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89–038 PDF 2003

S. Hrg. 108–120

SARS: BEST PRACTICES FOR IDENTIFYING AND

CARING FOR NEW CASES

HEARING

BEFORE THE

PERMANENT SUBCOMMITTEE ON INVESTIGATIONS

OF THE

COMMITTEE ON

GOVERNMENTAL AFFAIRS

UNITED STATES SENATE

ONE HUNDRED EIGHTH CONGRESS

FIRST SESSION

JULY 30, 2003

Printed for the use of the Committee on Governmental Affairs

(
(II)

COMMITTEE ON GOVERNMENTAL AFFAIRS

SUSAN M. COLLINS, Maine, Chairman

TED STEVENS, Alaska

GEORGE V. VOINOVICH, Ohio

NORM COLEMAN, Minnesota

ARLEN SPECTER, Pennsylvania

ROBERT F. BENNETT, Utah

PETER G. FITZGERALD, Illinois

JOHN E. SUNUNU, New Hampshire

RICHARD C. SHELBY, Alabama

JOSEPH I. LIEBERMAN, Connecticut

CARL LEVIN, Michigan

DANIEL K. AKAKA, Hawaii

RICHARD J. DURBIN, Illinois

THOMAS R. CARPER, Delaware

MARK DAYTON, Minnesota

FRANK LAUTENBERG, New Jersey

MARK PRYOR, Arkansas

MICHAEL D. BOPP, Staff Director and Chief Counsel

JOYCE RECHTSCHAFFEN, Minority Staff Director and Chief Counsel

AMY B. NEWHOUSE, Chief Clerk

PERMANENT COMMITTEE ON INVESTIGATIONS

NORM COLEMAN, Minnesota, Chairman

TED STEVENS, Alaska

GEORGE V. VOINOVICH, Ohio

ARLEN SPECTER, Pennsylvania

ROBERT F. BENNETT, Utah

PETER G. FITZGERALD, Illinois

JOHN E. SUNUNU, New Hampshire

RICHARD C. SHELBY, Alabama

CARL LEVIN, Michigan

DANIEL K. AKAKA, Hawaii

RICHARD J. DURBIN, Illinois

THOMAS R. CARPER, Delaware

MARK DAYTON, Minnesota

FRANK LAUTENBERG, New Jersey

MARK PRYOR, Arkansas

RAYMOND V. SHEPHERD, III, Staff Director

JOSEPH V. KENNEDY, Chief Counsel

ELISE J. BEAN, Minority Staff Director and Chief Counsel

MARY D. ROBERTSON, Chief Clerk
(III)

C O N T E N T S

Page

Opening statements:

Senator Coleman .............................................................................................. 1

Senator Levin .................................................................................................... 4

Senator Collins ................................................................................................. 5

Senator Pryor .................................................................................................... 17

Prepared statement:

Senator Lautenberg .......................................................................................... 29

WITNESSES

WEDNESDAY, JULY 30, 2003

Marjorie E. Kanof, M.D., Director, Health Care-Clinical and Military Health

Care Issues, U.S. General Accounting Office ..................................................... 7

James M. Hughes, M.D., Director, National Center for Infectious Diseases,

Centers for Disease Control and Prevention, U.S. Department of Health

and Human Services, Atlanta, Georgia .............................................................. 20

ALPHABETICAL LIST OF WITNESSES

Hughes, James M., M.D.:

Testimony .......................................................................................................... 20

Prepared statement .......................................................................................... 61

Kanof, Marjorie E. Kanof, M.D.:

Testimony .......................................................................................................... 7

Prepared statement .......................................................................................... 30

EXHIBIT LIST

1. Charts prepared by Centers for Disease Control:

a. SARS Priority Areas .................................................................................. 74

b. CDC SARS Preparedness Planning ......................................................... 75

2. Protecting the Nation’s Health in an Era of Globalization: CDC’s Global

Infectious Disease Strategy, Centers for Disease Cotnrol and Prevention,

Department of Health and Human Services ...................................................... 76

3. Microbial Threats of Health: Emergence, Detection, and Response, Institute

of Medicine, March 2003 ..................................................................................... 149

4. Supplemental questions and answers for the record submitted by Senator

Frank Lautenberg for Dr. Majorie E. Kanof, General Accounting Office ........ 157

5. Supplemental questions and answers for the record submitted by Senator

Frank Lautenberg for Dr. James M. Hughes, National Center for Infectious

Disease, Centers for Disease Control and Prevention, Department of Health

and Human Srvices .............................................................................................. 162

6. Correspondence from Dr. Marjorie Kanof, GAO, regarding questions posed

at July 30th SARS hearing by Senator Carl Levin asking for comparison

of research dollars devoted to SARS and other respiratory infectious diseases ...................................................................................................................... 165

(1)

SARS: BEST PRACTICES FOR IDENTIFYING

AND CARING FOR NEW CASES

WEDNESDAY, JULY 30, 2003

U.S. SENATE, PERMANENT SUBCOMMITTEE ON INVESTIGATIONS, OF THE COMMITTEE ON GOVERNMENTAL AFFAIRS, Washington, DC.

The Subcommittee met, pursuant to notice, at 9:03 a.m., in room

SD–342, Dirksen Senate Office Building, Hon. Norm Coleman,

Chairman of the Subcommittee, presiding.

Present: Senators Coleman, Collins, Levin, and Pryor.

Staff Present: Raymond V. Shepherd, III, Staff Director; Joseph

V. Kennedy, Chief Counsel; Mary D. Robertson, Chief Clerk; Kristin Meyer, Staff Assistant; Caroline Lebedoff, Intern; Brittany Stevenson, Intern; Elise J. Bean, Minority Staff Director and Chief

Counsel; Christopher Kramer, Minority Professional Staff Member;

Priscilla Hanley (Senator Collins); John Meyer (Senator Specter);

Anne Schmidt (Senator Coleman); David Berrick (Senator

Lieberman); Rebecca Mandell (Senator Lautenberg); Reanne Brown

(Senator Durbin); and Tate Heuer (Senator Pryor).

OPENING STATEMENT OF SENATOR COLEMAN

Senator COLEMAN. Good morning. We are going to call this hearing to order. It is a pleasure to be here with our distinguished

Chairman, Senator Collins—thank you for being here—and distinguished Ranking Member, Senator Levin. This is the second in a

series of hearings by this Subcommittee aimed at helping the Nation respond to the threat of SARS. At the first hearing on May 21,

the Subcommittee heard testimony from a number of witnesses at

the national, State, and local levels. The first panel consisted of

three internationally known experts in epidemiology: Dr. Julie

Gerberding, currently head of the CDC; Dr. Anthony Fauci, currently head of the National Institute of Allergy and Infectious Diseases; and Dr. Michael Osterholm, Director of the Center for Infectious Disease Research and Policy at the University of Minnesota.

Each of these experts testified that it was their opinion that the

Nation would face additional outbreaks of SARS during the regular

flu season this fall and winter. For example, Dr. Osterholm testified that: ‘‘. . . I am convinced that with the advent of early winter

in the Northern Hemisphere in just 6 short months, we will see a

resurgence of SARS that could far exceed our experience to date.

If this projection is correct, we have every reason to believe that

this disease may show up in multiple U.S. cities as we continue to

travel around the world in unprecedented numbers and speed.’’
2

‘‘Imagine now the possibility of simultaneous SARS outbreaks in

multiple U.S. cities. You may ask how likely is this to occur. Honestly, no one knows. But, as a student of the natural history of infectious diseases, I am convinced that like the early days of the

HIV epidemic, the worst of SARS is yet to come.’’

If Dr. Osterholm and the other experts are correct in their assumptions that the worst of SARS is yet to come—and I believe

they may very well be—then it is incumbent upon us to take immediate and urgent measures to protect our Nation from this potential crisis.

Soon after that hearing, I requested that the General Accounting

Office undertake a survey of best practices for identifying and

treating SARS. Because of the short time frame for preparing for

new cases, I asked that the study be completed by the end of July.

At today’s hearing, GAO will release the results of the study. We

will also hear from the Centers for Disease Control and Prevention

about the work they are doing to properly inform and work with

local agencies.

I am especially concerned with the adequacy of response at the

local level. There is a consensus that the quality of the first response is crucial to preventing any single case from leading to a

more generalized outbreak. Local agencies must maintain a proper

state of vigilance so they can quickly identify new cases. They must

also know what to do when a new series of cases arise in order to

prevent further transmission. At the same time, local communities

need to be properly educated so they can protect themselves in a

rational manner.

A case of SARS implies that a large number of coworkers, schoolmates, and social friends and their families might potentially be infected. As soon as they learn that the parent of a schoolmate has

SARS, parents will want to know whether they should keep their

children home, send them to class wearing masks, or take other

precautions. The lack of education can make it difficult for people

to properly protect themselves from transmission. But it can also

lead to a sense of panic and overreaction, stalling the economic activity on which all employment depends.

I have a further statement, and what I am going to do is I enter

the full statement into the record.

The bottom line is this: We have got to make sure that local

health officials are properly informed. They need to know what to

do. They need to remain vigilant. We need to make sure that the

average citizen can intelligently respond to SARS when it appears

in his or her community. It was Franklin Roosevelt who said that

the greatest thing we have to fear is fear itself, and I believe with

SARS it is the sense of the unknown. We still do not know, as I

understand it, all the causes of SARS and all the treatments for

SARS and all the things we are doing, are they the right things

to do. So there is a lot of unknown out there, and that generates

greater fear.

Then, finally—and clearly it is why we are here today—we need

to have national and regional plans for dealing with SARS, particularly if there is a large-scale outbreak. And as I looked at the GAO

report, though there are many good things that are going on and

much preparation that has happened, there is still a concern about
3

the adequacy of the health care system to meet a widespread outbreak. And so there are challenges before us. I want to commend

those agencies and folks who have been dealing with SARS.

CDC has done a tremendous job. I have talked to folks at the

local level. They are very thankful. The GAO responded very quickly, and for that we are very appreciative.

This is a challenge. We are moving quickly. We are trying to do

the right thing, but challenges lie before us, and this is an important hearing.

[The prepared statement of Senator Coleman follows:]

PREPARED OPENING STATEMENT OF SENATOR COLEMAN

Good morning and thank you for attending the second in a series of hearings by

this Subcommittee aimed at helping the Nation respond to the threat of SARS. At

the first hearing on May 21, the Subcommittee heard testimony from a number of

witnesses at the national, State, and local levels. The first panel consisted of three

internationally known experts in epidemiology: Dr. Julie Gerberding, currently head

of the CDC; Dr. Anthony Fauchi, currently head of the National Institute of Allergy

and Infectious Diseases; and Dr. Michael Osterholm, Director of the Center for Infectious Disease Research and Policy at the University of Minnesota.

Each of these experts testified that it was their opinion that the Nation would

face additional outbreaks of SARS during the regular flu season this fall and winter.

For example, Dr. Osterholm testified that:

‘‘. . . I am convinced that with the advent of early winter in the Northern

Hemisphere in just 6 short months, we will see a resurgence of SARS that

could far exceed our experience to date. If this projection is correct, we have

every reason to believe that this disease may show up in multiple U.S. cities as we continue to travel around the world in unprecedented numbers

and speed.

‘‘Imagine now the possibility of simultaneous SARS outbreaks in multiple

U.S. cities. You may ask how likely is this to occur. Honestly, no one knows.

But, as a student of the natural history of infectious diseases, I am convinced that like the early days of the HIV epidemic, the worst of SARS is

yet to come.’’

If these experts are correct in their assumptions that the worst of SARS is yet

to come, and I believe they may very well be, then it is incumbent upon us to take

immediate and urgent measures to protect our Nation from this potential crisis.

Soon after that hearing, I requested that the General Accounting Office undertake

a survey of best practices for identifying and treating SARS. Because of the short

time frame for preparing for new cases, I asked that the study be completed by the

end of July. At today’s hearing, GAO will release the results of the study. We will

also hear from the Centers for Disease Control and Prevention about the work they

are doing to properly inform local agencies.

I am especially concerned with the adequacy of response at the local level. There

is a consensus that the quality of the first response is crucial to preventing any single case from leading to a more generalized outbreak. Local agencies must maintain

a proper state of vigilance so they can quickly identify new cases. They must also

know what to do when a new case arises in order to prevent further transmission.

At the same time, local communities need to be properly educated so they can protect themselves in a rational manner.

A case of SARS implies that a large number of coworkers, schoolmates, and social

friends and their families might potentially be infected. As soon as they learn that

the parent of a schoolmate has SARS, parents will want to know whether they

should keep their children home, send them to class wearing masks, or take other

precautions. The lack of education can make it difficult for people to properly protect

themselves from transmission. But it can also lead to a sense of panic and overreaction, stalling the economic activity on which all employment depends.

Intelligent education requires several steps. First, local doctors need to know how

to recognize that new cases of SARS are appearing and need to know whom to turn

to for information and support. At the national and international level, agencies

must continue to develop information about the characteristics of SARS in order to

treat patients and prevent its spread. The World Health Organization, the National

Institutes of Health, and the Centers for Disease Control and Prevention perform
4

this role well. Last, the information these agencies develop must be transmitted

back to mayors, hospital administrators, and airport officials so that doctors, airline

attendants, researchers, and average citizens know how and what to do in order to

protect themselves. Today’s hearing is focused on this last step.

I believe we face three primary tasks. The first is to make sure that local health

officials are properly informed about the need to remain vigilant against possible

SARS cases. Although no new cases have been reported recently, most experts

believe that SARS has established itself in the population and reemerge. Unfortunately, its symptoms resemble those of other respiratory flues and tuberculosis. Unless local doctors remain mindful of the possibility of SARS, the first cases may not

be isolated in time to prevent further transmission.

Second, we need to make sure that the average citizen can intelligently respond

to SARS when it appears in his or her community. Individuals need to know what

precautions to take at various stages of an outbreak. They also need to know what

the true status of risk is, so that they do not over respond. In Asia the indirect economic costs of SARS far exceeded the direct costs of combating the disease.

Finally, we need regional and national plans for dealing with a large-scale outbreak of SARS. We saw in Toronto that SARS can quickly overwhelm even a modern health care system if the first cases are not quickly contained. When this happens, regional and national resources must be available to fill in the gap. Dr. Kanof

will testify about some of the hurdles we face in developing such a plan. I am

pleased that CDC is currently working hard to overcome these.

I want to take this opportunity to commend both of the organizations before us

for their previous role in dealing with SARS. I have repeatedly heard of the great

assistance that the CDC has provided to local agencies searching for information on

SARS. With respect to this disease, it is hard to think of how the agency could have

responded better. Doctors Gerberding and Hughes deserve our great appreciation for

the great work that they and their staff have performed under tremendous pressure.

In the report being released today and in previous reports and testimony, GAO has

played a valuable role in keeping Congress informed of this fast-breaking development. Today’s report was completed in a very short time frame and I appreciate Dr.

Kanof’s support in making it happen.

Senator COLEMAN. With that, I would turn to the distinguished

Ranking Member, Senator Levin.

OPENING STATEMENT OF SENATOR LEVIN

Senator LEVIN. Thank you, Mr. Chairman.

First, let me commend you for holding this hearing to push for

the development of best practices for responding to SARS cases before there is an immediate or imminent problem. For the reasons

you gave, this is a problem which has not gone away and will not

go away readily. It needs to be addressed in many ways, and advanced planning now can save lives and prevent future confusion

and unnecessary costs.

SARS is a disease which we cannot afford to ignore. Its global

impact has already been significant. Cases have been reported in

approximately 30 countries. Almost 1,000 individuals have died

while hundreds more have suffered and recovered. Hospitals’ quarantine facilities and health resources have been strained. Global

travel has been disrupted and just recently restored. That is going

to increase the potential threat of SARS.

Economists are struggling to evaluate SARS’ economic impact on

China and on Canada. Experts are warning of a possible SARS epidemic in developing regions of the world where health care systems

are not equipped to deal with rapid large-scale infection.

Here in the United States, we have so far avoided having to deal

with high levels of infection. But as I put it at the last hearing,

while we can try to isolate SARS patients, we cannot isolate our

Nation from this disease. SARS has already made its way across

our borders in several instances, and it is crucial that we establish
5

best practices for identifying, treating, and halting this illness.

While we can hope for the best, we must prepare for the worst if

we are going to avoid it.

Despite positive steps to deal with the virus, important problems

and questions remain unanswered. Health officials responding to

reported SARS cases need better guidance on how best to protect

their communities and our country, without implementing measures that may be costly or excessive. For example, they must determine an appropriate degree of screening for hospital patients and

staff, determine how best to handle patients suspected of carrying

the disease, and establish plans in the event of a SARS outbreak

involving multiple patients. They need to know how to communicate what is happening in their local communities to the Nation’s

SARS specialists. In addition, health officials must decide how best

to inform the public about the disease without causing undue concern or panic.

We also need to deepen our understanding of the disease itself.

We need to develop a rapid, accurate testing procedure for SARS,

determine how the disease is transmitted, and identify high-risk

populations. Individuals need to know whether they have or are

likely to contract the disease. Doctors need to be able to quickly diagnose and treat their patients. And health officials need to know

whether their communities are at risk for high rates of infection.

I look forward to the testimony of the General Accounting Office

today and to the testimony of the Centers for Disease Control. The

American public will hopefully be better prepared to stop future

SARS cases from occurring because of the work of the witnesses

and others that you mentioned, Mr. Chairman, and I believe also

because of the work of the Subcommittee itself.

Thank you.

Senator COLEMAN. Thank you very much, Senator Levin.

It is now my pleasure to turn to the distinguished Chairman of

the Committee on Governmental Affairs, Senator Collins.

OPENING STATEMENT OF CHAIRMAN COLLINS

Chairman COLLINS. Thank you very much, Mr. Chairman, and

thank you for calling this hearing. You have been a real leader in

the Senate in our efforts to deal with the SARS epidemic, and this

hearing is the second that you have held on this issue. It is important that we make sure that our local communities are properly

prepared to respond to an outbreak of SARS because, after all, it

is the health care workers and others who are on the front lines

who will first encounter the disease.

SARS has proven itself to be a formidable global threat. There

is no cure for this deadly, highly contagious virus that has spread

throughout Asia and into parts of Europe, Canada, and the United

States. To date, there have been more than 8,400 probable cases

of SARS reported in 29 countries, and more than 800 people have

died.

In an age of international travel, diseases know no boundaries.

Quick action on the part of the Centers for Disease Control and

Prevention as well as by our State and local health officials has resulted in a relatively low number of SARS cases in the United

States so far, with, fortunately, no deaths. Moreover, no new out-
6

breaks of the disease have been reported in recent weeks, and travel alerts have been lifted from many cities in Asia and in Canada.

I was, however, in Beijing at the height of the SARS epidemic.

I saw firsthand what happens when the local, provincial, and Federal response is slow, inadequate, and uncoordinated.

There is much good news lately to report about SARS, but we

should not rest easy. I believe that we are dealing with a sleeping

giant, and I was very disturbed by the testimony that the Subcommittee heard at its first hearing on SARS in May. The Director

of the Center for Infectious Disease Research at the University of

Minnesota told the Subcommittee that the disease has now seeded

itself in a significant number of humans as to make its elimination

impossible. He then went on to tell us that he was convinced that,

like the early days of the HIV epidemic, the worst of SARS is yet

to come—the point made by the Subcommittee’s Chairman.

Virtually all of the public health experts who testified agreed

with his prediction that there will be a resurgence of SARS with

the onset of the flu season next winter that could far exceed our

experience with the disease to date. We must be prepared.

While there is absolutely no evidence that SARS is part of any

planned biological or terrorist attack, our institutional capability to

deal with such an epidemic is the same whether it is the consequence of a terrorist attack or a naturally occurring event. In

fact, a major side benefit of all of our efforts to strengthen our

homeland defense capabilities should be an improved ability to respond to all kinds of epidemics.

Since physicians, nurses, and other health care workers on the

front lines are likely to be the first individuals to encounter cases

of an emerging infectious disease like SARS, it is critical that they

have the support and information that they need from Federal

agencies such as the CDC to identify and effectively contain such

an outbreak. I therefore want to commend the Chairman for his efforts to try to identify ways that we can help those on the front

lines in our local communities to protect our citizens.

Once again, thank you for convening this hearing.

Senator COLEMAN. Thank you very much, Senator Collins.

I would now like to welcome our first witness at today’s important hearing, Dr. Marjorie E. Kanof, Director of Clinical and Military Health Care Issues for the U.S. General Accounting Office. As

I mentioned in my opening statement this morning, she is here to

release the results of the GAO study that I requested of national

best practices for identifying and treating SARS cases. While officials from global health agencies have indicated that for the moment SARS appears to be stabilized, there is a concern that this

is simply the lull before the storm and, to reflect upon Chairman

Collins’ words, that what we have here is what could be phrased

as ‘‘a sleeping giant’’ that we have to be prepared for.

With that in mind, I look forward to hearing the results of the

GAO study as I believe it is essential for the health care community to be prepared. I am hopeful that this study will be widely

used by the health care community.

Before we begin, pursuant to Rule 6, all witnesses who testify before this Subcommittee are required to be sworn. Dr. Kanof, at this

time, I would ask you to please stand and raise your right hand.
7

1The prepared statement of Dr. Kanof appears in the Appendix on page 30.

Do you swear that the testimony you give before this Subcommittee

will be the truth, the whole truth, and nothing but the truth, so

help you God?

Dr. KANOF. I do.

Senator COLEMAN. Thank you, Dr. Kanof, and with that you may

proceed.

TESTIMONY OF MARJORIE E. KANOF, M.D.,1 DIRECTOR,

HEALTH CARE-CLINICAL AND MILITARY HEALTH CARE

ISSUES, U.S. GENERAL ACCOUNTING OFFICE

Dr. KANOF. Good morning, Mr. Chairman and Members of the

Subcommittee. I am pleased to be here today as you consider infectious disease control measures to help contain the spread of SARS

should future outbreaks occur. Although the current outbreak is

believed contained, the fact that SARS is a type of coronavirus, the

source of many common colds, leads many to suggest that SARS

could be seasonal and, as such, could recur in the fall and winter

months.

SARS transmission is most likely spread through person-to-person contact. Experts agree that infected individuals are contagious

when symptomatic, a time when they are most likely to seek medical attention and come into contact with health care workers. In

fact, one unique characteristic of the SARS outbreak was the high

rate of infection among health care workers who, before the institution of specific protective measures, may have become infected

while treating patients with SARS. The SARS outbreak in Asia

demonstrated that the disease can also spread rapidly in the community.

Currently, there is no definitive test to identify SARS during the

early phase of the illness, which complicates diagnosing the disease. As a result, early diagnosis of SARS relies more on interpreting individuals’ symptoms and identification of travel to locations with SARS transmission. The symptoms of SARS are similar

to other respiratory illnesses, such as the flu and pneumonia. Although SARS did not infect large numbers of individuals in the

United States, the possibility that SARS may re-emerge raises concerns about the ability of public health officials and health care

workers to prevent the spread of SARS in the United States.

My remarks this morning will focus on the infectious disease control measures that were practiced within health care and community settings for the containment of SARS and the initiatives and

challenges in preparing for a possible SARS resurgence.

Infection disease control experts all emphasize that well-established infectious disease control measures, case identification and

contact tracing, transmission control, and exposure management

played a pivotal role in containing the spread of SARS in both the

health care and community settings. No new measures were introduced. Instead, experts said strict compliance with and added vigilance to enforce use of the current measures was sufficient.

For SARS, case identification within health care settings includes screening individuals for fever, cough, and travel to a country with active cases of SARS. In California and New York, States
8

with high numbers of potential SARS cases, emergency room staff

used questionnaires to screen incoming patients, and an individual

identified as a potential SARS case was given a surgical mask and

moved into a separate area for further medical evaluation.

Toronto, which experienced a much greater prevalence of SARS

than the United States, used somewhat different practices. At the

height of their outbreak, everyone entering a hospital was asked

screening questions and had their temperature checked before they

were allowed to enter. As a further measure, Toronto health officials established SARS assessment clinics, also known as ‘‘fever

clinics,’’ that they used as screening centers instead of hospital

emergency rooms or other outpatient clinics.

Contact tracing was important for the identification of individuals at risk for SARS and for implementation of appropriate measures to reduce their possible spread of the disease to others.

In New York City, teams interviewed each possible SARS case in

order to identify contacts, and then they called each contact to advise them of the symptoms, provide information about the risks of

SARS, and to ensure that the contacts were following infection control measures. Each contact received three to five routine calls during a 10-day period.

Transmission control measures, or the spread of the disease, was

similar for both health care settings and in the community. According to several experts, the simple things your mother taught you,

such as washing your hands and covering your mouth and nose

with a tissue when sneezing or coughing, are effective in reducing

the spread of SARS.

Hospital transmission control guidelines included routine standard precautions, including hand washing, contact precautions such

as gown and gloves, and airborne precautions such as an isolation

room and the use of an N–95 disposable respirator for individuals

entering the room.

Hospitals in the United States generally saw few SARS patients,

one or two patients at a time, so they were able to manage the

SARS patients in available isolation rooms with available staff. Because of the greater prevalence of SARS in Toronto, however, all

22 acute-care hospitals were directed to have SARS units in which

they had staff who only cared for SARS. Health department officials in Toronto later designated four hospitals in the city to be

SARS hospitals.

The use of face masks or N–95 respirators was recommended as

an effective means of transmission control. In Canada, however,

health care workers used an additional level of protective equipment, almost a total body protective system, when conducting highrisk procedures such as respiratory intubation.

Transmission control guidelines for community settings incorporated many of the same measures for containing the spread of

SARS in the hospital. In addition, SARS patients were advised to

continue infectious disease measures for 10 days after their symptoms had abated and to remain in their homes during this time period.

Exposure management practices, isolation and quarantine, occurred in both health care and home settings. In Toronto, isolation

was typically used in the hospital, even in cases where individuals
9

were not ill enough to require hospitalization. In the United States,

home isolation was used, unless an individual required hospitalization for medical treatment. Similarly, quarantine guidance was

based on the prevalence of SARS in the community. CDC advised

individuals who were exposed but not symptomatic to monitor

themselves for symptoms. Individuals were not instructed to remain in their homes. In contrast, Toronto, which experienced a

very high level of person-to-person transmission, required individuals who did not have symptoms but had been in close contact with

SARS-infected individuals to stay in their homes and avoid public

gatherings for 10 days.

Toronto health workers were restricted to a work quarantine.

They were allowed to travel to and from work alone in their own

vehicles, but they were not allowed to visit public places.

Effective communication among health care professionals and the

general public reinforced the need to adhere to all of these infectious disease control measures. According to health officials, rapid

and frequent communication of crucial information about SARS

were vital components of their efforts to contain the spread of disease.

But how do we prepare for a resurgence of SARS? While no one

knows whether there will be a resurgence, Federal, State, and local

health care officials agree that this is necessary to prepare for the

possibility of a large-scale resurgence. As part of these preparations, CDC, along with State and local health associations, are involved in developing SARS-specific infectious disease control guidelines. These preparations will also improve the health care system’s

capacity to respond to other infectious disease controls. Implementing these plans, however, may prove difficult due to limitations in both hospital and workforce capacity.

We recently reported that most hospitals lack the capacity to respond to large-scale infectious disease outbreaks. Most emergency

departments have experienced some degree of overcrowding, and

therefore, may not be able to handle a large influx of patients during a potential outbreak of SARS, especially if SARS recurs during

the peak season for flu.

Few hospitals have adequate staff, medical resources, and equipment needed to care for the potentially large number of patients

that may seek treatment. In addition, the monitoring of individuals

placed under isolation and quarantine may strain resources if widespread isolation and quarantine are needed. Follow-up with isolation and quarantine individuals requires additional health care and

community resources. In Canada, it was the police and the Red

Cross that were helping purchase and deliver food to those under

isolation or quarantine.

In conclusion, the global spread of SARS was contained through

an unprecedented level of international scientific collaboration and

the use of well-established infection control measures that had

been used effectively in the past to control diseases such as tuberculosis and smallpox. Worldwide disease surveillance will facilitate

prompt identification of a resurgence of SARS which would allow

rapid implementation of infectious disease control measures, which

would in turn reduce both the spread of SARS and the risk of a

large outbreak.
10

Preparations are underway, and they do encompass in large part

approaches similar to those for pandemic influenza plans, and they

are also a component of more general bioterrorism preparedness

plans. However, should a large-scale outbreak occur in the near

term, limitations in the capacity of our Nation’s health system to

undertake effective and rapid implementation of the infectious disease control measures could prove problematic.

A major SARS outbreak would necessitate rapid escalation of infectious disease control resources, including health care workers,

emergency room and hospital capacity, and the requisite control

and support equipment.

Mr. Chairman, this completes my statement. I would be happy

to respond to any questions you have.

Senator COLEMAN. Thank you very, much, Dr. Kanof, and let me

say that it is very gratifying to have empirical data that says doing

what mother taught us is a good thing. I feel very uplifted. I am

sure my mom will give me a call after this to say, ‘‘See, I told you

so.’’

Let me make a couple of observations. I get a sense that the

things in this post-September 11 world, the stuff that we did—concerns about anthrax, concerns about bioterrorism—really have in

many ways kind of formed the basis for having a system in place

that gives us at least a high state of readiness. Is that a fair assumption?

Dr. KANOF. Absolutely.

Senator COLEMAN. But in the end, your conclusion is that should

a large-scale outbreak occur in the near term, there are limitations

that could prove problematic—staffing, worker limitations, health

care capacity limitations, or equipment limitations.

What is necessary? Is there a minimum standard that we should

have at the national level to say here is what we need to do to deal

with this? How do we address that limitation issue better?

Dr. KANOF. In the previous work that we have done in which we

looked at seven cities and we looked at the preparedness of each

of these cities, one key observation was that, in fact, the more frequently a city or a community had, unfortunately, encountered previous natural disasters, be it a hurricane or even an infectious disease, they were, in fact, better prepared to respond to ongoing challenges. So I think that is an important observation to make.

The other observation we made in the previous study was that,

in fact, not every city and community had gone through preparedness drills, which is something that a few cities have done. There

have been some more done recently during the summer, but it was

really key to have overcome the barrier of not wanting to do a preparedness drill, because an important factor in being prepared is

not just at the hospital but also have you established all the right

connections to both the public health department, the police, the

firemen, other communities, and in certain borders, other States.

And so it is important to think about initiating more of these initiatives.

In terms of resources, what we have found in our previous study

was that hospitals lacked equipment, that most hospitals had only

one ventilator for 100 staff beds, that they only had one protective

suit, that they only had one isolation bed. Half the hospitals had
11

six ventilators for 100 beds, three or less protective suits, and four

isolation beds.

So there is a significant need within communities to have the

proper equipment.

Senator COLEMAN. One of the concerns that I saw as a mayor in

looking at the resource issue and talking to my colleagues was all

of us looking for the same thing at the same time. Would it be your

recommendation that States set up some kind of regional perspective so that we have pooling of equipment? I think it would be

probably impossible for every community to have all the resources

that they needed. There are no specific recommendations to that effect in this report, just kind of observations of the state of readiness. Would that be a recommendation to proceed in that manner?

Dr. KANOF. Well, in fact, what we have included in the report—

is a SARS preparedness checklist that, in fact, has been developed

between the State and the communities and CDC, that, in fact,

highlights many of those issues that you have just discussed.

Senator COLEMAN. And I was going to compliment you on that

checklist. I would hope that folks would then use that checklist.

That was a very clear and focused and thorough kind of formula

for determining are we prepared and what do we need. So I would

hope that folks take a look at that checklist. I think it is extremely

well done.

What has been the impact of SARS on hospitals? And, in particular, is there a higher level of fear among health care workers

because of the high incidence of SARS among health care workers?

Dr. KANOF. The health care workers that we spoke to in Toronto

clearly had a higher level of concern than similar health care workers we have spoken to in the United States. But, clearly, there is

a big difference between walking into a hospital where you know

you have very ill patients. But I think among health care workers

that we have spoken to, it is a heightened level of concern in your

differential diagnosis of when you are seeing a patient, but, more

importantly, in your own appropriate use of protective measures

such as masks, gloves, and hand washing.

You referred back to HIV and AIDS. There was a time that we

drew blood as health care workers without wearing gloves, something that I think most people would not do today under normal

circumstances. And so I think among health care workers there is

just a heightened realization that protective measures are important.

Senator COLEMAN. In the last outbreak—the first incidence, really, of SARS, we knew where it came from—China and those areas

that had larger contact with China—New York, California, and Toronto, centers of focus. If, in fact, going back to Dr. Osterholm’s

comment from our last hearing, saying that SARS has now embedded itself in the population, does the dynamic change in terms of

state of readiness? In other words, I represent Minnesota—now if

SARS is embedded in Toronto, it is no longer looking at a Beijingto-Minneapolis connection, now it is Maine to Canada, now it is

Minnesota to Canada. Would that be a correct assumption? Does

that mean that health care workers across the board in any community have to have this higher level of readiness as we enter the

cold and flu season?
12

Dr. KANOF. I think that gets to the unknown and that we do not

know exactly what will happen, but I think that clearly recommendations that have come from the CDC and other public

health departments would stress that, as we enter the flu season,

as you see individuals and you establish triage centers in almost

every emergency room, clinic, physician’s office, that you need to

ask certain questions.

You are right, we might not be able to ask have you recently

traveled to a SARS transmission country, since we might not have

known that. But it needs to be quickly in individuals’ differentials,

and when they have a suspect case—I think the difficulty with

SARS is we do not have a test that says you have it—they need

to immediately begin protective control measures and alert the

public health surveillance system, because what we are really

going to need to do is be on alert to understand where there is a

trigger event.

Senator COLEMAN. And it is interesting that the three Senators

here, Senator Levin, Senator Collins, and I, we all represent border

States. I have been on that bridge between Michigan and Canada.

It is a very thin line. So I think for all of us there it is a heightened

level of concern.

Let me then ask a final question at this point in time. It is a resource question. Do we have enough resources? What recommendations would you make for this body, for this Congress today as we

look to the future, knowing what we know and knowing what we

do not know when it comes to the issue of resources?

Dr. KANOF. Well, I think we have in numerous reports actually

looked even closer on the health care delivery, to determine if the

public health systems are prepared. We have noted many times

that there are significant limitations in our resources in the public

health department and the health care delivery system, be it electronic disease surveillance, be it electronic databases in which to

capture the information. We have highlighted that there is a deficiency in the number of health care workers, and we have highlighted numerous times the shortages at hospitals of basic equipment. And so all of those put together, we have highlighted the

need to both ensure that there are sufficient resources and that

there have been Federal dollars that have been given specifically

for bioterrorism and specifically for hospital preparedness. The

question, though, is: Is that enough, and how much more is available to give?

I think what’s critical, though, is ensuring that communities

know how to share their resources.

Senator COLEMAN. Thank you, Dr. Kanof. And I again want to

thank the GAO for the expeditious manner in which they pulled together all this information and the work that they did, and particularly the checklist that you mentioned. I think that could be very

helpful. Thank you.

With that, I will turn to Senator Levin.

Senator LEVIN. Thank you, Mr. Chairman.

I would like to ask about that checklist. I am afraid I have not

seen it. Could you describe how that checklist relates to policy positions of CDC? For instance, does CDC recommend a particular

policy on screening and then the checklist relates to a specific rec-
13

ommended policy? Is there a recommended policy by CDC on isolation and then the checklist relates to that policy? How does that

work?

Dr. KANOF. Dr. Hughes can also answer that question, but the

CDC, through their website and through their health alert system,

basically have published guidelines. They have revised those guidelines as we have learned more about SARS specifically for situations in terms of when do you do isolation, when do you quarantine, and when do you use gowns and gloves.

This checklist includes all that type of information at a high

level, but a large part of this checklist, because it was also done

with ASTHO, the Association of State and Territorial Health Officials, and the National Association of County and City Health Officials, goes through some really broader issues, such as the legal

and policy issues. For example, agreements have been obtained

with State health insurers, Medicare programs and health care

product and service providers, for cooperation during an epidemic.

It talks about authority. Do you have the authority that you need

for isolation and quarantine? It talks about surge capacity and

talks about do you have established relationships with communities adjacent to you and public health officials.

Senator LEVIN. I have the checklist now in front of me, but does

it say that you should do those things, you should have in place

X policy or you should have a relationship with—the one you just

read——

Dr. KANOF. It recommends.

Senator LEVIN. It does make the recommendation and then asks

whether or not that recommendation has been carried out.

Dr. KANOF. Yes.

Senator LEVIN. It is connected to the recommendations. Have

these checklists been compiled by that association or by anybody

else?

Dr. KANOF. I am sorry. Have they been?

Senator LEVIN. Been compiled, have we gotten the return of

these so we can say 38 percent of the public health entities in our

States have this, 28 percent do this? Do we have any ideas statistically?

Dr. KANOF. No. What has been done in the past is that for bioterrorism preparedness, those preparedness plans were, in fact, sent

to HHS and, in fact, they came before money was released, and so

people have evaluated those. But I am not aware of anybody looking to see if we have checked each State, each community for their

infectious disease plan.

Senator LEVIN. So, for instance, CDC has made a recommendation, or there has been a recommendation that has been worked

out between our national people and the State and local people on

isolation. If that is on the website, we do not have any idea as to

what percentage of public health entities in the States have adopted that recommendation.

Dr. KANOF. I am not aware of that at all.

Senator LEVIN. Would that be helpful if we could learn that to

see how well prepared we are, if we could perhaps ask the CDC,

for instance, to make some kind of spot check assessment as to

what percentage of recommendations have been adopted?
14

1See Exhibit No. 6 which appears in the Appendix on page 165.

Dr. KANOF. I think it would be—it is always helpful, whether it

is done on a Federal or the State level, but people should be checking to make sure that there is a level of preparedness. It is similar

almost to the report that we did just about a year ago. We looked

to see were people prepared.

Senator LEVIN. The Chairman asked you about research dollars,

and I want to ask that question in a slightly different way. Could

you compare the research dollars that we are devoting to SARS to

research dollars on other kinds of diseases? Is there any way of

telling us how many dollars are being devoted to SARS, or that it

is 10 percent as much as we are doing on some other infectious disease?

Dr. KANOF. We could get back to you with the answer,1 but I do

not know that off the top of my head.

Senator LEVIN. That would be helpful to us, I believe.

On the border question, which the Chairman also raised, have

we made an assessment as to the adequacy and the appropriateness of checking at our borders? Is it spotty? Is it consistent? Are

there clear guidelines for trying to identify people somehow or

other, asking questions perhaps of people coming in from areas

that have seen a large number of infections? Is there any kind of

a coherent national policy at our borders?

Dr. KANOF. That is an excellent question and one that we did not

look at in great detail. I can tell you that CDC clearly, again, did

have individuals at key locations. They were at the airports. They

did provide information at all key sites. But we did not look, so I

cannot tell you the status.

Senator LEVIN. Thank you very much, and thank you, Mr. Chairman.

Senator COLEMAN. With that, I will turn the questioning and the

gavel over to Senator Collins, and I will be back literally in 5 minutes. I have one other hearing where I have to take care of some

business. Senator Collins.

Chairman COLLINS [presiding]. Thank you, Mr. Chairman.

Doctor, quick action on the part of the CDC and our State and

local health officials has so far resulted in a relatively low number

of SARS cases in the United States. I believe that to date we have

had about 40 probable cases and not a single victim in the United

States has died.

Why do you believe that the American experience has been so

different from that in Canada?

Dr. KANOF. Well, I think part of it, to quote many scientists and

physicians asked that question that we interviewed was somewhat

luck and somewhat timing in that if we understand the epidemiological spread of this disease, there was a physician who treated

SARS patients who was in a hotel room in Hong Kong, and several

individuals acquired the disease from that individual, and one of

them, or perhaps two, landed in Toronto as opposed to directly in

the United States. And so Toronto was experiencing illness that we

now recognize as SARS before it was really known that there was

SARS and before we really knew that you needed to have all the

health care precautions that you did.
15

We were very fortunate in that we did not get that first wave per

se and that we were actually on alert in a time period after Toronto.

Chairman COLLINS. Similarly, why has the infection rate among

health care workers been so much higher in Canada? Does it all

go back to that one physician and where he happened to be?

Dr. KANOF. Unfortunately, in large part, yes. It goes back to unfortunate lessons we have learned from Canada. We understand

now the significance of the respiratory spread, and so while in Canada, individuals might have been using masks and gloves as individuals got sicker and required more intensive care and health care

workers were having potentially either more intense exposure to

some of the virus or during procedures such as intubation not being

protected, more individuals got exposed.

Also, in Canada, not knowing initially about the disease, they did

not have a system in place to contact everyone who had been taking care of a patient, which is why they began to create SARS units

and SARS-dedicated staff so you knew who was, therefore, at a potential risk and could then track them to make sure they were not

getting ill.

Chairman COLLINS. During the SARS outbreak in Toronto, more

than 10,000 people were quarantined in their homes. In addition,

many health care workers were work-quarantined; in other words,

they were allowed to travel to and from work in their vehicles, but

they were not allowed to visit public places.

How difficult would it be for Federal, State, and local public

health authorities to impose the same kind of quarantine restrictions here in the United States should we be faced with a massive

outbreak of SARS? Do you think that would be accepted in the

United States? Do you think we have the knowledge and the resources to implement a significant quarantine?

Dr. KANOF. The lessons learned from Toronto are really very interesting. I think you can break your question into two parts. One

is: Do you have the authority? Then, how do you monitor? And

then, even more importantly, but how do you provide resources? It

is one thing to tell someone they need to stay in their home, but

how do you get them all that they need?

I think one of the things in the checklist that is very important

is that States are supposed to be checking to make sure that they

do have the authority. Information to date appears that States do

have the authority from a health protection point of view to do isolation and quarantine as appropriate, and States are, I know, actively looking to make sure that extends to SARS.

The bigger issue, though, is how do we mobilize the resources so

that for Toronto, as you talked about the work quarantine, we

learned that they went so far to have supermarkets within the hospital so that as you are asking the health care workers to come and

not go anywhere else, they could at least obtain the basic supplies

that they need. And I think that you are asking an important question that extends beyond just the health care delivery system, but

the community needs to begin working now to ensure that resources are available to supply individuals when you ask them to

stay at home.
16

Chairman COLLINS. What do you think the response of the American public would be to a quarantine order similar to what was imposed in Toronto?

Dr. KANOF. I probably would hope, just as you would hope, that

as necessary, people would understand the need to do that. And I

think that an important message learned from Toronto was the

communication, was the actual explaining to individuals the need

for why this was appropriately done.

Chairman COLLINS. I mentioned in my opening statement that

there is no evidence that SARS was part of a planned bioterrorism

attack but that it, indeed, arose from natural sources. But the capability of State and local health officials to deal with such an epidemic should be the same whether or not it is due to a bioterrorist

attack or whether it is a naturally occurring phenomenon.

In fact, I think there are a lot of lessons that can be learned from

the SARS outbreak, including how quickly and rapidly it spread to

29 countries, that would help us better respond to a planned attack.

Could you comment on whether or not you see capabilities that

we have developed for homeland security assisting us in dealing

with a naturally caused epidemic like SARS?

Dr. KANOF. I think we believe they are all intertwined, and, in

fact, not focusing too much on this checklist, but many are really

sub-components of a general bioterrorism plan, and that resources

that have gone out already to both local communities and hospitals

in response to bioterrorism preparedness will definitely assist them

to prepare for any infectious disease, be it a bioterrorism threat or

a real infectious disease threat.

Chairman COLLINS. The CDC has been widely credited with an

effective response to the SARS epidemic. When I was in Beijing

and travelling through Asia, CDC experts were in all of the cities

that our congressional delegation visited. They were at all of the

public health meetings, providing their expertise and assistance,

which was particularly critical in China, where a slow reaction on

the part of officials allowed the epidemic to be more serious than

it otherwise would have been.

This contrasts to the anthrax attacks back in 2001 when the

CDC was widely criticized for putting out conflicting and inconsistent guidance, and even contradictory information.

Do you think that the CDC has learned and incorporated lessons

from its experience with anthrax that it applied to the SARS epidemic? Why do you think the performance was so different?

Dr. KANOF. I think CDC has significantly learned from the anthrax. I think they are continuing to learn and improve on a regular basis. But I think key observations that you can make the contrast to, but for SARS, they now have an emergency response team

and an emergency response room. Eight hundred people, I think,

were involved in the United States or around the world from the

CDC for helping contain SARS.

But I think more importantly what they learned is the importance of rapid communication, and I think Dr. Gerberding is quoted

as saying she knows that needs to be out there and to tell the facts

as you know them and to keep increasing your knowledge and

sharing those facts on a regular basis, not just to physicians but
17

to hospitals and to the public. And I think that is what you have

seen here with SARS, not just in the United States but throughout

the world.

So there were significant lessons learned that we saw with

SARS.

Chairman COLLINS. Thank you, Doctor. Senator Pryor.

OPENING STATEMENT OF SENATOR PRYOR

Senator PRYOR. Thank you, Senator Collins. Thank you for your

leadership, and also to Senator Coleman and Senator Levin, I appreciate them bringing this very important issue to our attention

and keeping us focused on it.

Let me ask, if I may, a few questions about the spread of SARS

and our preparedness for it. First I would like to focus on rural

issues, rural versus urban. Do you think that it is likely, more likely, that SARS will start in urban areas and spread out into rural

areas, or vice versa?

Dr. KANOF. Again, I think we will learn about SARS as we get

more experience with SARS. But I think the key is that close-toclose—person-to-person contact plays an important role in transmission of SARS. And so the density of the population clearly is an

important factor in the transmission of SARS. And so, again, if one

were to follow that logic, and the density of a city in which there

is more close-to-close contact would put that city at potentially

higher risk. That is one side of the equation.

What you need to ensure, though, is that the health care delivery

system, both in the city and the rural, though, have equal awareness, equal training, equal connections with the public health system so that if they suspect an individual has SARS, they can tap

in equally quick to the appropriate resources.

Senator PRYOR. Given that you have just gone through this study

to try to help the government get a handle on this issue, do you

feel that you can disseminate the information that you have and

disseminate it effectively to the health care community around the

country?

Dr. KANOF. That we can disseminate the information?

Senator PRYOR. Right.

Dr. KANOF. I think that we are helping inform Congress, and

that in turn will help disseminate that information. I think key for

the dissemination of the information is really that is the critical

role of the CDC and the State and local communities. And what we

have seen is that there is active work on all those agencies’ part,

all those Federal, State, and local agencies, in order to obtain information.

Senator PRYOR. Has CDC seen your report here? And do they

agree with it? Are they going to use the guidelines therein?

Dr. KANOF. Well, in fact, we do not have any new guidelines in

our report.

Senator PRYOR. OK. So you are taking information from the

CDC.

Dr. KANOF. Absolutely.

Senator PRYOR. Perfect. OK.

Now, one thing I have noticed in just the last few months is a

number of stories about medical conditions that are spreading
18

around the country and around the world. Just a few, of course, are

SARS and another one is monkeypox and another one is West Nile

virus. In fact, when I was home in my State of Arkansas this last

weekend, there were stories in the paper about the State possibly

confirming the first West Nile virus case in a human in Arkansas,

and actually, as I sit here today, I am not sure whether that was

confirmed or not.

But in your work and in your research into this issue, are there

other diseases and potential threats out there that we, as policymakers, need to know about, things that really have not hit the

headlines yet like SARS has? Are there other diseases on the horizon that we need to be focused on and be getting ourselves prepared for?

Dr. KANOF. I think the answer to that is yes, but if you ask me

what they are, my answer to you will be I do not think we know.

Senator PRYOR. Ask the CDC? [Laughter.]

Dr. KANOF. It would be an interesting question to ask them. I

just think, though, that we are a global economy, and travel and

the world at large is introducing new diseases on a regular basis.

And I think that is the significance of disease surveillance, and it

is not disease surveillance limited to the United States, but it is

disease surveillance for the world.

Senator PRYOR. One last line of questions in terms of your research and what you have been doing on this issue, and that is the

impact on hospitals and the preparations that hospitals need to

have in place in order to be prepared to address SARS if it does

re-emerge and the expense involved in that. Is it your sense that

American hospitals generally are prepared for this and that they

have the protocols in place and the training and the equipment

that they need to handle a re-emergence of SARS?

Dr. KANOF. We did not look at hospital preparedness for SARS.

We have, though, in previous work looked at hospital preparedness

for other infectious disease. And there is evidence that they are

prepared in terms of having plans, and there is evidence that they

have trained their staff in terms of infectious disease. But there is

definite concern that they do not have enough of the resources,

both equipment, protective equipment, and staff, to handle a largescale outbreak of any infectious disease that would require hospitalization.

Senator PRYOR. OK.

Dr. KANOF. And the point is that I think it extends beyond the

hospital. It goes throughout the health care delivery system.

Senator PRYOR. I tend to agree with that as well. Senator Coleman, that is all I have.

Senator COLEMAN [presiding]. Thank you very much, Senator

Pryor.

One last question, Dr. Kanof, and I apologize if it was addressed

in my absence, but it is following up on preparedness of rural

areas. I look at Toronto, and, first, two questions. One, in the Toronto situation, was everything focused in the metropolitan area

there, or were there experiences that rural hospitals had in trying

to deal with SARS? Are you aware of that?

Dr. KANOF. I am not aware of that.
19

Senator COLEMAN. And it would kind of then tie into the second

part of that question. Within this country, any sense of the level

of preparedness in smaller towns and rural communities?

Dr. KANOF. I think, to go back to a previous answer, I think we

will have more of a risk of, let’s say, SARS in a large city as opposed to rural areas just because of the transmission of close-toclose contact.

What we do know, though, from Toronto is that they did share

information in terms of signs and symptoms with surrounding

areas, with the United States, and I think that is really what is

most critical for rural areas in the United States, that they, too,

are trained to recognize signs and symptoms, that they do have

limited resources but we ensure that they have basic resources in

case they do see an individual with SARS, but that most importantly they are connected to their local and State and Federal public health departments so that they are getting all the information

that they need.

In Tennessee, they are trying to figure out how do I get information out to all physicians in rural areas where they do not have Email, and they are working to see if people have fax machines and

maybe they can get information to them through their fax machines.

So I think that is what we really need.

Senator COLEMAN. Thank you very much, Dr. Kanof.

Senator Pryor, any follow-up?

Senator PRYOR. No, thank you.

Senator COLEMAN. Thank you very much.

I would now like to call our second witness. I welcome Dr. James

M. Hughes, the Director of the National Center for Infectious Disease at the Centers for Disease Control and Prevention in Atlanta,

Georgia. Thank you, Dr. Hughes. I appreciate your attendance at

today’s hearing. I look forward to your testimony on what the CDC

is doing to help communities apply the lessons learned from this

Spring.

I am also eager to hear about your plans for developing contingency plans to handle a large-scale outbreak this fall.

Pursuant to Rule 6, all witnesses who testify before this Subcommittee are required to be sworn. At this time I would ask you

to rise and please raise your right hand.

[Witness sworn.]

Senator COLEMAN. Thank you very much, Dr. Hughes.

Dr Hughes, before you proceed with your testimony, I want to

make a public note of the work that the CDC has done. I talk to

folks at the local level. There has been a lot of outreach, a lot of

communication, and within the health care community a deep

sense of appreciation for the way in which the CDC has dealt with

SARS to date. So I want to express my thanks for your efforts.
20

1The prepared statement of Dr. Hughes appears in the Appendix on page 61.

STATEMENT OF JAMES M. HUGHES, M.D.,1 DIRECTOR, NATIONAL CENTER FOR INFECTIOUS DISEASES, CENTERS FOR

DISEASE CONTROL AND PREVENTION, U.S. DEPARTMENT OF

HEALTH AND HUMAN SERVICES, ATLANTA, GEORGIA

Dr. HUGHES. Thank you very much, Mr. Chairman. Good morning. Senator Pryor, good morning.

Thank you for convening this important hearing on critical issues

regarding Severe Acute Respiratory Syndrome, or SARS. I very

much appreciate the opportunity to appear before you today on behalf of CDC. I would like to briefly update you on the status of the

outbreak, the worldwide response to this emerging global microbial

threat, and CDC’s involvement in collaborative efforts to prepare

for the potential recurrence of SARS.

As we have seen recently, infectious diseases continue to threaten our Nation’s health. The emergence of SARS, the first reported

outbreak of monkeypox in the Western Hemisphere, and this year’s

first cases of West Nile encephalitis are strong reminders that infectious diseases respect no boundaries and that national and global health are inextricably linked. They also clearly indicate the

need for continued vigilance in our efforts to address emerging infections.

In early 2003, the first cases of what would later be called SARS

began to be reported to the World Health Organization (WHO)

from several countries in Asia. SARS spread globally in a matter

of weeks, primarily infecting health care workers and family members of index patients, but also resulting in community transmission in several areas. As of its latest update on July 11, WHO

had received reports of more than 8,400 cases and more than 800

deaths among individuals from nearly 30 countries.

As of July 29, 159 suspect and 33 probable cases of SARS had

been reported in the United States. These current numbers are

based on a recent change in the U.S. surveillance case definition

for SARS as recommended by the Council of State and Territorial

Epidemiologists. The revised case definition allows for exclusion of

cases whose convalescent serum specimens tested negative for evidence of SARS-associated coronavirus infection. With this change,

the number of reported cases decreased by more than 50 percent—

from greater than 400 to a little less than 200.

Although the global response to SARS has highlighted many priorities for the future, it also represents extraordinary collaboration

among the clinical, scientific, and public health communities worldwide. WHO’s coordination of the global response provided an opportunity for international assistance and rapid sharing of critical information that helped to minimize the spread of SARS and to rapidly identify the causative agent. At CDC, more than 800 individuals were mobilized to help respond to the outbreak.

The U.S. response involved intense collaborations among public

health officials at the local, State, and national levels, the clinical

and academic communities, members of professional organizations,

and industry representatives. Existing collaborations have been

strengthened, and new ones have been formed both nationally and

globally.
21

1See Exhibit No. 1a which appears in the Appendix on page 74.

2See Exhibit No. 1b which appears in the Appendix on page 75.

3See Exhibit No. 3 which appears in the Appendix on page 149.

Despite these successes, much remains to be done. Although we

do not know if SARS will reappear, we must avoid complacency

and use this time to address future priorities. Toward this end, the

World Health Organization held a global conference on SARS in

June in Kuala Lumpur, Malaysia. More than 1,000 individuals

highly involved in the SARS response attended the conference to

share data and experiences, review lessons learned, and develop

recommendations to address critical issues.

At CDC we are developing an after-action plan to identify gaps

and assess priority action areas. We are also developing a research

agenda to help build the scientific base to ensure that the global

clinical and public health communities have the necessary knowledge and tools to meet the challenges of SARS. Priority research

areas include early detection and prompt reporting of cases, improved testing and treatment, increased understanding of the disease, efforts to prevent transmission, and effective communications.1

We have established a SARS preparedness task force comprising

the following teams:2 Surveillance, clinical, laboratory, special studies, information technology, communication and education, and preparedness and response for communities and for the public health

and health care systems. These teams are collaborating with many

other national and international partners to develop effective response mechanisms that can rapidly and efficiently detect the introduction of SARS into the United States and that can be easily

adapted to meet a range of local needs.

In mid-March, within 1 week of WHO’s first global advisory on

SARS, the Institute of Medicine of the National Academy of

Sciences published a comprehensive report describing the spectrum

of microbial threats to national and global health, factors affecting

their emergence or resurgence, and measures needed to address

them effectively. This report, ‘‘Microbial Threats to Health: Emergence, Detection and Response,’’ 3 emphasizes the need for increased capacity at the local, State, and national levels to detect

and respond to national and global microbial threats, both naturally occurring and intentionally inflicted. As indicated in the report and clearly reinforced by the emergence of SARS, strong global

public health systems, robust health service infrastructures, and

adequate surge capacity and expertise that can be rapidly mobilized and deployed remain our best defenses against any disease

outbreak.

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

Senator COLEMAN. Thank you very much, Dr. Hughes. Dr.

Hughes, first a question about the redefinition of SARS. Actually

what I am focused on is mortality. You mentioned there were 8,400

cases, 800 deaths. Those 8,400 cases, were they under the old definition?

Dr. HUGHES. Yes, they were. And those 8,400 cases included only

the U.S. probable cases. So the U.S. probable cases made up only

about 74 of those 8,400.
22

Senator COLEMAN. I guess my question is, do we have a good estimate of what the level of mortality is for SARS, percentage?

Dr. HUGHES. The level of mortality is directly related to age. The

older people are, the higher the mortality rate. Evidence from Toronto and heavily impacted areas in Asia suggests that for people

over 60 the mortality rate can be 50 percent or more.

Senator COLEMAN. How does that compare to pandemic flu and

some other diseases?

Dr. HUGHES. A mortality rate of 50 percent or more would be

substantially higher than the mortality rate that follows influenza

epidemics that occur each year. But as you know, there are about

36,000 people in an average year in this country that die of influenza.

Senator COLEMAN. Getting back to influenza, one of the things—

I know we dealt with severe outbreaks of severe pandemic flu. I

would guess it is kind of the same level of preparedness. If you are

prepared for one, would it be fair to say you would be prepared for

dealing with SARS?

Dr. HUGHES. I think there are many lessons from the SARS experience that are directly relevant to the thinking along preparedness for the next influenza worldwide epidemic or pandemic which

we absolutely know will occur. We simply do not know when. Back

in February when we first heard about these unexplained cases of

pneumonia in South China, shortly thereafter we heard about some

cases of influenza in Hong Kong caused by the H5N1 influenza

virus similar to the one that caused the bird flu outbreak back in

1997. We were actually initially concerned that the outbreak in

South China might be influenza, but laboratory studies rapidly

ruled that out.

This experience with SARS though shows how critical it is that

surveillance systems be strengthened around the world so that

these new problems can be rapidly detected. It certainly applies to

influenza because we know that the more lead time we have when

the next pandemic begins, the better, because it will give us time,

hopefully, to develop a new influenza vaccine directed against the

pandemic strain.

Senator COLEMAN. I am just wondering though if you can tie in

the preparation for re-emergence of SARS into the pandemic flu

planning? As I look at that I recall last year, I believe there was

a report by an Association of State Health Officials that only 12

States have completed a pandemic flu response plan. I am wondering whether it goes to the question that the Ranking Member

Senator Levin talked about, regarding the checklist. Have we compiled or do we know who is actually prepared and who is not? Can

you help me get an understanding of—do we have a sense of how

many States truly have a good planning process for SARS? Is the

lack of preparation for pandemic flu, is that something that gives

us cause for concern?

Dr. HUGHES. I think that the Association of State and Territorial

Health Officials and the National Association of County and City

Health Officials have done a terrific job in developing this checklist

for preparedness as it relates to SARS. I think in doing that, we

have worked with them and they have drawn from some of the bioterrorism preparedness thinking as well as some of the influenza
23

pandemic thinking and planning that has been going on a number

of years.

Actually there are 53 elements on this checklist. I doubt that

there is a jurisdiction in the country anywhere that could put a yes

in all 53 boxes. This checklist includes things that ought to be in

place, and if they are in place for SARS, we are going to be much

better off in dealing with pandemic flu or a bioterrorism attack.

Progress has been made, but as we have heard, there is much that

remains to be done.

Senator COLEMAN. What is the plan for the distribution of that

checklist?

Dr. HUGHES. We will be working with, and talking frequently

with ASTHO and NACCHO officials in terms of not only sharing

this with their membership, but then as suggested in some of the

previous conversation I think the need to assess where we currently are and then monitor progress is important.

Senator COLEMAN. Talk to me a little bit about early detection.

My sense is that early detection is not an easy thing to do. That

we are still not really sure what it is that we need to see in order

to be positive that it is SARS. With that lack of certainty, the difference between SARS and a cold or the flu, tell me what you mean

by early detection and how effective you think it is.

Dr. HUGHES. That question is right on the mark. SARS, when it

presented, you may remember the initial reports out of South

China were that this was a community-acquired atypical pneumonia. We see atypical pneumonias in the United States all the

time, particularly in the wintertime, and there is a broad range of

causes. But even in research studies that are done looking at people who have atypical pneumonia, only about 50 percent will actually have a specific cause identified using the broad range of techniques currently available. So that right there is, in and of itself,

a research priority even before SARS came along.

The problem now, if SARS returns in the winter, the problem is

going to be sorting out patients with acute respiratory disease who

either contact their health care provider or are present for medical

care. So it is important that we look, and we are with others, very

closely at the clinical manifestation of SARS. Hopefully we will be

able to come up with a clinical description that is more precise, or

an algorithm maybe that helps clinicians make a better judgment

in terms of whether they might be dealing with a case of SARS or

not.

Clearly, this is where we go back to the global surveillance. We

do not have any evidence that the virus is circulating in this country at this time. It could be but we do not have any evidence that

it is. We do not know the source of it in South China. The evidence

suggests that the virus probably originated in an animal species

there. It has been found in a couple of exotic animals in South

China. But the original source in nature has not been identified.

The more warning we have, the better, of course, if it does

resurge. So we are working with Chinese public health officials and

others in Asia, along with WHO, to try to support them in

strengthening surveillance efforts there, at the same time that we

are trying to strengthen surveillance efforts here. We and others

are working to develop better, more sensitive, more specific rapid
24

early diagnostic tests, not only for SARS, but if we had rapid tests

for the other agents that cause atypical pneumonia we could at

least know a subset of the people that we do not have to worry

about because they have another specific cause, and be able to

focus in on those cases of unknown etiology.

So a long-winded response but a big research agenda with absolutely direct, concrete public health relevance and urgency.

Senator COLEMAN. How close are we to that research giving us

the capacity to measure what it is we have, whether it is SARS or

something else?

Dr. HUGHES. There is some very promising, innovative research

going on. We currently have antibody tests, and we have RT–PCR,

these rapid molecular amplification techniques that need further

evaluation and refinement. We have deployed those in State public

health laboratories but they are not yet at a stage where they can

get out into the clinical laboratory settings for use which is where

we really need them. So this is urgent but I cannot sit here and

tell you that we will have these this week or next month or in time

for the next flu season.

Senator COLEMAN. You stated, if SARS returns in the winter,

and you note there is no evidence it may, that it is a seasonal condition. Do you disagree with Dr. Osterholm’s statement at the first

hearing where he said, ‘‘I am convinced that with the advent of

early winter in the Northern Hemisphere in just 6 short months

we will see a resurgence of SARS that could far exceed our experience to date?’’

Dr. HUGHES. I think, like Dr. Osterholm, that we are at the beginning of the experience of SARS, not at the end. I think we will

encounter it again. I think it is important to point out to you, it

might not wait till winter, because we do not know the animal reservoir. We do not know how it got into people in South China. We

do not know that it could not get back into people there sooner

than the wintertime. So we are not going to be complacent here in

the next few months while we are in the hot season. We have to

be alert and vigilant now, but move as rapidly as we can for increased preparedness in the fall and winter because of the reasons

we have talked about.

Senator COLEMAN. When we talk about fall and winter, again,

coming from a cold weather State, I think the reality is in the winter we tend to be grouped indoors in closer spaces versus in the

summer we celebrate being outside. But it is that close contact that

creates a great potential for an outbreak.

Dr. HUGHES. Yes, but I had the opportunity to go to that meeting

in Kuala Lumpur that I mentioned and I passed through Singapore

which is right on the equator and they had a very dramatic SARS

outbreak there. So it is not going to be a problem just limited to

colder climates in the winter-time, I am afraid.

Senator COLEMAN. Thank you. Senator Pryor.

Senator PRYOR. Thank you, Mr. Chairman. Let me ask a question or line of questions about China specifically. I promise you, I

do not ask this in any way to criticize China or to cast any disparities on China and how they responded to SARS. But I would like

to hear your thoughts on lessons learned from China, maybe some

of the mistakes they made or some things that we should be pre-
25

pared for so we can handle this in the event that we do see an outbreak here. What have we learned from China?

Dr. HUGHES. Clearly, we have learned that the earlier a new and

unusual problem is recognized to be something unique, the easier

it is to confront and control. There is no question that there were

major delays in recognition, and particularly in reporting of that

occurrence.

After it was recognized, some laboratories studies were done in

China. There was some laboratory evidence, as I understand it,

that supported the possibility that this illness was caused by an organism that is called Chlamydia pneumoniae, which is one of a

number of organisms that we have in this country that does in fact

cause atypical pneumonia. But it would have been unusual, I

think, for a community-wide outbreak or outbreaks as they occurred in South China to have been caused by Chlamydia

pneumoniae. So I think they were misled by that. They underestimated the gravity. They perhaps did not realize they were dealing

with a new problem and then they obviously had major communication problems as well.

So lessons are vigilance, sensitive surveillance supported by adequate laboratory capacity that allows you to rule in or rule out

agents. By ruling out common agents, that leads you quickly to the

suspicion that you may be dealing with something unusual. That’s

what happened with hantavirus pulmonary syndrome in the

United States. You may recall back in 1993 in the Southwest a severe acute respiratory syndrome, when it was recognized, with a

very high fatality rate where basic laboratory studies looking for

common agents were negative. So very rapidly we and others got

on to the fact that this was something unusual and moved quickly

to identify the cause.

That approach and the approach used here with SARS, once it

was recognized to be unusual—you are familiar with the incredible

levels of international collaboration and the rapidity with which

this agent was identified and characterized.

So in the modern age where we do have the tools—now, not

every laboratory has these tools, but we need to continue to support and make sure that at the State and national levels these

tools exist to rapidly recognize new infections when they occur.

Senator PRYOR. You mentioned surveillance in your testimony,

and I noticed in some of the budget numbers that we have seen

here in Washington, I believe the House has about $80 million for

global surveillance of disease, and I believe the Senate version has

$130 million for global surveillance of disease. Are you familiar

with those numbers?

Dr. HUGHES. Not those specific numbers, but I know that there

are amounts in the bills.

Senator PRYOR. How do you watch this disease? How do you

monitor it? What is that money used for and how can we use that

money best and most strategically?

Dr. HUGHES. We and the World Health Organization are thinking about that and trying to work with the countries in Asia as

well. We have had very close collaboration, I think you realize,

with the Canadians. We have learned a lot from their experience.

We have been to their meetings, they have been to ours. We had
26

1See Exhibit No. 3 which appears in the Appendix on page 149.

a liaison representative assigned to Health Canada and they to

CDC throughout this. So we have learned a lot from the Canadian

experience.

We have worked closely, as you have heard, with colleagues in

the countries in Asia. We have tried to help them assess surveillance needs. We have shared reagents with them. In some cases we

have shared the virus or viral RNA with them, because they need

to have in place surveillance systems for atypical pneumonia and

that needs to be backed up by laboratory support at the national

level. Of course, laboratory capacity at the national level in those

countries varies quite a bit. It is quite substantial in Singapore and

Hong Kong but less so in other parts of Asia.

We have been talking with the Chinese about collaborating with

them to strengthen their field epidemiology training program that

they have and build up the laboratory capacity that is linked to

that.

This allows me to make what I think is another important point

and it is just dramatically illustrated by the discussion this morning. For many years there has been quite a gulf in this country between the world of clinical medicine and the world of public health.

Whether you are dealing with bioterrorism or antibiotic resistance

or West Nile or SARS, we have to break down some of those traditional barriers. We have made a lot of progress. So there are a lot

of opportunities provided now with this attention to SARS that we

need to capture, and that will help with surveillance both in this

country and in other countries as well.

Senator PRYOR. A few moments ago I asked the previous witness

a similar question to this and that is, I said I noticed in a lot of

the media reports, etc., that there are other diseases out there that

seem to be spreading through various populations, monkeypox is

one, SARS is another, West Nile is another disease out there.

Those have received some media attention and some public focus

but what other things are out there that we need to be concerned

about as policymakers? What do we need to be preparing for?

Dr. HUGHES. Thank you very much for asking that question. I

would refer you to this Institute of Medicine report on Microbial

Threats to Health.1 They have a long list of many things that could

keep you up at night, but I will tell you some of the things that

I worry about. Obviously, I am extremely concerned about the

threat of bioterrorism and we experienced that with a small attack

involving anthrax, and we are intimately familiar with the consequences of that.

West Nile, we saw the dramatic sweep through much of the

country last year. We are early in the season but it looks like we

are at a level more or less similar to where we were this time last

year, so we need to be prepared for that.

Now in terms of other things that we have not talked about that

I personally worry about, we have alluded to pandemic influenza.

That next pandemic will occur and we need to be better prepared

to detect early and respond to that.

On top of that, I worry about antibiotic resistance, a major problem in health care settings and increasingly in community settings
27

as well. It did not get much attention last year because of everything else that was going on, but for the first time in this country

we found two cases of infection with a fully vancomycin-resistant

strain of Staphylococcus aureus. You have been hearing perhaps for

a few years about some strains of Staph. aureus that have had intermediate susceptibility to vancomycin, which is often the last line

of antibiotic defense against that organism. Last year we found two

cases for the first time that were fully resistant. Fortunately, they

were susceptible to other antibiotics. But if we get a multiply-resistant Staph. aureus strain that is truly resistant to vancomycin

then you are back in the 1920’s in terms of dealing with people

with common staphylococcal infections.

The vector-borne and zoonotic disease arena is obviously a hot

one. In addition to West Nile, dengue remains a global problem.

There is always the possible threat of introduction of yellow fever

into Asia. In a way we were lucky we got West Nile. We would not

want to get Japanese encephalitis which is a genetically somewhat

similar virus and a big problem in Asia that could be introduced

into the United States.

So the bottom line is, we live in a global village. We could encounter any infectious disease at any time that occurs anywhere

else in the world, and a lot of our recent experience drives that

home.

Senator PRYOR. Thank you, Mr. Chairman. That is all I have.

Senator COLEMAN. Thank you very much, Senator Pryor.

Dr. Hughes, a question about when SARS would recur. You have

mentioned we are still not sure exactly how it got started. Is there

a sense that once it is in the human population that it is dormant

until something triggers it?

Dr. HUGHES. I do not think we have evidence that it is dormant.

The illness itself, the people who are infected with it have evidence

of viral activity in the first and particularly in the second week.

Those who develop severe respiratory disease then may go on and

be on ventilators for a prolonged period of time and some of them

will die. The virus then, over time, disappears from those people

though. We do not currently have evidence that I am aware of that

there is any chronic carriage of the virus, although there are follow-up studies in progress to assess that possibility.

We do not have evidence that there is much, if any, asymptomatic infection that occurs. But I think we have to keep an open

mind and say the jury is still somewhat out on that it. We do not

know in nature, as I have said, where it originated. To my mind,

the most likely scenario would be that it jumps from animals back

into people and spreads that way again.

We have learned that in contrast to other coronaviruses that

have been previously recognized, this virus survives a bit longer in

the environment so you have to consider the possibility that there

could be an environmental source. It does not survive indefinitely,

but that is just another little complication of this microbe.

Senator COLEMAN. Last comment, a concern again about rural

areas. If somebody from Canada had a virus and brought it to Minneapolis-St. Paul and went to a concert at the Excel Energy Center

in St. Paul and somebody from Hawley, Minnesota, a little town in

the west, were to be there, they would bring it back to their com-
28

munity. Do you have a sense of confidence that folks in our rural

communities have the level of preparedness that they need today

to deal with this?

Dr. HUGHES. I think it starts with awareness. So we need to

focus on rural as well as urban areas in terms of the professional

education and the public education that needs to be done. That is

one scenario that could occur, a person from a rural area sitting in

the row in front of somebody from an affected area who is ill at the

time could easily take it into a rural area. People from rural areas,

obviously, travel to Asia also. So there is no assurance that—rural

areas are certainly not immune to this, and probably on balance

are less prepared to deal with it. Because of just the nature of the

population not being as concentrated, one would hope if you had

good surveillance in place, if it did occur in a rural area you would

pick it up early when there might only be one or a couple of cases

and therefore it would be easier to deal with.

Senator COLEMAN. When we had the outbreak of SARS I know

there were efforts made to educate airline passengers, kind of a

proactive outreach. Do you have in your communication, education

SWAT team, do you have that same kind of planning to get out

there and proactively educate should the outbreak recur?

Dr. HUGHES. Yes, we do. We have not talked very much about

this here today, but we were very active in working with Customs,

Immigration, Agriculture, and other Federal colleagues in ports of

entry in the United States to give information to passengers who

were returning from SARS-affected areas. We actually distributed

over 2.7 million of these health alert multi-language cards to people. We actually know that a number of people—I cannot give you

precise numbers—but we know that a number of patients with suspect or probable SARS actually went to their physicians and

showed them this card and said, I am here because I have been

there and I have this card and maybe you ought to think of this.

So that helped.

We have other approaches to providing travel alerts and travel

advisories to outgoing travelers. So we have systems in place to do

that. We work closely with the airlines and the airline unions. I

think there is more work to be done in that area to be better prepared for the next time this occurs. So there is progress, there are

conversations, there is communication but there is more to be done.

Senator COLEMAN. Dr. Hughes, I appreciate you noting that you

are not going to be complacent at this time and that we will be

doing the best we can to be ready for the next time.

Dr. HUGHES. Thank you.

Senator COLEMAN. Thank you. With that, the record of this hearing will be kept open for 30 days for additional questions and comments. Some of my colleagues may be in touch with you, Dr.

Hughes, or Dr. Kanof, with some additional concerns and questions. So with that, thank you for your participation. Thank you for

your good work.

This hearing is adjourned.

[Whereupon, at 10:33 a.m., the Subcommittee was adjourned.]
(29)

A P P E N D I X

PREPARED STATEMENT OF SENATOR FRANK R. LAUTENBERG

Thank you, Mr. Chairman, for holding today’s hearing on State and local preparedness as it relates to Severe Acute Repository Syndrome—SARS.

Mr. Chairman, one thing that struck me at the last hearing the Subcommittee

held on SARS was that all of the witnesses attributed the absence of a widespread

outbreak here in the United States, to some extent, to luck.

New Jersey, my State, is developing guidelines for enhanced preparedness for an

outbreak based on the CDC’s recommendations. The three key elements to breaking

the cycle of transmission are: (1) early detection; (2) intense surveillance; and (3)

isolation.

New Jersey followed this plan during the first SARS outbreak and did it well. But

luck was involved, too, and I don’t want to rely on luck. Sometimes, luck runs out.

There is a lull in the SARS epidemic right now but we must remain vigilant: The

resurgence in late May of cases in Toronto where the disease was thought to have

been contained is a sobering reminder of the resilience of SARS and its capacity to

surprise us.

Disease prevention requires more than bolstering State and local preparedness

and other domestic capabilities—as vital as all of that is. It also requires training

experts in epidemiology in other countries and coordinating with agencies around

the world.

Diseases don’t respect borders. If SARS persist in Asia for the long-term, it will

continue to threaten us here in the United States. As Barry Bloom, dean of the Harvard School of Public Health, wrote in a recent issue of Science, ‘‘The lesson here

is that it is time to support a global war on disease.’’

Thank you, Mr. Chairman.
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