Federal News Service - Hearing of the Senate Health, Education, Labor, and Pensions Committee

Federal News Service

April 7, 2003 Monday

HEADLINE: HEARING OF THE SENATE HEALTH, EDUCATION, LABOR AND PENSIONS COMMITTEE
 
SUBJECT: SEVERE ACUTE RESPIRATORY SYNDROME THREAT (SARS)
 
CHAIRED BY: SENATOR JUDD GREGG (R-NH)
 
LOCATION: 430 DIRKSEN SENATE OFFICE BUILDING, WASHINGTON, D.C.DATE: APRIL 7, 2003

WITNESSES: JULIE L. GERBERDING, M.D., MPH, DIRECTOR, CENTERS FOR DISEASE CONTROL AND PREVENTION; ANTHONY S. FAUCI, M.D., DIRECTOR, NATIONAL INSTITUTE OF ALLERGY AND INFECTIOUS DISEASE (NIH); AND DAVID L. HEYMANN, M.D., EXECUTIVE DIRECTOR, COMMUNICABLE DISEASES, WORLD HEALTH ORGANIZATION

SENATOR EDWARD KENNEDY (D-MA): Thank you. Thank you very much, Senator Gregg, for calling this hearing, which is enormously important, and the incredibly significant to our fellow citizens here in this country and people around the world. And I join in welcoming Dr. Gerberding and Dr. Fauci, who are two very special leaders, not only in understanding this challenge but in so many other health related areas.

It's less than a month since the first reports surfaced of this dangerous new disease, and it's already spread around the globe with thousands of cases and dozens of deaths. And we live in a time when deadly disease can leap oceans and travel the globe in a matter of hours -- as fast as an airline passenger can fly. And it is spread easily from person to person, and there is no vaccine or miracle cure. The evidence indicates that it's caused by a virus. Treatments based on how we treat flu-like disease are all we can provide so far. The best weapons in combating this deadly disease are the skill of our health care workers and the ingenuity of our scientists.

I had the opportunity to hear from some of the nation's best doctors and scientists at a forum on SARS on Friday in Boston. We drew on experts from clinical medicine, public health and basic science to hear the best insights and recommendations on how to recommend -- to respond to this extraordinary new health challenge.

Even without a single death so far in the United States, the impact of SARS has been significant. I heard on Friday that restaurant bookings in Boston's Chinatown had dropped by over 60 percent because of possible fears of outbreak there. The state health department is receiving over 200 calls a day about the disease. In a recent town meeting held in the Boston Department of Public Health drew over 100 people, and they were expecting 15 or 25 -- all anxious to receive the latest information.

Congress has provided a down payment on the resources that will be needed to fight this epidemic. Last week, the Senate accepted an amendment that Senator Clinton, Senator Murkowski and I offered that will add $16 million to the CDC, the Centers for Disease Control, budget to fight SARS. And I understand that the CDC has assigned over 300 personnel to this outbreak, so more resources will clearly be needed in the near future. Health departments across the country are already reeling under the impact of budget cuts, and the burden of implementing the small pox vaccination plan, and this new epidemic will strain their capacities yet further.

So SARS is also a wake-up call for another reason. There's no indication it began as a terrorist attack, but what if it had? A virus could be just as destructive as a bomb or a missile. Homeland security means protecting our country against health threats as vigorously as we protect them against military threats, yet today we are already stretched to the limit in protecting the country against bio-terror (ills ?). Obviously, we must provide the resources needed to meet both the man-made threat of terrorism and the natural threat of SARS.

Senator Frist and I held hearings in the past on possible threats from bioterrorism. Bioterror provisions in the bill enacted after 9/11 were a key turning point in preparing a response. We've been worried about the other germ threats as well, such as West Nile Virus. We're concerned about the widespread, routine use of antibiotics in agriculture, for animal feed, and the dangers that germs will mutate into forms that are resistant to all forms of antibiotics. Clearly, we need to strengthen our defenses against these perils. Health departments and hospitals across the nation are taking needed steps to improve preparedness against these modern disease threats. At a time like this, it makes no sense for either Congress or the states to be cutting reimbursements to public health agencies and hospitals struggling to face these challenges.

Today we'll hear about SARS from three of our best experts. Dr. Gerberding has led the CDC through some of the greatest challenges in its history. She has helped protect the nation against the deliberate use of infectious disease as a weapon, and now the talents of CDC's extraordinary doctors are being mobilized against SARS. One of the points made at the forum on Friday was the extraordinary respect by public health professionals for the job that CDC has done in responding so far.

We're also pleased that Dr. Fauci is here. He and the NIH have given extraordinary service to the nation in their work on AIDS and many other infectious diseases, and I commend him for his leadership. And we're also honored to have David Heymann from the World Health Organization joining us by video conference. And he is at the forefront of the emergency international efforts to combat SARS.

And I look forward very much to the testimony of these impressive witnesses at this extremely important hearing. And I thank you, Mr. Chairman.

BREAK IN TRANSCRIPT

SEN. GREGG: Senator Kennedy?

SEN. KENNEDY: Thank you very much, Mr. Chairman. And we are really -- we are reminded again about what a small world community we are when it comes to health care. Your dates of time going back to mid February, now just about getting into mid April, a two-month period, and the steps that have been taken by yourself, the CDC are enormously important. But see how rapidly this can spread in a very short period of time and affect families here in the United States.

Just quickly, Dr. Heymann, which countries are doing the best things? Could you tell us? Are all the nations doing pretty much -- following your recommendations? We -- that you know of?

DR. HEYMANN: Yes. All countries are following our recommendations, and there's been a great rallying around this outbreak. In the 21st century, there's a new way of working. And I have to say that we didn't anticipate the support that we've had. We've only had one ministry of health concerned because they were caught off guard. So, it's a very -- it's a solidarity internationally on this. And all countries, including the U.S. and Canada, are following the recommendations of the WHO.

SEN. KENNEDY: Let me ask you -- your life has been studying these kinds of diseases -- how does this one rate? How does this figure in the range of different kinds of virulent either viruses or pathogens that you've studied? Where would you put it in terms of its danger to mankind?

DR. HEYMANN: What is concerning about this is that it's a disease which has probably emerged from nature into humans, but instead of having a dead end in humans, in other words infecting humans but not transmitting on, it continues to transmit through chains of transmission, through health workers and then to their families and others. It is not a highly virulent disease. Four percent is not a very high case fatality rate, but what is high is the fact that it is killing health workers, who are the pillars of our societies. So, it is a very important disease because of that. If you look at a disease like Ebola, which kills between 50 and 80 percent of people, but that disease is so virulent that it doesn't have a chance to spread. This disease has spread very rapidly around the world, and continues to transmit from person to person. So, it's a disease which may not be high as far as mortality, but it certainly is high as far concerns transmission around the world.

SEN. KENNEDY: Dr. Fauci, do you want to add something to that?

DR. FAUCI: Yes, Senator Kennedy. I agree with Dr. Heymann, we are all concerned, but since it's an evolving epidemic, I think we need to emphasize, because whenever we say "concerned," some people say "well then, gee, we should be panicking, we should be -- what should we be doing that we're not doing?" I think that the public health measures that are being taken internationally under the leadership of WHO, and internationally and domestically under the leadership of the CDC are right on, and Dr. Gerberding described some of these. So, I am concerned for the reasons that Dr. Heymann mentioned, is the transmissability, the fact that it's a new virus. The point that Dr. Heymann made is an excellent one. When we had the problem with the bird flu a few years ago and then just most recently the small number this year, it was a type of a flu that is involved with chickens, and it's called an H5N1. And when it jumped from the chicken to the human, it jumped from chicken to human with several cases. We dodged a bullet because it didn't then go from human, to human, to human. The problem with this one is that it very likely jumped from an animal species to a human, but now it's spreading in humans, and that's the thing that's concerning us all.

SEN. KENNEDY: Dr. Gerberding, I think most Americans want to know what can they do to prevent getting it. What would you say to people that are watching this and say, "What can I do in order to try and avoid it?" What advice would you give them?

DR. GERBERDING: Right now, we have indicated that people should avoid non-essential travel to the countries where this is especially problematic, and particularly in community situations. And so we are recommending that unless you have to go, defer your trip and wait until we have a little bit better handle on containment in these regions.

If -- on the domestic standpoint, we have a very small number of cases of SARS, but if you are a household contact or a healthcare worker, to be alert and use the recommended precautions. Beyond that, I think what people can do right now is be informed, stay up to date, understand where the epidemic is, understand what's going on in the community, and --

SEN. KENNEDY: Talk to their doctors? Get more information?

DR. GERBERDING: Exactly. Exactly.

SEN. KENNEDY: Do you have websites on this?

DR. GERBERDING: Yes, we -- we, I think, passed --

SEN. KENNEDY: Maybe you'd mention what you'd suggest to people -- I'm going to give you an opportunity -- what, to people who that are watching, or reading about this hearing or watching the hearing, what can they do? Obviously, we'd be interested in telling them about the website, and then calling their public health or their doctors to find out about it.

DR. GERBERDING: Absolutely. We have put a high emphasis on trying to get all the information out as quickly as we can. As WHO has something, we turn it around and get it back up. Our website is a very good resource. It's www.cdc.gov, and you can find pretty much all of the guidance, all of the information from WHO and anything else that would offer advice. We have information there for clinicians which are clearly very critical in recognizing cases and implementing isolation precautions. I should also mention that just Friday, with WHO and CDC, and clinicians in Asia, we were able to do a satellite video conference to educate clinicians and infection control professionals globally about how to recognize and isolate SARS patients. We got many thousands of people who were able to get that information on the web as well as through the satellite.

SEN. KENNEDY: As I understand, there's a categories of the communication of various diseases called the R-0 value, which you're familiar with. The tops is measles, which is 16, and the bottom is small pox, which is four. Of course, we thought we had eradicated the small pox. And then there's polio, which is five, and we've made progress. And then this SARS, the best estimate is six, which looks like it's fairly low in terms of the range. But that could be deceiving, could it not? This could, if people didn't have some form of immunity, or potentially some other kinds of protections, I imagine, this could go very rapidly through the population. Could you comment on it so that they have an accurate -- we don't want to unduly alarm people, but we ought to have the best in terms of science information. What is your view?

DR. GERBERDING: The R-0 is a number that tells us how efficiently a disease is being transmitted, and it has to be greater than one for an epidemic to propagate. The estimate of six is a very preliminary estimate. One of the things that's probably going on with this epidemic is that some patients have an R-0 that's quite low. They're not transmitting to very man people at all. And then there may be a few patients for whom the R-0 is very large. And so that is kind of confusing the situation in terms of understanding this.

We don't want to alarm people unnecessarily, but we do want to express the fact that this is the beginning of a problem. We're learning as we go. It has the potential to spread very quickly, and we've seen that. And it has the potential to spread globally -- we've seen that. So, we've got to work with our public health agencies and our clinician community to do everything we can to identify and contain cases when they do occur here, and to be alert to where the threats are internationally.

SEN. KENNEDY: You mentioned it's the beginning of the problem. I'd ask Dr. Heymann, too -- where are we? Are we in the first inning? Are we in half-time? Are we coming into the --

SEN. GREGG (?): They don't do innings --

SEN. KENNEDY: -- Geneva -- this is -- Dr. Heymann is a good American and understands these. Where would you -- can you tell us where we are? Someone said of the first lines of the opening scene -- where are we?

DR. HEYMANN: Let me go back to what Dr. Fauci said earlier. When a virus emerges from nature into humans, there are many things it can do. It can merge; it can not spread from human to human. It can merge and spread from human to human -- attenuate or decrease in its power over time, or it can spread from person to person and continue to spread and become an endemic disease in our population. We're somewhere between the second and the third as far as our understanding of this disease goes, because we've only had a limited time to study it. We're now in the third and fourth generations of people who were infected. We don't know if this virus will continue with the same power and infect others as we go along, or whether it will drop off as time goes on and not be so virulent. We suspect the worst and we have to be ready for the worst, but we're still between that second part when it transfers from person to person, and it may be decreasing in virulence over time, and the third when it transfers from person to person and remains a very serious disease. I think probably Dr. Gerberding could supplement that a bit better.

SEN. KENNEDY: Anything you'd add?

DR. GERBERDING: Yes. It's too early to say, is the short answer to your question. We agree with the WHO position that we can be hopeful but we need to be prepared for the worst-case scenario. And actually we are already looking at our influenza pandemic planning process and seeing if we can translate that plan to make sense for SARS, just in case. And we want to make sure that if that worst-case scenario does happen that we've got the steps in place to deal with it.

SEN. KENNEDY: Just a -- my time is just about up -- just a final two questions. One is, why do there appear to be more deaths in other countries than there are in the cases that we have had here so far?

DR. GERBERDING: The main reason for the low death rate here is probably that we have a much broader case definition in this country. But what WHO is reporting under the probably cases are people who have the whole pneumonia. Here we're reporting travelers with fever and respiratory illness, and less than half of them actually have pneumonia. So, we're including people who are not as sick to make sure that we know who they are and that we are doing everything we can to contain the spread.

SEN. KENNEDY: I read in your article, you said that there's a possibility that we might get a seasonal, you know, bounce with this. Can you comment about that, whether you think with the coming into the warmer weather -- I guess when you have an influenza epidemic, it doesn't necessarily -- the seasons don't make much of a difference, but they do if you don't have (great ?). What do you think with this? Do you think there's some possibility that you get to the warmer weather and the summer that it might diminish to some extent?

DR. GERBERDING: The other human corona viruses do have a seasonal pattern. In fact, most respiratory illnesses are seasonal. The problem is that what the winter months here is the summer months in the southern hemisphere, and vice versa, so a seasonal pattern might allow a specific region to get a head start on containment, but that doesn't mean the global problem will quiet down at any particular point.

SEN. KENNEDY: One -- just a point -- you put out -- I guess your warnings in English and in Spanish. You might take a look at doing the other languages. We have a very significant Chinese population in Boston that we're looking in their public health --in Boston they're translating it, but it's taking them some time. And if -- I don't know if you have all of these capacities -- you know, I mentioned there's a range of different obvious languages in this country now, and to the extent that could be added, give you one more thing to do.

DR. GERBERDING: Well, I appreciate that. The travel card is in other -- in many languages, but we've recognized this same issue and have put together an Asian community team at CDC this past week to try to do a better job with that. So, thank you.

SEN. KENNEDY: Well, this little -- this little card here was enormously important in Massachusetts because we have two known cases -- potentially four cases, but two known cases -- one an infant. And the doctor in Springfield, Massachusetts, a pediatrician, was able to diagnose it because they had received this kind of a warning. And it just goes to show what it means in terms of communication, good communication early on. Thank you.

DR. GERBERDING: Thank you.

BREAK IN TRANSCRIPT

SEN. DODD: I think he calls it Frist-Dodd. (Laughter.)

SEN. GREGG: Senator Kennedy.

SEN. KENNEDY: Let me ask you, Dr. Gerberding, what are the symptoms? We tried in the earlier round to ask you what people might be able to do. But what would you say -- what can you -- could you tell us about the symptoms for the people who are watching or hearing this? How is this different from sort of the flue? What --

DR. GERBERDING: The short answer is that it doesn't differ very much from the flu. It's pretty much the typical viral-like illness when it starts. We have a hint that it kind of has the bi-phasic pattern, so --

SEN. KENNEDY: You want to just describe that again a little -- I think most of us know what the flu is about, but just so that we -- people be reminded about it.

DR. GERBERDING: Not everyone starts off with a fever, but they usually feel tired, they have muscle aches, they have a sore throat. And then usually a fever develops -- sometimes headache is a prominent feature. In a few people they have that early illness, and then the fever goes away, and then that's followed by coughing and sort of the pneumonia-type symptoms of the chest pain, the tightness, progressing to the troubled breathing. But in the very earliest days it looks like any other kind of common cold or common viral illness. And what you have to know is that you've been either a traveler or you've been exposed. And if you have those very early symptoms you need to contact your health care professional.

SEN. KENNEDY: And the -- at least the best treatment now, what would you -- what would you say, Dr. Gerberding, what are the best treatments now for that?

DR. GERBERDING: There are nonspecific treatments which particularly for the people who have pneumonia, include making sure that they are hydrated, that they have got good nutrition, good nursing care and so forth. But because at the beginning we often can't tell it apart from other common causes of pneumonia many patients will need to be on antibiotics in case we're wrong, it's not SARS, it's regular old pneumococcal pneumonia or something. Some patients have been treated with anti-flu antiviral medications.

In terms of specific treatment for SARS or for Corona virus, or for other viruses per se, there isn't any. Many clinicians globally have tried ribavirin. The results aren't in, but I don't think it looks real promising right now for that to be a solution. Some other things have been tried, and it's just anecdotal and far too soon.

We do have already an investigational new drug protocol developed to look at ribavirin treatment more systematically to see if it's offering anything. And the results of the work that's going on in screening antiviral drugs will help guide future protocols. So I think we'll have things to try in the future, but right now we don't have much on the shelf that makes sense.

SEN. KENNEDY: Dr. Fauci talked about the vaccine. What about the diagnostic test? That can be developed much earlier. Can you tell us what you -- when you think that might be available?

DR. GERBERDING: Well, last week we distributed the first test results to state health departments with case patients in the United States. We can't sensibly give test results until we have that second day-21 sample. And since so many of our cases are just now coming into that epidemiology curve, it's too soon to interpret anything, especially the negatives at this point in time. But we expect over the next couple of weeks that we will be getting at least some of the test reagents out broadly.

SEN. KENNEDY: So, I mean, that's very encouraging, and should be, to all of the public health that these kinds of tests are going to be out and available in a very early period of time. It will be enormously valuable and helpful to them, I would expect.

DR. GERBERDING: We are hoping that will prove to be the case. Of course, we have to test uninfected people and we have to test really very sick people, and then the kind of mixed picture in between to really know how sensitive are these tests, how specific are these tests, and overall what does a specific test mean in a given individual. And that's where I think FDA will help us go through the process of really validating this for individual patient use.

SEN. KENNEDY: And they are obviously working with you now.

DR. GERBERDING: Absolutely. Actually, Secretary Thompson has pulled together a departmental working group on this with NIH and FDA and CDC, and we are all part of a team pulling together the reagent development as well as the vaccine product development.

SEN. KENNEDY: Let me ask, Dr. Heymann, are other countries working on the diagnostic tests or the vaccines? We obviously are. Are other countries? And could you tell us where they might be?

DR. HEYMANN: On the diagnostic tests, tests are being developed in Hong Kong. Singapore is working on some different tests, as are laboratories in Germany and also in other laboratories around the world. So in these 11 laboratories that are collaborating they are also working. The beauty is that they are exchanging their information so that they are getting results faster.

SEN. KENNEDY: That's important. And vaccines? Anything going on Europe at this time, or any of the other --

DR. HEYMANN: (Only thing with ?) vaccines at this point is in the United States, as far as we know.

SEN. KENNEDY: Just, finally, there is really no difference, Dr. Fauci, in the corona virus -- this is, you believe it to be a corona virus -- in the early time there was some question of whether it might be or might not be, but you believe -- because that's obviously basic in terms of developing the vaccine --

DR. FAUCI: Right.

SEN. KENNEDY: -- you believe that the science to date is that's what it is?

DR. FAUCI: The virus that the CDC and others have isolated is unquestionably a corona virus. The evidence, absolutely 100 percent that this is causing it, is almost there, but not 100 percent yet. But we're assuming it is. All the work that I described is -- I'm confident enough to make the investment to go ahead with the research that's assuming this.

SEN. KENNEDY: Well, that's reassuring, and I'm glad that you would -- Finally, can you tell us what -- the president signed the executive order on quarantine -- what's that going to mean to people? Can you explain it to -- to us and to the American people, what that might mean for somebody coming back from China and they've been in this area -- what are their chances, or if they're getting in quarantine, what will this mean to them, and how widely do you anticipate that this might be used?

DR. GERBERDING: Well, first of all, right now we're not quarantining anyone in the United States and we're not planning to quarantine anyone in -- given what we're seeing right now. What the executive order does, it gives the authority to quarantine for SARS in the same way that we can quarantine for other communicable diseases like cholera already. So, it's just simply a matter of adding SARS to a list of diseases that already, if necessary, we can take action to prevent a spread within the community. So, it is a precaution -- a just-in-case kind of executive order.

SEN. KENNEDY: I want to thank -- thank you all. This has been enormously interesting, and very helpful. And I must say, Mr. Chairman, I think it's very reassuring to the American people, this is -- as Dr. Gerberding pointed out -- the list on the -- articles that are about it. It's an enormous concern -- it is in my state, it is all across this country. And I think the reassurance that the American people should have with the fact that we have been on this so quickly, with the leadership of the World Health Organization, the NIH already moving with the vaccines, Dr. Gerberding and the communication, and working with public health groups -- it's -- people, the American people ought to understand that this is a danger, but that our leading health research agencies, including the FDA, are working on this and we have really the best in the world that are working on it. And there are going to be others who probably will be infected and it will be -- some will lose their lives, but I think the American people should be very reassured that we have got the best working on it and dealing with in an important, scientific way, and help is on its way.

I thank you, Mr. Chairman.