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Washington File

09 April 2003

Emergence of SARS Shows Danger of Becoming Complacent

(Disease Centers director Gerberding testifies to Senate) (2600)
More needs to done to defend against a deadly virus, said Dr. Julie
Gerberding, director of the U.S. Centers for Disease Control and
Prevention (CDC), April 7. "The emergence of SARS (severe acute
respiratory syndrome) has reminded us yet again that we must not
become complacent."
In her prepared statement given before the Senate Committee on Health,
Education, Labor and Pensions, Gerberding called SARS "an emerging
global microbial threat."
"It is not possible to adequately protect the health of our nation
without addressing infectious disease problems that are occurring
elsewhere in the world," Gerberding testified.
Gerberding noted that much progress has been made in the last decade
to better the nation's capability to deal with the threat of
infectious diseases, but surveillance and laboratory capacity must
still be improved.
The CDC is recommending that persons "postpone non-essential travel to
mainland China, Hong Kong, Singapore, and Hanoi, Vietnam." Anyone who
has traveled to affected areas and experiences flu-like symptoms is
instructed to contact a physician.
CDC is participating in an international collaboration of health
agencies working to analyze the nature of the virus causing SARS and
developing strategies to contain it. The Atlanta, Georgia-based agency
has devoted more than 300 members of its staff to the SARS
investigation.
Following is Gerberding's testimony as prepared for delivery:
(begin text)
Testimony 
Before the Committee on Health, Education, Labor, and Pensions
United States Senate
CDC Response to Severe Acute Respiratory Syndrome (SARS) 
Statement of Julie L. Gerberding, M.D., M.P.H. 
Director 
Centers for Disease Control and Prevention
Department of Health and Human Services
Monday, April 7, 2003
Good morning, Mr. Chairman and Members of the Committee. I am Dr.
Julie L. Gerberding, Director, Centers for Disease Control and
Prevention (CDC). Thank you for the invitation to participate today in
this timely hearing on a critical public health issue: severe acute
respiratory syndrome (SARS). I will update you on the status of the
spread of this emerging global microbial threat and on CDC's response
with the World Health Organization (WHO) and other domestic and
international partners.
As we have seen recently, infectious diseases are a continuing threat
to our nation's health. Although some diseases have been conquered by
modern advances, such as antibiotics and vaccines, new ones are
constantly emerging, such as Legionnaires' disease, Lyme disease, and
hantavirus pulmonary syndrome. SARS is the most recent reminder that
we must always be prepared for the unexpected. SARS also highlights
that U.S. health and global health are inextricably linked and that
fulfilling CDC's domestic mission-to protect the health of the U.S.
population-requires global awareness and collaboration with
international partners to prevent the emergence and spread of
infectious diseases.
Emergence of SARS 
Since late February 2003, CDC has been supporting WHO in the
investigation of a multi-country outbreak of unexplained atypical
pneumonia referred to as severe acute respiratory syndrome (SARS). As
of April 3, 2003, a total of 2300 probable or suspected cases of SARS
have been reported to WHO from 16 countries, and 79 of these patients
have died. This includes 115 suspected cases in the United States,
from 29 states. None of the suspected cases in the United States have
died.
In February, the Chinese Ministry of Health notified WHO that 305
cases of acute respiratory syndrome of unknown etiology had occurred
in Guangdong province in southern China since November 2002. In
February 2003, a man who had traveled in mainland China and Hong Kong
became ill with a respiratory illness and was hospitalized shortly
after arriving in Hanoi, Vietnam. Health-care providers at the
hospital in Hanoi subsequently developed a similar illness. During
late February, an outbreak of a similar respiratory illness was
reported in Hong Kong among workers at a hospital; this cluster of
illnesses was linked to a patient who had traveled previously to
southern China. On March 12, WHO issued a global alert about the
outbreak and instituted worldwide surveillance for this syndrome,
characterized by fever and respiratory symptoms.
On Friday, March 14, CDC activated its Emergency Operations Center
(EOC) in response to reports of increasing numbers of cases of SARS in
several countries. On Saturday, March 15,
CDC issued an interim guidance for state and local health departments
to initiate enhanced domestic surveillance for SARS; a health alert to
hospitals and clinicians about SARS; and a travel advisory suggesting
that persons considering nonessential travel to Hong Kong, Guangdong,
or Hanoi consider postponing their travel. HHS Secretary Tommy
Thompson and I conducted a telebriefing to inform the media about SARS
developments.
Of the 115 reported suspected cases among U.S. residents, 109 have
traveled to mainland China, Hong Kong, Singapore, or Hanoi, Vietnam, 4
had household contact with a suspected case, and 2 are healthcare
workers who provided medical care to a suspected case. Cases in the
United States have had relatively less severe manifestations of SARS,
compared to cases reported in other countries. Forty-three cases have
been hospitalized. As of April 3, 12 remain in the hospital, and none
have died. Community transmission of SARS has not been identified
within the United States. Transmission to healthcare workers has only
been observed in one cluster involving two healthcare workers in the
United States, in contrast to the numerous instances of possible
transmission to healthcare workers that have been reported in several
other countries.
Cases of SARS continue to be reported from around the world. The
disease is still primarily limited to travelers to Hong Kong, Hanoi,
Singapore, and mainland China; to health care personnel who have taken
care of SARS patients; and to close contacts of SARS patients. Based
on what we know to date, we believe that the major mode of
transmission is through droplet spread when an infected person coughs
or sneezes. However, we are concerned about the possibility of
airborne transmission and also the possibility that objects that
become contaminated in the environment could serve as modes of spread.
CDC Response to SARS 
CDC continues to work with WHO and other national and international
partners to investigate this ongoing emerging global microbial threat.
This is a major challenge, but it is also an excellent illustration of
the intense spirit of collaboration among the global scientific
community to combat a global epidemic.
CDC is participating on teams assisting in the investigation in
mainland China, Hong Kong, Taiwan, Thailand, and Vietnam. In the
United States, we are conducting active surveillance and implementing
preventive measures, working with numerous clinical and public health
partners at state and local levels. As part of the WHO-led
international response thus far, CDC has deployed approximately 30
scientists and other public health professionals internationally and
has assigned almost 300 staff in Atlanta and around the United States
to work on the SARS investigation.
CDC has issued interim guidance to protect against spread of this
virus for close contacts of SARS patients, including in health care
settings or in the home. We have also issued interim guidance for
management of exposures to SARS and for cleaning airplanes that have
carried a passenger with suspected SARS. We have issued travel
advisories and health alert notices, which are being distributed to
people returning from China, Hong Kong, Singapore, and Vietnam. We
have distributed more than 200,000 health alert notice cards to
airline passengers entering the United States from these areas,
alerting passengers that they may have been exposed to SARS, should
monitor their health for 10 days, and if they develop fever or
respiratory symptoms, they should contact a physician.
WHO is coordinating daily communication between CDC laboratory
scientists and scientists from laboratories in Asia, Europe, and
elsewhere to share findings, which they are posting on a secure
Internet site so that they can all learn from each other's work. They
are exchanging reagents and sharing specimens and tissues to conduct
additional testing. Our evidence and that of many of our partners
indicates that a new coronavirus is the leading candidate for the
cause of this infection.
Initial laboratory efforts were focused on a diagnosis based on
clinical symptoms and available epidemiologic information. On the
basis of this initial diagnosis, CDC used classical microbiologic
approaches and molecular diagnostic methods to identify the agent or
agents involved. A broad range of pathogens primarily associated with
respiratory disease and for which respiratory symptoms might be
secondary were targeted for detection in SARS specimens. Various
methods were used for detection, including light and electron
microscopy, immunohistochemistry, cell culture isolation techniques,
serology, and other modern molecular techniques. An apparently new
coronavirus was isolated in cell cultures, and coronavirus nucleotide
sequences specific to this virus were detected in diseased tissues.
This finding, coupled with the increasing reports that many WHO
collaborating laboratories have detected this virus in specimens from
SARS patients, suggests that this coronavirus is involved in the
etiology of the disease. Efforts to further characterize the role of
this coronavirus in SARS are ongoing at CDC and in other laboratories.
Rapid and accurate communications are crucial to ensure a prompt and
coordinated response to any infectious disease outbreak. Thus,
strengthening communication among clinicians, emergency rooms,
infection control practitioners, hospitals, pharmaceutical companies,
and public health personnel has been of paramount importance to CDC
for some time. In the past three weeks, CDC has had multiple
teleconferences with state health officials to provide them the latest
information on SARS spread, implementation of enhanced surveillance,
and infection control guidelines and to solicit their input in the
development of these measures and processes. On Friday, April 4, WHO
sponsored, with CDC support, a clinical video conference broadcast
globally to discuss the latest findings of the outbreak and prevention
of transmission in healthcare settings. The faculty was comprised of
representatives from WHO, CDC, and several affected countries who
reported their experiences with SARS. The video cast is now available
on-line for download. Secretary Thompson and I, as well as other
senior scientists and leading experts at CDC, have held numerous media
telebriefings to provide updated information on SARS cases, laboratory
and surveillance findings, and prevention measures. CDC is keeping its
website current, with multiple postings daily providing clinical
guidelines, prevention recommendations, and information for the
public.
Prevention Measures 
Currently, CDC is recommending that persons postpone non-essential
travel to mainland China, Hong Kong, Singapore, and Hanoi, Vietnam.
Persons who have traveled to affected areas and experience symptoms
characteristic of SARS should contact a physician. Health care
facilities and other institutional settings should implement infection
control guidelines that are available on CDC's website.
We know that individuals with SARS can be very infectious during the
symptomatic phase of the illness. However, we do not know how long the
period of contagion lasts once they recover from the illness, and we
do not know whether or not they can spread the virus before they
experience symptoms. The information our epidemiologists have suggests
that the period of contagion may begin with the onset of the very
earliest symptoms of a viral infection, so our guidance is based on
this assumption. SARS patients who are either being cared for in the
home or who have been released from the hospital or other health care
settings and are residing at home should limit their activities to the
home. They should not go to work, school, or other public places until
at least ten days after they are fully asymptomatic.
If a SARS patient is coughing or sneezing, he should use common-sense
precautions such as covering his mouth with a tissue, and, if possible
and medically appropriate, wearing a surgical mask to reduce the
possibility of droplet transmission to others in the household. It is
very important for SARS patients and those who come in contact with
them to use good hand hygiene: washing hands with soap and water or
using an alcohol-based hand rub frequently and after any contact with
body fluids.
For people who are living in a home with SARS patients, and who are
otherwise well, there is no reason to limit activities currently. The
experience in the United States has not demonstrated spread of SARS
from household contacts into the community. Contacts with SARS
patients must be alert to the earliest symptom of a respiratory
illness, including fatigue, headache or fever, and the beginnings of
an upper respiratory tract infection, and they should contact a
medical provider if they experience any symptoms.
Emerging Global Microbial Threats 
Since 1994, CDC has been engaged in a nationwide effort to revitalize
national capacity to protect the public from infectious diseases.
Progress continues to be made in the areas of disease surveillance and
outbreak response; applied research; prevention and control; and
infrastructure-building and training. However, SARS provides striking
evidence that a disease that emerges or reemerges anywhere in the
world can spread far and wide. It is not possible to adequately
protect the health of our nation without addressing infectious disease
problems that are occurring elsewhere in the world.
Last month, the Institute of Medicine (IOM) published a report
describing the spectrum of microbial threats to national and global
health, factors affecting their emergence or resurgence, and measures
needed to address them effectively. The report, Microbial Threats to
Health: Emergence, Detection, and Response, serves as a successor to
the 1992 landmark IOM report Emerging Infections: Microbial Threats to
Health in the United States, which provided a wake-up call on the risk
of infectious diseases to national security and the need to rebuild
the nation's public health infrastructure. The recommendations in the
1992 report have served as a framework for CDC's infectious disease
programs for the last decade, both with respect to its goals and
targeted issues and populations. Although much progress has been made,
especially in the areas of strengthened surveillance and laboratory
capacity, much remains to be done. The new report clearly indicates
the need for increased capacity of the United States to detect and
respond to national and global microbial threats, both naturally
occurring and intentionally inflicted, and provides recommendations
for specific public health actions to meet these needs. The emergence
of SARS, a previously unrecognized microbial threat, has provided a
strong reminder of the threat posed by emerging infectious diseases.
Conclusion 
The SARS experience reinforces the need to strengthen global
surveillance, to have prompt reporting, and to have this reporting
linked to adequate and sophisticated diagnostic laboratory capacity.
It underscores the need for strong global public health systems,
robust health service infrastructures, and expertise that can be
mobilized quickly across national boundaries to mirror disease
movements. As CDC carries out its plans to strengthen the nation's
public health infrastructure, we will collaborate with state and local
health departments, academic centers and other federal agencies,
health care providers and health care networks, international
organizations, and other partners. We have made substantial progress
to date in enhancing the nation's capability to detect and respond to
an infectious disease outbreak; however, the emergence of SARS has
reminded us yet again that we must not become complacent. We must
continue to strengthen the public health systems and improve linkages
with domestic and global colleagues. Priorities include strengthened
public health laboratory capacity; increased surveillance and outbreak
investigation capacity; education and training for clinical and public
health professionals at the federal, state, and local levels; and
communication of health information and prevention strategies to the
public. A strong and flexible public health infrastructure is the best
defense against any disease outbreak.
Thank you very much for your attention. I will be happy to answer any
questions you may have.
(end text)
(Distributed by the Office of International Information Programs, U.S.
Department of State. Web site: http://usinfo.state.gov)



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