Senate Health, Education, Labor and Pensions Committee Holds Hearing on Severe Acute Respiratory Syndrome
FDCH TRANSCRIPTS
Congressional Hearings
Apr. 7, 2003
Senate Health, Education, Labor and Pensions Committee Holds Hearing on Severe Acute Respiratory Syndrome
KENNEDY:
Thank you. Thank you very much, Senator Gregg, for calling this hearing, which is enormously important and the incredibly significant -- our fellow citizens here in this country and people around the world and I join you in welcoming Dr. Gerberding and Dr. Fauci, who are two very special leaders not only in understanding this challenge, but in so many other health related areas.
It's less than a month since the first reports surfaced of this dangerous new disease and it has already spread around the globe with thousands of cases and dozens of deaths.
We live in a time when deadly disease can leap oceans and travel the globe in a matter of hours -- as fast as an airline passenger can fly. It is spread easily from person to person and there is no vaccine or miracle cure.
The evidence indicates that it is caused by a virus; treatments based on how we treat flu-like disease are all we can provide so far. The best weapons in combating this deadly disease are the skill of our health care workers and the ingenuity of our scientists.
I had the opportunity to hear from some of the nation's best doctors and scientists on a forum on SARS on Friday in Boston. We drew on experts from clinical medicine, public health and basic science to hear the best insights and recommendations on how to respond to this extraordinary new health challenge.
Even without a single death so far in the United States, the impact of SARS has been significant. I heard on Friday that restaurant bookings in Boston's Chinatown 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, over 100 people last week, when they were expecting 15 or 25, all anxious to receive the latest information.
Congress has provided a down payment on the resources that will be needed to fight this epidemic. Last week the Senate accepted an amendment that Senator Clinton, Senator Mikulski and I offered their labs $16 million dollars to the CDC, the Centers for Disease Control budget to fight SARS. I understand that the CDC has assigned over 300 personnel to this outbreak; so more resources would clearly be needed in the near future.
Health departments across the country are already reeling under the impact of budget cuts and the burden of implementing the smallpox vaccination plan and this new epidemic will strain their capacities yet further.
SARS is also a wakeup call for another reason. There is no indication it began as a terrorist attack, but what if it had. A virus can be just as destructive as a bomb or a missile. Homeland security means protecting our country against health threats as vigorously as we protect it against military today. Yet, today we are already stretched to the limit in protecting the country against bioterrorism.
Obviously, we must provide the resources needed to meet both the manmade threat of terrorism and the natural threat of SARS.
Senator Frist and I held hearings in the past on possible threats from bioterrorism. Bioterror provisions in the bill enacted after 9/11 were 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 danger that germs will mutate into forms that are resistant to all forms of antibiotics.
Clearly, we need to strengthen our defenses against these perils. Health departments and hospitals across the nation are taking needed steps to improve preparedness against these modern disease threats. At a time like this, it makes no sense for either Congress or the states to be cutting reimbursements to public health agencies and hospitals struggling to face these challenges.
Today we will hear about SARS from three of our best experts. Dr. Gerberding has led the CDC through some of 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 and their work on AIDS and many other infectious diseases and I commend him for his leadership. We're also honored to have David Heymann from the World Health Organization joining us by videoconference. He is at the forefront of the emergency international efforts to combat SARS. I look forward very much to the testimony of these impressive witnesses at this extremely important hearing. I thank you, Mr. Chairman.
BREAK IN TRANSCRIPT
KENNEDY:
Thank you very much, Mr. Chairman.
We are really -- we are reminded again about what a small world community we are when it comes to health care of your dates of time going back to mid-February. We are now just about getting into mid- April. Over a two-month period, the steps that have been taken by yourself, the CDC, are enormously important, but we see how rapidly that 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 that you know of?
HEYMANN:
Yes. All countries are following our recommendations and there has been a great rallying around this outbreak. In the 21st century there is a new way of working. And that is to say that we didn't anticipate the support that we had. We only had one ministry of health concerned, because they were caught off guard.
So, it's a solidarity internationally on this and all countries, including the U.S. and Canada are following the recommendations of WHO.
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?
HEYMANN:
What is concerning about this is that it is a disease which probably has emerged from nature into human. But instead of having a dead end in humans, in other words, infecting humans and not transmitting on, it continues to transmit through chains of transmission to health workers and their families and others.
It's not a highly virulent disease. Four percent is not are very high case fatality rate. But what is high is the fact that it killing health workers who are the center of our society.
So, it is a very important disease because of that. If you look at a disease like Ebola, it 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 is a disease, which may not be high as far as mortality, but it certainly is high as concerns transmission around the world.
KENNEDY:
Dr. Fauci, do you want to add something to that?
FAUCI:
Yes, Senator Kennedy. I agree with Dr. Heymann. We are all concerned, but since it is an evolving epidemic, I think we need to emphasize because whenever we say "concerned", some people say, well, gee, then 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. Dr. Gerberding described some of these.
So, I am concerned for the reasons that Dr. Heymann mentioned is the transmissibility, the fact that it is a new virus. The point that Dr. Heymann made is an excellent one. When we had the problem with the bird flu a few years ago and then just most recently the small number this year, it was a type of a flu that is involved with chickens and it is called an H5N1 and when it jumped from the chickens 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 is spreading in humans and that is the thing that is concerning us all.
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 saying, "What can I do in order to try and avoid it?" What advice would you give them.
GERBERDING:
Right now we have indicated that people should avoid non-essential travel to the countries where this is especially problematic, particularly in community situations. So, we are recommending that unless you have to go, defer your trip and wait until we have a little bit better handle on containment in these regions.
If in the domestic standpoint we have a very small number of cases of SARS, but if you are a household contact or a health care worker to be alert and use the recommended precautions. Beyond that, I think what people can do right now is be informed. Stay up to date, understand where the epidemic is, understand what is going on in the community and...
KENNEDY:
Talk to their doctors, get more information.
GERBERDING:
Exactly.
KENNEDY:
Do you have web sites on this?
GERBERDING:
Yes. We, I think, passed...
KENNEDY:
Maybe you've mentioned what would you suggest to people -- good, I'm going to give you an opportunity -- what to people that are watching or reading about this hearing or watching the hearing, what can they do. Obviously, we would be interested to tell them about the web site and then calling your public health or their doctors to find out about it.
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 web site 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 this Friday with WHO and CDC and clinicians in Asia, we were able to do a satellite videoconference to educate clinicians and infection control professionals globally about how to recognize and isolate SARS patients.
We've got many thousands of people who were able to get that information on the web as well as through the satellite.
KENNEDY:
As I understand this, categories of the communication of various disease is called the R-zero value, which you are familiar with, the top is measles, which is 16 and the bottom, which is smallpox, which is four. Of course, we thought we had eradicated the smallpox. And then there is polio, which is five. We've made progress.
And then this SARS, the best estimate is six, which looks like it is 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 kind of protection, I would imagine, this could go very rapidly through the population. So, could you comment on it so they could 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...
GERBERDING:
The R-zero is a number that tells us how efficiently disease is being transmitted. 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 is probably going on with this epidemic is that in some patients have an R-zero that is quite low. They're not transmitting to very many people at all. And then there may be a few patients for whom the R-zero 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 are 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 communities to do everything we can to identify and contain cases when they do occur here and to be alert to what the threats are internationally.
KENNEDY:
You mentioned it's the beginning of the problem. I'll ask Dr. Heymann, too. Where are we? Are we in the first inning? Are we in halftime? Are we coming into the -- Dr. Heymann is a good American. He understands these. Where would you -- could you tell us where we are? Someone said of the first lines of the opening scene? Where are we?
HEYMANN:
Let me go back to what Dr. Fauci said earlier. When a virus emerges from nature into humans, there are many things it can do. It can emerge; it cannot spread from human to human. It can emerge and spread from human to human, but attenuate or decrease in its (inaudible) over time.
Or it can spread from person to person and continue to spread and become an endemic disease in our population. We are somewhere between the second and the third as far as our understanding of this disease goes, because we've only had a limited time to study it. We are now in the third and fourth generations of people who are infected. We don't know if this virus will continue with its same power to infect others as we go along or whether it will drop off as time goes on and not be so virulent.
We suspect the worst and we have to be ready for the worst, but we are still between that second part when it transfers from person to person and may be decreasing in virulence over time and the third when it transfers from person to person and remain a very serious disease.
I think Dr. Gerberding could supplement that a bit better.
KENNEDY:
Anything that you would add?
GERBERDING:
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. 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.
KENNEDY:
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?
GERBERDING:
The main reason for the low death rate here is probably that we have a much broader case definition in this country. What WHO is reporting under the probable cases are people who have the whole pneumonia. Here we are reporting travelers with fever and respiratory illness and less than half of them actually have pneumonia. So, 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 spread.
KENNEDY:
I read in your article you said that it was a possibility that we might get a seasonal bounce with this. Can you comment about that, whether you think that 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 (inaudible).
What do you think with this? Do you think there is some possibility that as you get to the warmer weather in the summer it might diminish to some extent?
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.
KENNEDY:
One point. You point 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 are looking at. The public health in Boston are translating it, but it is taking them some time. I don't know if you have all of these capacities. I mentioned there is a range of different obvious languages in this country now and to the extent that that could be added. I'll give you one more thing to do.
GERBERDING:
I appreciate that. The travel card is in other many languages, but we recognize the same issue and have put together an Asian community team at CDC this past week to try to do a better job with that, so thank you.
KENNEDY:
This little card here was enormously important in Massachusetts, because we have two known cases, potentially four cases, but two known cases -- one an infant. And the doctor in Springfield, Massachusetts, a pediatrician, was able to diagnose it, because they had received this kind of a warning.
And it just goes to show what it means in terms of communication, good communication earlier.
BREAK IN TRANSCRIPT
KENNEDY:
Let me ask you, Dr. Gerberding, what are the symptoms. We tried to ask you in the earlier round might be able to do, but what would you say, can you tell us about the symptoms so people that are watching or hearing this, how is this different than sort of the flu?
GERBERDING:
Well, 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 a biphasic pattern.
KENNEDY:
Do you want to describe that again? I think most of us know what the flu is, but just so that people be reminded about it.
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 the fever goes away and then that is followed by coughing and sort of pneumonia type symptoms of the chest pain, the tightness, progressing to the trouble breathing. But in the very earliest days, it looks like any other kind of common cold or common viral illness. What you have to know is that you've been either a traveler or you have been exposed and if you have those very early symptoms, you need to contact your health care professional.
KENNEDY:
And at least the best treatment now, what do you say, Dr. Gerberding, what are the best treatments now for that.
GERBERDING:
There are non-specific treatments which particularly for the people who have pneumonia include making sure that they are hydrated, that they've 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 are 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 Corona virus or for other viruses per se, there isn't any. Many clinicians globally have tried Riboviran. 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 is just anecdotal and far too soon. We do have already an investigational new drug protocol developed to look at Riboviran treatment more systematically to see if it is offering anything, but the results of the work that is going on in screening antiviral drugs will help guide future protocols.
So, I think we will have things to try in the future, but right now we don't have much on the shelf that makes sense.
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?
GERBERDING:
Well, last week we distributed the first test results to state health departments with case patients in the United States. We can't give test results until we have that second day 21 sample and since so many of our cases are just now coming into that epidemiology curve, it is too soon to interpret anything, especially the negatives at this point in time.
But we expect over the next couple of weeks that we will be getting at least some of the test reagents out broadly.
KENNEDY:
So, that is 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.
GERBERDING:
We're 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 is the test, are these tests, how specific are these tests and overall, what is the specific test mean in a given individual. And that is where I think FDA will help us go through the process of really validating this for individual patient use.
KENNEDY:
And they are obviously working with you now.
GERBERDING:
Absolutely. Secretary Thompson (ph) 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.
KENNEDY:
Let me ask Dr. Heymann, are other countries working on either the diagnostic tests or the vaccines? We, obviously, are. Are other countries and can you tell us where they might be?
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. (Inaudible) exchanging more information so they're getting it faster.
KENNEDY:
Vaccines, anything going on in Europe at this time.
HEYMANN:
The only thing with vaccine at this point is the United States as far as we know.
KENNEDY:
Just finally, there is really no difference, Dr. Fauci, in the Corona virus. This is, you believe, to be a Corona virus. There was some question whether it might be or might not be, because you believe because that's obviously basic in terms of developing the vaccine. You believe that the science to date is that is what it is.
FAUCI:
The virus that the CDC and others have isolated is unquestionably the Corona virus. The evidence absolutely 100 percent that this is causing it is almost there, but not 100 percent yet. We are 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 is assuming this.
KENNEDY:
Well, that is reassuring. Finally, can you tell us what the president signed the executive order on quarantine? What is that going to mean to people. Can you explain it to us and to the American people what that might mean, somebody coming back from China, they've been in this area. What are their chances if they are getting in quarantine, what will this mean to them and how widely do you anticipate that this might be used?
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 are seeing right now. What executive order does is 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.
KENNEDY:
I want to thank you all. It's been enormously interesting, very helpful. And I must say, Mr. Chairman, I think it is very reassuring for the American people. As Dr. Gerberding pointed out, the list -- the articles that are about it, it is an enormous in my state as it is all across this country and I think the reassurance of 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 in the communication in working with public health groups.
KENNEDY:
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 will probably be infected and some will lose their lives, but I think the American people should be reassured that we've got the best working on it and dealing with it in an important, scientific way. Help is on its way.
I thank you, Mr. Chairman.