular scenario. Those 
individuals have now returned to CDC. They have done their work 
here and they are in the process of following up some of the 
laboratory testing----
    Senator Specter. Would you provide the subcommittee with 
the specifics on those eight suspect cases and what precautions 
are being taken to see to it that those individuals do not 
infect other people, or are not infected with the capacity to 
infect other people?
    Dr. Gerberding. Absolutely, and I can get that information 
probably while we are in this room if Mr. Gimson would just 
simply call the Pennsylvania team at CDC, we can get that for 
you.
    Senator Specter. That would be fine. We would like that. We 
may have to prolong this hearing, but we would like to know 
that because those assurances are very important to the people.
    Dr. Rhodes. Just one important point to follow up.
    Senator Specter. Sure, Dr. Rhodes.
    Dr. Rhodes. My concern is--and I am sure we all share 
this--this is what keeps me up at night--this patient, for 
example, could be presenting to any of the counties--any 
hospital in Pennsylvania tonight, and be, instead of Asia or 
Toronto, be returning from the Indian subcontinent, we know 
that the Indian subcontinent is just now getting involved with 
SARS.
    That person could end up and go to a hospital in 
Pennsylvania and our meeting today, or this meeting would be 
all about the catastrophic event that occurred in one of the 
Pennsylvania hospitals; whereby, 14 healthcare workers, nurses, 
doctors, medical students, et cetera, and numerous family 
members, had become infected with SARS.
    Right now we are looking at a definition where we see 
people from Asia, Toronto, when we get to the traveler part, 
one part of it, my concern is that is our official, borough 
official, and someone is going to get burned when the first 
person comes from India or some other place and brings SARS in 
and gets admitted, et cetera. That is what happened in Toronto. 
We should not let that happen here because we cannot afford it.
    Senator Specter. How do you suggest we prevent it?
    Dr. Rhodes. My recommendation is the clinicians are asked--
I am sure it has been around the table about 15 times an hour--
as an infection doctor, my recommendation is a patient who has 
a fever and a cough, both the person taking the interview and 
the patient, should have a mask on at the earliest possible 
moment.
    Now, that sounds heavy gambit and that is because we do not 
have record diagnostic tests, but there are other things that 
you do not catch with somebody who has a fever and coughing, 
tuberculosis, influenza, and the like, and it is a lot easier 
to take that mask off and maybe even giggle about it later 
saying it was overkill, than it is to find out on the second or 
third or fourth hospital day----
    Senator Specter. How do you identify the individuals coming 
into the United States where you ought to take those 
precautions?
    Dr. Rhodes. Fever, cough, travel would be a good general 
screening.
    Senator Specter. Traveled anywhere?
    Dr. Rhodes. International travel.
    Senator Specter. Is that realistic and practical, Dr. 
Gerberding?
    Dr. Gerberding. Well, what Dr. Rhodes is really describing 
is what you do recommend as the standard of infections within 
this country which is a concept of standard precautions. That 
is, if you have a patient with a fever and a cough, then put a 
mask on the patient until you've had a chance to evaluate the 
situation. And if the patient is too sick to have a mask, that 
the healthcare personnel should be masked. The problem is that 
people do not take that seriously unless there is a specific 
reason or a specific scenario that is sounding the alarm.
    So the vigilance of doing that is not as high as it should 
be for a lot of complicated reasons, but it is one of the areas 
that I think we have learned a lesson with SARS. I do agree 
with you that while we are relying on the WHO and the whole 
international community right now, it is extremely vigilant 
about detecting SARS in each of the countries that you have 
mentioned. There is no guarantee that someone is not going to 
pop up in a new country and import a case from a new area of 
the world.
    Senator Specter. When you say international travel, cough 
and fever, that would implicate many, many, many people. Is it 
realistic to try to identify them, what you are suggesting in 
sending out an advisory for everyone on international travel 
with a cough and a fever to identify themselves when they 
disembark to be met by a public health expert?
    Dr. Gerberding. No. I think that right now we have 
confidence that the WHO recognizes the hot spots in the world, 
and remember, it is not just travel, it is travel to an area 
where there is more than a case of SARS. It is travel to an 
area where there is ongoing transmission in the community, and 
so, travelers who go about their business run into infected 
people and pick up the infection.
    Senator Specter. Are there any countries on the WHO list 
besides the so-called hot spots you mentioned, China, Hong 
Kong, and Taiwan?
    Dr. Gerberding. Singapore is an area that is bringing the 
problem under control, but right now there still is a travel 
advisory because of the kind of transmission risks going on 
there.
STATEMENT OF ANTHONY S. FAUCI, M.D., DIRECTOR, NATIONAL 
            INSTITUTE OF ALLERGY AND INFECTIOUS 
            DISEASES, NATIONAL INSTITUTES OF HEALTH, 
            DEPARTMENT OF HEALTH AND HUMAN SERVICES
    Senator Specter. Let me turn to Dr. Fauci at this point to 
get your input on what we have already heard. Dr. Anthony Fauci 
is the director of the National Institute of Allergy and 
Infectious Disease at the National Institutes of Health. He has 
been at NIH since 1968 and has had a remarkable career there, 
obtained an M.D. from Cornell University Medical College, and 
is a world-renowned expert on infectious disease.
    Dr. Fauci, I would like your evaluation first as someone 
who studied the SARS problem very closely. What is your 
evaluation as to risk to people in the United States at the 
present time?
    Dr. Fauci. I think at the present time given the burden of 
cases that we have now, the level of alertness that we have 
been put on, the measures that the CDC has taken in 
surveillance and public health and infection control, that the 
risk is relatively small.
    In fact, when we say that, I think it is important to 
underscore what Dr. Gerberding and I have said many times and 
even before you hold a committee hearing in Washington, is that 
we still need to be on a state of alert and to take this very, 
very seriously. But the realistic risk is small, and that is 
the reason why we say we should not panic, but in the same 
breath we need to underscore that we need to take it very 
seriously and follow it on a real time, day by day basis as we 
had been doing.
    I think the testimony of Dr. Rhodes--I was really quite 
shook--I must tell you, Mr. Chairman, because what he was 
saying was in the trenches playing out of what we would hope to 
have seen in response to what the CDC is doing on a national 
level. He was monitoring the information that was coming out, 
and as soon as he heard it, he made the appropriate steps to 
how he handled, how his colleagues handled cases that were 
suspected of being SARS.
    I think if we maintain that degree of, one, alertness, two, 
seriousness and, three, implementation of the kind of 
directives that come from the CDC, my evaluation as an 
infectious disease physician is that the risk will remain 
small, but we need to keep alert.
    Senator Specter. Dr. Fauci, what is your evaluation as to 
steps to be taken, but yet countries like China who tell World 
Health Organization or CDC or other health officials what is 
happening so that we do not have a four to five-month delay and 
have the spread and tremendous problems which emanated from 
China with SARS?
    Dr. Fauci. Well, I think prior to SARS it would have been 
difficult to change the combination of cultural, political, or 
other factors that go into a country's reluctance to 
communicate on an open forthcoming basis with the rest of the 
world regarding health.
    It certainly is inexcusable and unconscionable not to do 
that. I believe with all of the pain and unfortunate events 
that have subsequently happened because of the reluctance of 
the Chinese early on to be forthcoming, I see that as being now 
a global wake up call to any country, as recalcitrant as they 
may be, to see what the dire consequences, not only for the 
rest of the world, but within their own country, that keeping 
silent--because right now China is bearing the brunt of not 
only the responsibility in some respects to what is going on, 
but some significant duress from their own country.
    Part of the problem of the disruption that is going on in 
China right now, and one of the major stumbling blocks in their 
being able to implement what they are trying to do is that the 
people just do not believe the government anymore.
    That was a self-made situation. Hopefully they will correct 
that, and as they in good faith implement good public health 
measures, there will be a return of confidence in the 
government and the government will, in fact, realize that from 
the beginning they should have done it correctly.
    I think that example will be a wake-up call to any other 
country of what the dire consequences are of not being 
forthcoming when it comes to health.
    Senator Specter. You have identified a very serious 
political problem which faces China internally now and also a 
very substantial economic problem, tremendous--not loss of 
tourism, absence of tourism, and breakdown of the function of 
the economy. So let us hope that that is an impetus, but more 
is going to have to be done on the international level as a 
follow up.
    Dr. Gerberding, in our discussions before, you emphasized 
to me a number of problems which need to be implemented, such 
as the access for CDC to specimens from other countries, and 
there is a whole range of items which you identified, such as 
having personnel who are trained in countries like China or 
Africa and the ability to get specimen are problems. What about 
the adequacy of people in China or Third World countries in 
Africa to identify a problem like SARS which might spread 
around the world, including the United States?
    Dr. Gerberding. We talk about the neglected public health 
system in this country, and we are fixing the system here. But 
the international public health system is in even worse shape. 
And of course some countries basically have no system at all. 
They have no laboratories, they have no disease detectives who 
can respond to an outbreak. So we are only as strong as our 
weakest link.
    Senator Specter. We have CDC in Africa. I know I traveled 
there last August with Senator Shelby and we found CDC people 
on the AIDS issue, but that is such an international crisis, 
that we are willing to stand that, but to what extent are CDC 
personnel available in other countries?
    Dr. Gerberding. We have CDC people in 12 African countries 
and two Caribbean countries for AIDS. In Asia we have a 
beginning of a regional center for emerging infectious diseases 
in Thailand. We also have a very small field station inside of 
China that we support with some dollars but we do not have any 
personnel there. We have very small investments in some 
laboratories throughout Asia, the Soviet Union, and Eastern 
Europe that help us detect the new flu viruses that come out 
every fall or spring, and we work with those laboratories.
    It is a very small investment. I think something like 
$30,000 per lab to help get the specimens back to CDC so that 
we can predict what we need to put in the new----
    Senator Specter. $30,000 per lab?
    Dr. Gerberding. It does not take a lot of money and the 
resource per area to make a huge difference in the capacity to 
detect new problems, but the lab is not the only piece because, 
of course, you have to have the collaboration and the 
integration with the ministers of health and the in-country 
resources and the doctors.
    Senator Specter. Dr. Gerberding, how should that be 
undertaken? Can the World Health Organization handle it? Is it 
something that is necessary for CDC, as you specified already 
been quite a number of countries? How expensive is it? Is it 
realistic for CDC to undertake it? Is it necessary for CDC to 
undertake a greater presence around the world to protect 
Americans here in the United States?
    Dr. Gerberding. WHO is clearly the essential coordinator of 
all of it, but as we learned last week, I have 400 people at 
CDC working on SARS, WHO had 39 people. So if we are going to 
realistically create a global safety net for emerging 
infectious diseases, we are going to have to utilize U.S. 
resources to support that. Again, the Institute of Medicine 
just took up this problem and they have men at NIH, CDC, USDA, 
and the DOD bring our existing resources together into a single 
uniform network and then identify the gaps----
    Senator Specter. Dr. Gerberding, Pennsylvania's 67 
counties, they are going to ask you a question, should the 
United States be the doctor of the world? I asked the question 
whether the United States should be the doctor of the world. 
The willingness of the American taxpayers to undertake this 
kind of expense might turn directly on the nature of imminence 
of the threat to the people here in the United States.
    If we are really at risk on infectious diseases like SARS, 
I mean the only way we can protect ourselves is to have a 
dispersal of CDC personnel around the world, is to have them in 
some spots, that might be persuasive, but to what extent is 
there a list of people in the United States from these emerging 
infectious diseases?
    Dr. Gerberding. I do not think we can argue about the 
absence of a risk any longer. SARS is here--it is here now in 
this country and it is affecting people in Pennsylvania. We saw 
West Nile come in from other parts of the world. West Nile is a 
problem across our Nation this year. So we live in a global 
community and we are a resource-rich Nation, we have to do our 
share to----
    Senator Specter. We are not talking about a share. We are 
really talking about doing it.
    Dr. Gerberding. We are talking about both things. We do 
some things independent of WHO. We also do a lot of things in 
collaboration with WHO as a partner in the global community. So 
certainly our Canadian partnerships and partnerships with other 
countries that have resources--sort of the global fund idea for 
AIDS--to be in the area where we need lots of people to 
contribute.
    Senator Specter. Dr. Gerberding, as we go through a 
checklist of things that you would like to have in order to 
limit infectious diseases, the Congress is going to need what 
it would cost. And then it would be a matter for public 
discussion, public debate, and an evaluation of the risk of 
infectious diseases contrasted with what the cost would be; but 
it sounds to me when we have 400 people in the CDC and in the 
World Health Organization, 39 you said, then it is really 
pretty much asking the United States to be the doctors of the 
world.
    Let us pick up some of the other things which are sore 
points or inadequacies. You talked to me about the difficulty 
of getting the specimens in your laboratories and the 
impossibility of getting airplanes and the pilots to bring them 
to CDC. Could you discuss that problem with us for the record?
    Dr. Gerberding. This is a huge challenge every time there 
is a new infectious disease problem. We know how to package 
stuff and move them safely from one point to another, but when 
there is fear, we cannot get pilots of the contracted aircraft 
to move the specimens, and the people on the ground to handle 
them in the baggage plane, et cetera.
    Senator Specter. You have had specific experience with 
that?
    Dr. Gerberding. I have just recent experience in the last 
month trying to get specimens out of Hanoi to CDC in Atlanta 
and having them sit on the ground for several days until the 
point where they were no longer valuable as specimens, because 
any chance of recovering virus in them was lost because they 
are sitting in the baggage area.
    Senator Specter. So what is the answer? Authority to the 
CDC to lease planes?
    Dr. Gerberding. We need to evaluate what our authority is. 
We do have an authority to lease aircraft because of our 
stockpile responsibilities, our national pharmaceutical 
stockpile responsibilities; but we do need clarity of whether 
or not that applies internationally and whether or not we can 
not just lease the aircraft, but whether we could use it for 
this particular activity and whether or not we could also 
contract or lease pilots. Because unless we really have trained 
pilots that are comfortable and experienced in moving 
infectious disease specimens, it is not enough to have a plane, 
you have to have somebody to fly it.
    Senator Specter. So you can work it out, you can find 
pilots and baggage handlers, et cetera, who will handle it if 
they are trained right, but you need authorization from 
Congress and obviously funding to do that?
    Dr. Gerberding. Yes. We need to get back to you about the 
authorities and the resource needs for this. As I said, we do 
have some authority, but we have to get a legal opinion about 
whether or not it would extend to this particular enterprise.
    Senator Specter. You also told me about the difficulties 
you have which frankly surprised me not having the state-of-
the-art diagnostic equipment in Atlanta. Do you have to send to 
California for some analysis or could you elaborate upon that?
    Dr. Gerberding. Well, as you know our laboratories are 
undergoing rehabilitation in large part to the efforts that 
this committee and your leadership have shown. So part of our 
buildings and facilities really is to rebuild our lab. That is 
work in progress and a lot has been done, but today if you came 
to CDC to look where we sequenced the coronavirus or where we 
at first identified it in the electron microscope, you would 
probably still be frightened by the environment that you would 
enter.
    Our scientists--before SARS started, we had no dedicated 
scientists for the coronavirus. Obviously we are going to have 
to develop some enhanced capacities in this regard.
    Senator Specter. No scientists who knew how to handle the 
coronavirus?
    Dr. Gerberding. They knew how to handle, but they were not 
specialists in coronavirus. So we pulled people from our 
respiratory pathogens activity to work on this virus because 
they understood related viruses and related problems, you have 
to have what we would call probably a pathogen discovery team 
of scientists who are experts at looking at an unknown illness 
and figuring out what is causing it.
    They did that with Hanta virus, they have done it with this 
one, we contributed to the Legionella pathogen detection. So we 
know how to do this, but today, due to the good work that is 
happening at the NIH, we have tools and resources that allow us 
to identify organisms on the basis of their genetic 
fingerprint, as opposed to growing them, culture, isolating 
them in petri dishes----
    Senator Specter. You are on two points now. You talk about 
state-of-the-art diagnostic facilities. One item is equipment 
and another item is personnel.
    Dr. Gerberding. That is true.
    Senator Specter. Start with the equipment. You had to send 
to California for the equipment or have California make the 
diagnosis on state-of-the-art equipment which they had and you 
did not have.
    Dr. Gerberding. We actually did make the discovery at CDC 
using the more traditional methods, but we wanted to see if we 
could get it as fast as possible and some scientists at the 
University of California have a gene chip that allows a much 
more rapid screening for the kinds of viruses that could 
potentially have been involved here. And we did not have that 
capacity at CDC. We collaborated with----
    Senator Specter. Is it adequate for you to collaborate, or 
as a matter of timing do you need to have the state-of-the-art 
diagnostic facilities at the CDC headquarters?
    Dr. Gerberding. I believe we could do it either way, but we 
need to have agreements and the arrangements and the support 
for the collaborators in place ahead of time so that we can be 
working on these things in advance and to speed up the whole 
process when we need to.
    Senator Specter. You need to tell this subcommittee and we 
will tell the rest of the Congress just what you need, and if 
you can do it collaboratively without additional expense, fine, 
but you tell us what it is you need.
    You also mentioned to me the need for test compounds for 
animals. Can you elaborate about what is involved there?
    Dr. Gerberding. We have animal facilities at CDC and have 
large BSL for state-of-the-art laboratories going up right now 
that will allow us to do some kinds of research, but right now 
the question people keep asking us is, do you know whether a 
viral treatment worked, and in order for us to answer that 
question quickly, we need to have an expanded capacity to test 
compounds and inoculate animals with this virus at CDC.
    We do not have the facilities and the resources to do that 
kind of rapid screening of test compounds. We can test them and 
tested with NIH and the Department of Defense over at Fort 
Detrick. We are screening now, thanks to Dr. Fauci's support.
    A large number of compounds and pharmaceutical companies 
are making double off their shelf, but we need animal models at 
CDC to help accelerate our discovery as well as our drug 
testing on site as we are learning about new emerging problems 
like this. We are also going to need the capacity to determine 
resistance to antivirals or antibacterials as they emerge and 
we need animal models for some of those studies as well.
    Senator Specter. You also told me in our prior 
conversations about the need for quarantined areas, that there 
are only six to eight entry areas which would have adequate 
quarantine if we face an epidemic coming in from overseas. 
Could you elaborate upon that?
    Dr. Gerberding. The CDC has the quarantine authority to 
protect our borders from incoming infectious diseases. Right 
now we have a very small number of quarantine stations, less 
than ten around the country, but we have many ports of entry, 
over 20 ports of entry just from Asia alone.
    So we need to make sure that when you have a situation 
where we have to go to the borders, hand information to people, 
or screen passengers who are ill with infections on airplanes, 
that the personnel are there at the time that the passenger 
arrives, a little bit like the experience Dr. Rhodes had in 
Pennsylvania where when somebody comes in off the plane, they 
have to be met by health officials. And the Federal Government 
has the responsibility for doing that at the international 
ports of entry. When we----
    Senator Specter. So what would you do today if you had a 
problem and needed a quarantine?
    Dr. Gerberding. Well, what we had done in the emergency 
situation is we had deputized other Federal employees who had 
some of the skills necessary to go and conduct an assessment, 
so we pulled them from other duties and gave them this 
temporary position to help us out because it is such an urgent 
problem. But I think over the long run we need to really 
develop a better plan and better coverage of our ports of entry 
generically, and we certainly cannot rely on this emergency 
solution if this SARS problem is going to go on very long 
because we are going to wear out.
    Fortunately, the Department of Homeland Security has helped 
us tremendously with distribution of the alerting parts, 
particularly at the Canadian border, so we are making 
arrangements with other Federal agencies to help out with some 
of those. But the health assessment has to be done by medically 
qualified CDC quarantine officers and they are few and far 
between right now.
    Senator Specter. But if you were to effectively quarantine, 
you would have to isolate people. Do you have facilities to do 
that if the need arose?
    Dr. Gerberding. The agreements are made on a site-by-site 
basis. Some of the international airports have clinics onsite 
and can isolate people until they can be transferred to the 
appropriate healthcare facility.
    We have different agreements and different locations, and 
we can make that work. It is just a matter of identifying what 
is the best local solution.
    Senator Specter. Dr. Rhodes, in your hospital do you have 
sufficient facilities to isolate if you should have a serious 
problem or a bioterrorist attack?
    Dr. Rhodes. Yes, we do. We have approximately between 60 
and 65 isolation rooms and that is unusually high. Again, I 
would stress that the healthcare facilities we have in Lehigh 
Valley are for a lot of reasons, they do not represent most 
small hospitals, most small--the bulk of what I see of 
Pennsylvania medicine at the practical level in the trenches, 
doctor's offices, small hospitals. We are blessed by having a 
lot of assets and an unusually cooperative local public health, 
long-term healthcare in particular, to form a partnership with 
them, and that is not most places.
    I can think of 15 hospitals in my immediate area who would 
have a great deal of trouble handling any degree of isolation 
beyond perhaps----
STATEMENT OF DR. JOHN COMBES, SENIOR MEDICAL ADVISER, 
            HOSPITAL AND HEALTH SYSTEM ASSOCIATION OF 
            PENNSYLVANIA
    Senator Specter. Dr. Rhodes, that is a good transition to 
bring Dr. Combes in. Dr. Combes is the senior medical adviser 
for the Hospital and Health System Association of Pennsylvania 
and the American Hospital Association.
    Do you have a hunch, Dr. Combes, of bioterrorist attack, 
and we are going to come to that with a question to Dr. 
Gerberding and Dr. Fauci in a few minutes, but while we are 
talking about isolationism and quarantine, how well-equipped 
are our Pennsylvania hospitals?
    Dr. Combes. I think on the average, hospitals are fairly 
well-equipped to meet this kind of challenge and I think in 
this whole epidemic that we have been seeing here in the United 
States the response has to be very similar, of course, as we 
have seen the excellent response from the Lehigh Valley 
Hospital.
    As Dr. Gerberding pointed out, there have only been two 
cases of secondary spread here in the United States and I think 
that is the unique cooperation between the public health 
services in the country and the acute care community and the 
local physician community. But the point that you made earlier 
about the funding for CDC and it has been referenced several 
times in terms of the weakness of the public health system here 
in this country, was very important for this issue, and all 
these unexpected issues, including bioterrorism, the same can 
be applied to hospitals as well and if the capacity becomes an 
issue, it has to do with concerns about funding of hospitals 
and their ability to keep meeting these challenges.
    We face new challenges every day. Hopefully we rise to the 
occasion like Lehigh Valley does, but when the system is itself 
in some crisis state, we have the same problems that the CDC 
has in terms of being able to respond to all the demands that 
are out there, and there are multiple demands upon us.
    Senator Specter. Dr. Fauci, you and I had discussed the 
significant assistance which has been given to the public 
health system in the United States as a result of 
appropriations which were initiated by this subcommittee 
putting in a bid at $100 million year before last and $1.4 
billion this year and projecting another significant increase, 
another $1.4 billion hopefully next year if we can find the 
money in our budget. All of that remains to be seen.
    But to what extent has that improved the ability of 
hospitals, local hospitals, in States like Pennsylvania to cope 
with these problems, the isolation problem, for example?
    Dr. Fauci. Well, certainly if you look at the public health 
infrastructure at the local level, which is mostly State and 
local public health authorities, they get the primary benefits 
of that $1.1 billion and $1.4 billion in the future.
    Senator Specter. Dr. Fauci, is it not true that the public 
health in American pretty much starved before we took a look at 
the problem of bioterrorism and----
    Dr. Fauci. Yes. If one looked at the public health 
infrastructure at the State and local level prior to the 
beginning of the rejuvenation that this committee has run to 
that prior infusion of resources, it has been unfortunately, 
and just about anyone in the business would recognize that, it 
was a local health infrastructure that had been left to go in 
disarray.
    Almost a victim of our own successes, in that with the 
advent of successful vaccinations and antibiotics and infection 
control, a very competent infrastructure that was perfectly 
suited for the kinds of things that we face in the 1930s and 
the 1940s and the 1950s, were left essentially behind.
    We now have to play some catch-up role. The first couple of 
years that this committee has allocated that money has been 
enormously helpful, but to rejuvenate a public health 
infrastructure system will take years.
    That is why we are very heartened, Mr. Chairman, by the way 
you put it, that we have not only the money from last year and 
this year, but it needs to continue because we are not going to 
fix the problem in one or two years. It is going to have to be 
a sustained commitment to that. But before the monies that you 
infused, it was in rather sad shape.
    Senator Specter. Dr. Combes, this is something that the 
subcommittee would like your help on a follow-up basis as to 
what is needed in Pennsylvania. I have visited many, many 
hospitals and the response I get consistently is that there are 
insufficient funds to handle the issue. Senator Santorum and I 
visited UPMC not too long ago and we found there some real 
steps have been taken to have a receiving unit where people 
would shower in an area close to or such an area that 
contained. But from what I hear generally, we are really just 
getting started. The public health system and SARS and then the 
impetus of bioterrorism threat activated some real concerns, so 
we were able to put up some money.
    I would like for you to give us a projection as to what it 
would take to really be able to handle the problem in our 
setting.
    Dr. Combes. First of all, I do want to thank you on behalf 
of Pennsylvania hospitals because some of the bioterrorism 
money does flow directly through the public health agencies to 
hospitals to help their preparedness, but as you have pointed 
out it is really just beginning to scratch the surface.
    Certainly issues of emerging new diseases, resistance of 
current diseases, those are things that are not being budgeted 
for in terms of what hospitals have to deal with, yet we deal 
with it every day.
    What is the overall--what do we need to do our business in 
terms of dollars? It is a hard number to come up with, but I 
know that in a State where we are facing severe Medicaid cuts 
for hospitals where I know the House and Senate have worked to 
restore some of the Medicare dollars for us and we are 
appreciative of that; but still our costs are rising, we have 
work force shortages, we have a professional liability crisis 
which is driving lots on costs, all of those things need to be 
dealt with. We certainly can come back to you with a number 
that it will take to get us to the level of preparedness.
    The other point I want to make out is just a commitment of 
healthcare professionals. The thing that I was impressed about 
Dr. Rhodes' testimony as well was the time that he and others 
in hospitals all over the country spent monitoring excellent 
resources, those of the CDC, and applying it pre-event to their 
hospitals.
    This is something that we do in addition to what we 
actually get funded for. This requires the dedication of 
professionals and administrative professionals in hospitals and 
we would like to work with your committee recognizing that and 
understanding how we can further that as we move forward 
because it is really this frontline action that will prevent 
the secondary spread of diseases like SARS and keep this 
country safe when other cities have had a major problem with 
this disease.
    So think in your costs as we go forward, and it is not only 
facilities, it is how we encourage and develop that 
professionalism and the education surrounding issues like this.
    Senator Specter. Tell us what it will take.
    Dr. Combes. We certainly will, Senator. You have been a 
good friend to us and we will keep you informed.
    Senator Specter. We have the responsibility under the 
Constitution to decide what to appropriate, but we cannot 
decide that unless we know what is needed. I am not saying that 
there will be a political will to do it, but you will find it 
in the subcommittee.
    Yes, Dr. Rhodes.
    Dr. Rhodes. Talking numbers, speaking numbers, I looked in 
the last report, our hospitals, network of three hospitals 
received about $60,000, again courtesy of Mr. Reed's efforts 
for the Homeland Defense Corporation. We spent that on 
communications here, decontamination here----
    Senator Specter. How about the $750,000 which the 
subcommittee awarded the last year? Do not forget that.
    Dr. Rhodes. I am going to right here in the dollars that 
came back.
    Senator Specter. Those are dollars that came right to your 
hospital.
    Dr. Rhodes. $750,000?
    Senator Specter. We allocated $750,000 on earmarks to each 
of the three hospitals in Lehigh Valley.
    Dr. Rhodes. I only saw $60,000.
    Senator Specter. You better go back and make sure the books 
are not----
    Dr. Rhodes. My point is this, we were at that time 
targeting and of course particularly focusing on anthrax, and 
so our $60,000 was well-spent and there may be more now, but we 
have spent almost that much, and a lot of effort and overtime 
and people just dedicated to the issue. There are hospitals 
with children who spend zero hours on that. Lehigh Valley 
Hospital, we spent a lot of time preparing it. That took away 
resources from other places.
    Now, I would say hospitals then that do that and 
participate personally want to account for these dollars. We 
should be all held accountable for what we do. And there should 
be an issue of dollars I think generated incenting people to 
perform--maybe that is being done. I am just talking from a 
perspective of a infectious disease physician.
    I asked before I came down here, how many dollars came down 
to our hospital complex, the number $60,000 was given to me, 
and where was it spent? Again, decontamination, radio and 
special protective equipment which was needed.
    I am sure it was well-spent, but I am going to say over the 
last 5 months we have been dedicated, we have had a very 
complicated and I think world-class program to get our 
healthcare center ready for smallpox immunization and a program 
in trouble nationally because of support. And then we felt 
compelled to do it right and sustain the common effort and 
energy to offer our smallpox vaccination. Now, this issue, just 
our two cases and as well as they seemed to go, I would guess 
that we spent probably $30,000, maybe more, on just those two 
cases.
    So the money goes fast and I think we have to account for 
it at the local level. And I am wondering about all of the 
other hospitals. I do not know what the exact number is, but 
what number do you take to hospitals in Pennsylvania of say 
$100 or less of the total number?
    Dr. Combes. In Pennsylvania actually a majority of our 
hospitals would be small rural hospitals numberwise, and that 
number is probably around 70 to 80 of that class. They would be 
the biggest class of hospitals. We have many small rural 
hospitals.
    Senator Specter. If you ask many more questions, Mr. 
Rhodes, I am going to have to make you co-chairman of the 
Senate Committee.
    Dr. Rhodes. That is my burning passion. If you say that 
many hospitals, I would say probably none, if any, have 
infectious disease consultative services or expertise, and 
probably have marginal infectious control because they are so 
tasked with many other duties, and that is who put the program 
like this together.
    Senator Specter. Dr. Gerberding, let me come back to the 
long line of concerns you have about being adequately funded in 
CDC and you talked about information technology and Internet 
and ways of getting communications as to what is happening in 
the five foreign corners of the world which come right back to 
our doorstep in Lehigh Valley and elsewhere. What do you have 
in mind on information technology which you would like to see?
    Dr. Gerberding. Can I just say, to frame this discussion, 
that what we have been doing over the last 2 years, anthrax, 
smallpox, terrorism preparedness, West Nile virus, SARS is 
responding to emerging crises when they come up and going full 
force with effort and diligence of the whole system. Everyone 
has stepped up to the plate and we have received congressional 
and presidential support for these programs when they emerge. 
So we have been given a lot. But what we are doing right now is 
solving crisis problems, and we are not thinking about how to 
fix the system in the long run.
    So, when I talk with you about the global safety network 
for emerging infectious diseases or a state-of-the-art 
information system that connects us from the hospital to the 
CDC to the NIH to China, I am talking about systematic longer 
term solutions to the problem that I think, in the long run, 
would pay off and take us out of crisis mode and put us into a 
system where we have a better infrastructure for managing these 
problems.
    But in terms of information technology, as you know in 
Pennsylvania where there are some excellent surveillance 
systems involving the private sector and the public health 
department----
    Senator Specter. That is in the Pittsburgh area where they 
have a new software computer model coming out of the University 
of Pittsburgh Medical Center where they are able to track in 
various locales, doctors' offices and hospitals, symptoms which 
can be correlated into an early warning of a biological attack 
or poisoning or something in the water.
    Is that the sort of a national or international system you 
are looking for?
    Dr. Gerberding. We want an international early protection 
system that will identify SARS, will identify arsenic 
poisoning, it will identify Anthrax or smallpox or any other 
threat as it pops up in the world.
    Senator Specter. You are going to have to tell us what you 
need, give us a model. Tell us what you have to do from a 
responsive approach.
    You had commented to me--moving away from SARS for just a 
few minutes onto the bioterrorism issue which is also your 
responsibility, and Dr. Fauci and I have had quite a number of 
discussions about the smallpox issue; but you made a particular 
point about insufficient knowledge as to chemical threats. 
Would you tell us what the problem is there?
    Dr. Gerberding. I think we have a lot of work to do in 
bioterrorism, but as we learned during some of the recent 
orange alerts, chemical terrorism is also an extremely 
important threat in this country.
    With bioterrorism we can get a vaccine potentially to help 
us out. With chemical terrorism we have invested so little in 
understanding what to do about antidotes or what we have not 
studied, what is the best decontamination method. The science 
is not keeping up with the need in the chemical arena and you 
really need some solid public health research here to help us 
even begin to develop sensible and prudent protocols.
    Senator Specter. Could that come, Dr. Fauci, from NIH?
    Dr. Fauci. Fortunately it can. It is the development of new 
and better improved antidotes against some of the chemicals. We 
now are dealing with antidotes that are good, but that have 
been in use for decades and decades and decades. So we do not 
have any improvements. I am not saying that the ones we have 
are bad.
    We also have detection capability, and as Dr. Gerberding 
mentioned. One of the critical issues is how you decontaminate 
if there is, for example, nerve gas. Nerve gas comes in 
different forms, liquid form, vaporized form. And when health 
workers are going to be called in to take care of individuals, 
we know from the experience of, for example, the sarin attacks 
in the Tokyo subway, that there was not a lot of basic 
knowledge or understanding of decontamination of materials such 
as clothing and facilities that would get contaminated. So we 
do have a ways to go, some of which would be contributed to by 
the NIH's research endeavor.
    Dr. Gerberding. I would just like to add that I talked with 
Dr. Zerhouni a little bit about the continuum of the research 
necessary to address some of these problems and there are many 
institutes like NIH that have an interest and the capacity to 
contribute to this knowledge. What we want to do is have a 
pipeline from NIH to taking that science and implementing it 
and evaluating it for new containment and new intervention 
protocols. So we need to work together on this and I know 
Secretary Thompson is helping us make sure we act as all one 
department.
    Senator Specter. NIH may be in a position, in fact Scott 
May is in a position. The NIH has been funded. Senator Harkin 
and I set out thinking that NIH was the crown jewels of the 
Federal Government. Maybe except for CDC the only jewel in 
Federal Government.
    But we have increased the funding from $12 billion to $27-
plus billion. Now, NIH has a lot of responsibilities on 
research on Parkinson's and Alzheimer's and heart disease and 
cancer, but there are funds available there which, $4 billion-
plus with CDC I guess, there are times of an emergency, and set 
our priorities, which NIH has to do.
    NIH has to determine the priorities for the $27 billion 
which it has. But it would seem to me that research and these 
chemical issues that Dr. Gerberding talks about--you talked 
about terrorist compounds which are readily available for 
industrial purposes. All of those really we need a line of 
defense on.
    Dr. Fauci. Can I make a comment in that regard, Mr. 
Chairman? Over the past 3 months in recognition of the precise 
point that you are making, I called a series of meetings of 
individuals in different sectors, particularly the Department 
of Defense, who had been the major players thus far in both 
chemical, radiologic, and nuclear defense. Fundamentally for 
the military we brought them together to get a feeling for what 
the scope of the landscape of what we have available, what are 
the gaps and how can we begin to fill those gaps.
    So we are already starting to move into the arena. We are 
fundamentally in the arena of biological terrorism vis-a-vis 
microbes. We are now moving into the arena of chemical 
radiological and nuclear to determine if there is anything that 
we can contribute to NIH.
    Senator Specter. The Department of Defense has its own 
independent laboratories doing all that work? Do they work with 
NIH on that?
    Dr. Fauci. They do now. In fact, it was through these 
meetings since--well, it started in a low level before 
September 11, but subsequent to September 11 and when we got 
the very large appropriation that you generously gave us, Mr. 
Chairman, we called in for even further intensification of 
interactions between ourselves and the Department of Defense. 
And we now already have very strong interactions with USAMRIID 
and we are now developing much stronger interactions with the 
chemical/medical unit of the Army as well as the 
radiobiological unit of the Navy.
    So it is coming together, as Dr. Gerberding says, but we 
are really having interaction.
    Senator Specter. Well, this subcommittee may be in a 
position to help you. CDC has $4.3 billion and NIH has $27.5 
billion, but I am not sure, but I think the Department of 
Defense has more?
    Dr. Fauci. They have more----
    Senator Specter. Do not pause too long.
    Dr. Fauci. The answer is yes.
    Senator Specter. Dr. Fauci, I want to move now to the 
subject of vaccines. I know you are working on a vaccine for 
SARS. Tell us what your progress is.
    Dr. Fauci. Yes. What we had done--there are several levels 
of generations of vaccines that are likely to be successful 
with SARS. The first and easiest thing to do is to get the 
virus, grow it up, kill it, and vaccinate an animal. And CDC 
isolated the virus within a very short period of time. They 
gave the virus to us in our laboratories up in Bethesda and it 
is now growing in quantities enough to start the following 
experiments.
    The first generation of vaccine is what we call whole 
killed or whole inactivated. Very simple. Nothing molecularly 
sophisticated. You grow it up, you kill it, you infect an 
animal with a live virus, you show that the animal can get 
sick, in this case the monkey, then you vaccinate the animal 
with the killed virus and you challenge the animal with the 
live virus. Those experiments are undergoing implementation 
right now. Within the next several months we should, by the end 
of this calendar year, have proved the concept that you can or 
not protect an animal from challenge.
    The reason why we are cautiously optimistic that this would 
be the case is that in fact we know that in the vast majority 
of people who get infected with SARS, their immune system can 
successfully contain the virus, which tells us that from a 
conceptual standpoint that is likely possible. That is very 
different from HIV/AIDS in which individuals who are infected 
and have established infection, their natural body's capability 
does not allow them to clear the virus at all.
    There are virtually no instances of that. So we are 
cautiously optimistic. Simultaneously with that first 
generation of killed whole virus vaccine, we are entering into 
several other levels. One of them is the recognitive vector. 
And by that we mean we take a simple virus that develops a 
benign virus like adenovirus. Now that we have the sequence of 
all of the genes of the SARS virus we can selectively take 
certain genes with codes for the protein that would induce 
protection if you would vaccinate, insert them into the vector, 
let them express themselves and then vaccinate individuals with 
that. So you have the safety of a benign virus, like an 
adenovirus, but the recognition of the SARS virus itself. 
Second best, second generation. That is already ongoing. We 
have entered into a collaborative agreement and a contract with 
a company called GenVec which will assist us in the ability to 
do that with HIV.
    The other is producing large quantities of purified protein 
by a certain vector that when you instill the gene and stick it 
in the bottom and let it rotate for a long period of time, that 
just spits out endless amounts of protein.
    The fourth one is a DNA vaccine approach where you take the 
purified DNA or complementary DNA that we can get from the 
virus and use that as a vaccine.
    The final one is the one that is the most difficult, but 
ultimately will have the greatest chance of being very 
effective, and that is a live attenuated vaccine, similar to 
the concept of the original Sabin polio vaccine.
    So there are at least five concepts, two of which have 
already hit the ground and I would expect that I know we are 
going to be interacting over the next year on how progress is 
coming along.
    Hopefully by the end of this calendar year you can say we 
have proven a concept. The actual development of the vaccine 
could be available for distribution, but even at its most rapid 
pace will take a few years, a couple years at least, 2 or 3 
years.
    Senator Specter. Any way to expedite that?
    Dr. Fauci. Yes. I think the way to expedite it is to put on 
the afterburners and just get as many resources and as many 
people involved in that.
    There are certain things you cannot rush----
    Senator Specter. Take the full $27 billion away?
    Dr. Fauci. I do not think we will take the full $27 
billion, but we will certainly use some of that, you bet.
    Senator Specter. I will put the afterburners on it.
    Dr. Gerberding, I saw a message from Garcia. Perhaps we 
answer the other eight spots in Pennsylvania?
    Dr. Gerberding. Yes. I am going to ask if I could tell you 
the locations of the patients when we go off the air because 
some of these are small communities and I do not want to say 
anything that would identify a specific patient in a small 
town.
    Senator Specter. Excellent idea. What are the communities, 
just a few? We will do it off the record.
    Dr. Gerberding. I would like to be respectful of that 
issue, but I can tell you that none of them have been at risk 
for transmitting infection to anyone else.
    Senator Specter. None of the others are in the hospital?
    Dr. Gerberding. None are in the hospital.
    Senator Specter. You can say that with respect to those 
eight other instances there is no risk factor?
    Dr. Gerberding. Exactly.
    Senator Specter. I had asked Secretary Ridge when we had 
Homeland Security and had them both before the Appropriations 
Subcommittee on Wednesday and before the Governmental Affairs 
Committee, I am on both those committees and I discussed this 
issue with Secretary Ridge.
    He is reluctant to get involved in health issues, per se, 
but I think this may be a matter for Homeland Defense on SARS 
depending on where it goes if he has not closed the door.
    With respect to the issues on bioterrorism and the costs 
involved there, I am glad to see the Department of Defense in 
it, but that is Homeland Defense core function and they have 
$38 billion so they should be working with you on that as to 
require a joint coordinated effort.
    As we have identified so many areas that need to be 
covered, I come back to the issue of what it is going to take 
to do it and I know that there is sometimes a little reluctance 
on the part of the executive branch that share the experience 
and expertise, but Congress has the responsibility under the 
constitution to appropriate and we need the information to 
determine what the appropriation levels should be and we are 
facing really enormously serious problems for the American 
people on healthcare for SARS or life problems as we are from 
bioterrorism.
    So, Dr. Gerberding, I understand the constraints under 
which you operate, but I want for the official record directly 
from you, the expert, your professional judgment concerning 
what resources CDC needs to protect the public health.
    I would like you to address all the relevant public health 
issues such as terrorism, homeland security and emerging 
infectious disease, including SARS, buildings, facilities, the 
obesity epidemic and other critical research that needs to be 
done by your agencies and I am requesting this information be 
made available to our subcommittee in ten work days, 16th day 
of May at the outset.
    I know that is a tall request, but we are going to be 
putting together for the budget and we are going to have to 
assess the needs you identify with the needs that we have as 
you know, not only health human services, but education and 
labor; so we have a lot of work to do to assess priorities.
    So can you do that?
    Dr. Gerberding. Yes, sir, I will do that and I appreciate 
fulfilling the recommendation and I also appreciate the 
priorities that your committee places.
    Senator Specter. And, Dr. Fauci, I would ask you the same 
question, recognizing the constraints under which you operate, 
but I want for our official subcommittee record, addressing 
that record, directly from you the expert, your professional 
judgment, what resources NIH needs to protect the public health 
concerning public health issues, terrorism, homeland security, 
emerging infectious diseases including SARS, what your building 
and facility needs are.
    We have a big problem with the obesity epidemic, strange to 
fit it in here, but it is part of our allocation of resources 
and other critical research that needs to be done, and I 
request this information for the subcommittee, you get it to us 
within 10 working days by May 16 if you would. Can you 
undertake that assignment, Dr. Fauci?
    Dr. Fauci. I will.
    Senator Specter. Okay. This has been a very informative 
hearing. It is a little different format than sitting around a 
roundtable, but we really appreciate your coming, Dr. Fauci and 
Dr. Gerberding.
    I repeat for the record my repeated inquiries to you as to 
how this would impact, but I think it is very important to hear 
the assurances which have been given today to the people.
    This will be noted far beyond the borders of the 
Commonwealth of Pennsylvania, and we thank you, Dr. Rhodes, for 
what you have done in the emergency situation and I admire your 
background and your ability to cope with it.
    It was your technical proficiency in all the hospitals in 
America. We would not give so much money to NIH and CDC, we 
just rely on you folks.
    Dr. Rhodes. I found the rest of the money. The $60,000 was 
the amount allocated for bioterrorism by hospitals in our area. 
The rest of the money was put into not only resources, but 
education, et cetera.
    So everybody knows where all the money is. I do not want to 
leave you nervous that we lost it.
    Senator Specter. And, Dr. Combes, thank you for joining us. 
I understand what the Pennsylvania Hospital Association does 
and we have attached you with some responsibilities to tell us 
what you need.
    I cannot promise, I am only one vote out of 100, but then 
we have the House of Representatives, but our subcommittees are 
starting to and we have shown that we have put resources behind 
needs, and our first subcommittee and the Congress are 
committed to it, and the Congress has the constitutional 
responsibility to decide what the priorities are, where the 
public's money should be.
    We have a $10 trillion national economy and a $2 trillion, 
$200 billion Federal budget, so we can do it. We have a lot of 
problems in this country, but we are up to the challenge.
    Dr. Combes. While I wrote down your request of Dr. 
Gerberding and Dr. Fauci, I would be very happy to have us 
submit the same type of information to you by May 16 if that 
would be helpful to you and the subcommittee.
    Senator Specter. Consider yourself bound.

                     additional committee questions

    There will be some additional questions which will be 
submitted for your response in the record.
    [The following questions were not asked at the hearing, but 
were submitted to the Department for response subsequent to the 
hearing:]
              Questions Submitted by Senator Arlen Specter
                        public health protection
    Question. I understand the constraints under which you operate, but 
I want, for the official record, directly from you, the expert, your 
professional judgment concerning what resources NIH needs to protect 
the public's health.
    Please address all relevant public health issues, such as terrorism 
and Homeland Security, emerging infectious diseases, including SARS, 
buildings and facilities, the obesity epidemic, and other critical 
research that needs to be done by your agency. I am requesting that 
this information be delivered to the Subcommittee within ten (10) 
working days at the latest.
    Answer. At the time the preliminary fiscal year 2004 budget was 
developed in the spring of 2002, NIH's professional judgement budget 
requested a total of $29,560 million. Detailed information on the 
professional judgement request for selected programs with high impact 
on public health are provided below. In reviewing this information, 
please keep in mind that neither the operating division request to the 
Secretary nor the HHS request to OMB was constructed in the context of 
other national priorities or government-wide budgetary limitations. We 
believe that the President's Budget is strong in its efforts to protect 
the public's health, especially in the context of all health priorities 
and needs. As I have stated publicly, I support the NIH request in the 
fiscal year 2004 President's Budget. The information provided on 
biodefense and emerging diseases was provided by Dr. Anthony Fauci, 
Director, National Institute of Allergy and Infectious Diseases.

PROFESSIONAL JUDGEMENT OF RESOURCE NEEDS FOR SELECTED NIH RESEARCH AREAS
                        [In millions of dollars]
------------------------------------------------------------------------
                                                Fiscal years
                                  --------------------------------------
                                       2003         2004         2005
------------------------------------------------------------------------
Biodefense.......................        1,488        1,886        2,296
Emerging Infectious Disease (inc.          200          504          609
 SARS) \1\.......................
------------------------------------------------------------------------
\1\ Excludes resources for emerging infectious diseases included in
  biodefense line.

    Biodefense Research.--Additional resources would accelerate the 
research and development of countermeasures against biological agents 
of terrorism. Funding increases will support the expansion of basic 
research, additional construction of regional high- containment 
laboratories for extramural researchers, and expansion of applied 
research with academia and industry to accelerate the research and 
development of the countermeasures.
    In addition to supporting the advanced product development of the 
next generation smallpox vaccine, the funding will also accelerate and 
support the advanced product development of candidate countermeasures 
against botulism toxin, plague, tularemia, and viral hemorrhagic 
fevers, such as ebola and rift valley fever.
    Emerging Diseases Research (including SARS).--Implements a 
comprehensive research agenda to combat SARS. Funding will support a 
multiprong strategy to rapidly expand research to develop multiple 
vaccine candidates to prevent SARS. Also initiates research on immune-
based therapies while expanding screening and testing of thousands of 
compounds for therapeutic activity against the SARS virus. Includes the 
rapid expansion of: basic research, including the pathogenesis of the 
disease; clinical research and infrastructure to test candidate drugs, 
vaccines and diagnostics; and the advanced product development of the 
most promising vaccine candidates.
    Obesity.--In fiscal year 2004, the NIH professional judgement 
request for obesity research is $390 million. These funds will 
facilitate progress in NIH research to address the increasingly severe 
obesity epidemic and its serious implications for public health. The 
recently formed NIH Obesity Research Task Force has identified the 
following topic areas as critical areas for expanded research. Examples 
of potential studies are listed below each topic area.
  --Identifying the Genetic, Behavioral, and Environmental Factors that 
        Cause Obesity and its Associated Comorbidities.--The results of 
        such research will open new avenues to investigate the causes 
        and potential therapies for obesity.
  --Understanding the Pathogenesis of Obesity and Associated Co-
        Morbidities.--The results of such research will provide 
        fundamental knowledge to fuel the search for new strategies to 
        prevent or treat obesity.
  --Prevention and Treatment of Obesity.--Research in this area would 
        be designed to analyze the efficacy of different approaches to 
        prevention and treatment of obesity on weight loss and 
        associated diseases, to test innovative approaches to prevent 
        inappropriate weight gain, and to understand the molecular and 
        behavioral factors underlying weight change.
  --Policy, Health Surveillance and Services, Economics, and 
        Translation to Practice.--Research in these areas will 
        facilitate the translation of obesity research discoveries into 
        practice to improve public health. Additionally, NIH-supported 
        research will provide a scientific foundation to inform policy 
        decisions.
  --Enabling Technologies.--Recent in advances in computer technology, 
        robotics, miniaturization and molecular biology have already 
        changed many aspects of our lives and promise to provide a new 
        lens to examine the fundamental processes in biology. 
        Application of these approaches to bridge the gap between our 
        knowledge of the human genome and human health and disease 
        holds particular promise in obesity research.
  --Development of Multi-disciplinary Teams.--Research towards 
        understanding, preventing, and treating obesity will benefit 
        from increased efforts to enhance collaborations among 
        scientists with fundamental laboratory research expertise, 
        behavioral scientists, and clinicians, as well as 
        collaborations among investigators from a variety of 
        disciplines within these fields.
    Buildings and Facilities.--In fiscal year 2004, the professional 
judgement request for Buildings and Facilities is $350 million. These 
funds would provide for the completion of the John E. Porter National 
Neuroscience building in fiscal year 2004, as well as increased funds 
for essential fire and safety programs, such as asbestos abatement, and 
rehabilitation of animal research facilities, in addition to increased 
funds for repairs and improvements.

                         CONCLUSION OF HEARING

    Senator Specter. Thank you all very much for being here. 
That concludes our hearing.
    [Whereupon, at 11:19 a.m., Friday, May 2, the hearing was 
concluded, and the subcommittee was recessed, to reconvene 
subject to the call of the Chair.]

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