[House Hearing, 113 Congress]
[From the U.S. Government Printing Office]
MEETING THE CHALLENGE OF DRUG-RESISTANT DISEASES IN DEVELOPING
COUNTRIES
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON AFRICA, GLOBAL HEALTH,
GLOBAL HUMAN RIGHTS, AND
INTERNATIONAL ORGANIZATIONS
OF THE
COMMITTEE ON FOREIGN AFFAIRS
HOUSE OF REPRESENTATIVES
ONE HUNDRED THIRTEENTH CONGRESS
FIRST SESSION
__________
APRIL 23, 2013
__________
Serial No. 113-56
__________
Printed for the use of the Committee on Foreign Affairs
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COMMITTEE ON FOREIGN AFFAIRS
EDWARD R. ROYCE, California, Chairman
CHRISTOPHER H. SMITH, New Jersey ELIOT L. ENGEL, New York
ILEANA ROS-LEHTINEN, Florida ENI F.H. FALEOMAVAEGA, American
DANA ROHRABACHER, California Samoa
STEVE CHABOT, Ohio BRAD SHERMAN, California
JOE WILSON, South Carolina GREGORY W. MEEKS, New York
MICHAEL T. McCAUL, Texas ALBIO SIRES, New Jersey
TED POE, Texas GERALD E. CONNOLLY, Virginia
MATT SALMON, Arizona THEODORE E. DEUTCH, Florida
TOM MARINO, Pennsylvania BRIAN HIGGINS, New York
JEFF DUNCAN, South Carolina KAREN BASS, California
ADAM KINZINGER, Illinois WILLIAM KEATING, Massachusetts
MO BROOKS, Alabama DAVID CICILLINE, Rhode Island
TOM COTTON, Arkansas ALAN GRAYSON, Florida
PAUL COOK, California JUAN VARGAS, California
GEORGE HOLDING, North Carolina BRADLEY S. SCHNEIDER, Illinois
RANDY K. WEBER SR., Texas JOSEPH P. KENNEDY III,
SCOTT PERRY, Pennsylvania Massachusetts
STEVE STOCKMAN, Texas AMI BERA, California
RON DeSANTIS, Florida ALAN S. LOWENTHAL, California
TREY RADEL, Florida GRACE MENG, New York
DOUG COLLINS, Georgia LOIS FRANKEL, Florida
MARK MEADOWS, North Carolina TULSI GABBARD, Hawaii
TED S. YOHO, Florida JOAQUIN CASTRO, Texas
LUKE MESSER, Indiana
Amy Porter, Chief of Staff Thomas Sheehy, Staff Director
Jason Steinbaum, Democratic Staff Director
------
Subcommittee on Africa, Global Health, Global Human Rights, and
International Organizations
CHRISTOPHER H. SMITH, New Jersey, Chairman
TOM MARINO, Pennsylvania KAREN BASS, California
RANDY K. WEBER SR., Texas DAVID CICILLINE, Rhode Island
STEVE STOCKMAN, Texas AMI BERA, California
MARK MEADOWS, North Carolina
C O N T E N T S
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Page
WITNESS
Tom Frieden, M.D., director, Centers for Disease Control and
Prevention..................................................... 7
LETTERS, STATEMENTS, ETC., SUBMITTED FOR THE HEARING
Tom Frieden, M.D.: Prepared statement............................ 12
APPENDIX
Hearing notice................................................... 44
Hearing minutes.................................................. 45
The Honorable Eliot L. Engel, a Representative in Congress from
the State of New York: Prepared statement...................... 46
The Honorable Christopher H. Smith, a Representative in Congress
from the State of New Jersey, and chairman, Subcommittee on
Africa, Global Health, Global Human Rights, and International
Organizations: Material submitted for the record............... 48
Tom Frieden, M.D.: Material submitted for the record............. 53
MEETING THE CHALLENGE OF DRUG-RESISTANT DISEASES IN DEVELOPING
COUNTRIES
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TUESDAY, APRIL 23, 2013
House of Representatives,
Subcommittee on Africa, Global Health,
Global Human Rights, and International Organizations,
Committee on Foreign Affairs,
Washington, DC.
The subcommittee met, pursuant to notice, at 3:05 p.m., in
room 2172, Rayburn House Office Building, Hon. Christopher H.
Smith (chairman of the subcommittee) presiding.
Mr. Smith. The subcommittee will come to order. And
welcome, Dr. Frieden. Good afternoon. Today's hearing will
examine a deadly phenomenon involving both natural and manmade
elements: Diseases that are resistant to most or all available
methods of treatment. While this is a growing problem of
increasing concern throughout the world, the subcommittee will
be focusing today on the impact of such diseases, known as
superbugs, in developing countries and the challenge to
preventing and treating these diseases in this part of the
world.
There is a family of germs that occur normally in
everyone's digestive system. They can cause infections when
they get into the bladder, blood, or other areas where they
don't belong. That is the natural part of this growing problem.
Gut flora are absolutely essential for health and an
effectively functioning immune response, and the increasing use
of things like probiotics is testimony to the fact that more
and more people are understanding that.
There are about 100 trillion microorganisms in our
digestive systems, 10 times the number of cells in our bodies.
Most of them help break down the foods that we eat, they help
us with our immune systems. Those that are not helpful usually
can be treated with existing medicines such as antibiotics.
The manmade part is that antibiotics have been increasingly
used to treat naturally occurring germs, but many of them have
become resistant to such treatment. These so-called superbugs
pose a threat because of overuse or misuse of antibiotics, but
they also pose a threat because of what some call a drug
discovery void in which there has been insufficient research
and development of new medicines to treat emerging mutating
infections.
This situation recently has become much more serious. In
the last 10 years, these drug-resistant diseases have been
identified in patients in more than 200 hospitals in 42 States
in this country. Over that period, there prevalence rate has
increased from 1 percent of patients to some 4 percent for
those in short-term care, but for patients in long-term care
facilities, the rate is as high as 18 percent.
Half of all patients who contract these diseases do not
survive. MRSA, one of the better known of these superbugs, now
kills as many as 19,000 Americans each year and a similar
number in Europe. That is higher than the annual rate of deaths
from HIV/AIDS.
Last year the World Health Organization identified strains
of gonorrhea and tuberculosis that are currently completely
untreatable, as well as a new wave of what might be called
``super superbugs'' with the mutation known as NDM-1. These
frightening new strains were first seen in India, but they have
now spread worldwide. The spread of the H7N9 birth flu in China
is also causing considerable concern, with more than 100
confirmed cases and 22 deaths reported thus far. According to
the AFP, the WHO said yesterday that there was still no
evidence that H7N9 was spreading in a sustained way between
people in China. I know Dr. Frieden will speak to that because
we are working with the Chinese on that issue.
According to WHO, artemisinin, when used in combination
with other drugs, is now considered the world's best treatment
against malaria, but malarial parasites resistant to the drug
have emerged in western Cambodia, along the border in Thailand,
as well in parts of Burma and in Vietnam.
In the developed world, we pride ourselves on having top
flight medical care widely available to patients. If we lose
half of all patients who contract these drug-resistant
diseases, what about patients in the developing world where
statistics are often scarce and effective medical care can even
be scarcer?
Using accepted protocols for treating these diseases, their
rate of infection can be curbed. In Israel, infection rates in
all 27 of its hospitals fell by more than 70 percent in 1 year
with a coordinated prevention program. By following accepted
protocols for handling these diseases, the Colorado Department
of Public Health and Environment and the Florida Department of
Health both have stopped outbreaks of these drug-resistant
diseases in recent years. But then again, what about hospitals
in developing countries?
For example, the brain drain has sent trained medical
personnel in Africa in search of better working conditions and
pay in the developed world. The lack of equipment and supplies
that partly led to this brain drain would facilitate the rapid
spread of drug-resistant diseases in these countries. What
would be simple interventions, including removing temporary
medical devices such as catheters or ventilators from patients
as soon as possible, is less likely under current conditions in
developing-world hospitals.
Adding to this problem is the presence of expired and
counterfeit drugs. Patients whose lives could be saved may not
be because of inadequate medical care. Unfortunately, because
so many countries do not maintain and report statistics on
medical issues, we have little idea how serious the situation
is today in many developing countries in Africa and elsewhere
around the world.
In our interconnected world, that means that infected
people in the developing and developed countries pose a mutual
threat. Last month a Nepalese man was detained at the Texas
border while trying to make an illegal crossing from Mexico.
Officials found that he was infected with an extensively drug-
resistant strain of tuberculosis and had carried this
potentially deadly airborne disease through some 13 countries
over 3 months, from his home of Nepal through South Asia,
Brazil, Mexico, and finally into the United States. Who can say
how many people he infected during this long journey.
Conversely, 6 years ago, an American infected with
multidrug-resistant tuberculosis traveled from our country to
France, Greece, and Italy, before returning through the Czech
Republic and Canada. Upon his return to the United States, he
became the first person subjected to a Centers for Disease
Control and Prevention isolation order since 1963.
Clearly, both developed and developing nations must work
together to prevent and treat these diseases and find a way to
implement the new strategies in an era of constrained budgets
and loosening control of authority in far too many countries.
However, the administration's proposed budget for 2014 does
call for a 19-percent cut in tuberculosis programming, and
hopefully we might get some answers today and again on Thursday
from Dr. Shah.
Today's witness, a very accomplished doctor, heads an
agency that is charged with examining the elements of disease
and helping to develop the strategies for addressing the
threats they pose not just to Americans, but to all mankind. We
look forward to hearing Dr. Frieden and exploring with him the
means by which the U.S. Government is working with developing
countries to counter global threats.
I would like to yield to Ms. Bass.
Ms. Bass. Thank you. And, Mr. Chairman, as always, I want
to thank you for convening today's hearing on drug-resistant
diseases in developing countries.
While we examine this very serious issue, I think it is
worth noting that this is an issue with global dimensions that
impacts all of us. While we sit in the halls of Congress, we
are neither immune nor are we protected from what is a mere
plane ride from this hearing room.
Globalization has done much for allowing us to be more
interconnected. The challenge before us today, however, is how
do we understand and move to effectively address the smallest
of things, microscopic organisms that have the ability to
rapidly adapt and either avoid detection or resist efforts that
would eliminate something that often has mortal consequences if
left unaddressed.
Dr. Frieden, I want to thank you for taking the time today
to testify before the committee. I remember us talking about a
very similar subject about a year ago, so I am very glad that
you are here today. We all know that you have dedicated your
life to addressing the great public health challenges of our
day. You have been on the cutting edge of public health
interventions and have undoubtedly saved millions of lives in
the U.S. and around the world. For an extraordinary depth of
work and experience, we owe you our thanks and look forward to
your testimony.
Without objection, I would like to submit for the record a
written statement by Ranking Member Engel. He has been a
staunch champion on a number of global health priorities and in
particular the spread of tuberculosis, both multidrug-resistant
and extensively drug-resistant TB.
It would be remiss for me not to acknowledge that in my
hometown of Los Angeles there has been a recent outbreak of TB,
and I understand it is close to 5,000 people that have been
diagnosed, and there is a concern that there is not a
sufficient supply of drug treatment to address this outbreak.
Dr. Frieden, perhaps in your remarks you can update us all on
the situation, how the CDC is working with local officials. I
am sure Los Angeles is not the only city that is dealing with
this.
But I will note that in the U.S. alone there are over
10,000 cases of TB infection annually. In a country like India,
four times our population size, there are approximately 2.3
million cases each year and close to \1/2\ million people can
die from it. The Wall Street Journal reports that India has the
largest number of people infected with drug-resistant strains.
In 2010, the Center for Global Development wrote a paper
entitled ``The Race Against Drug Resistance,'' and in that
paper the authors address the health and economic consequences
of global drug resistance, the drivers of drug resistance, and
the current global response to the problem. They concluded with
four recommendations that I would like to read for the
committee's consideration but also to get your feedback on.
Recommendation one, improve surveillance by collecting and
sharing resistance information across network of laboratories.
Two, secure the drug supply chain to ensure quality products
and practices. Three, strengthen national drug regulatory
authorities in developing countries. And four, catalyze
research and innovation to speed the development of resistance-
fighting technologies.
The challenge before us is multifaceted and will require a
comprehensive approach. Understanding the drivers of drug
resistance and addressing them is critical, including
strengthening health systems to include well trained and
equitably distributed health workers who can properly
administer treatments, eliminating substandard and counterfeit
drugs. And I would in particular like if you could comment
about the role that counterfeit drugs might play in this.
We need to have well-structured surveillance and reporting
systems that are in track to monitor outbreaks and infections
and a strong focus on research development. I would add that
public and private sectors must also play their part to ensure
financial resources and regulatory standards are in place for
the challenges of today. In Africa, for example, you don't have
to look very far to find stories that report on totally drug-
resistant TB or emerging concerns of increased drug-resistant
strains of HIV and malaria. These are troubling trends as our
Nation continues to fund programs that we hope will end these
crisis in our lifetime. We have heard President Obama and
former Secretary of State Clinton speak of an AIDS-free
generation, while at the same time you read a BBC article with
the headline, ``Drug-Resistant HIV on Increase in Sub-Saharan
Africa.''
The World Health Organization reports that India, China,
the Russian Federation, and South Africa are home to almost 60
percent of the world's cases of multidrug-resistant TB. I would
love to know your opinion, number one, if you agree with that
or if you have a sense of why that is when we consider that,
combined, India and China are home to over one-third of the
global population of 2.6 billion people.
This problem won't go away on its own and we continue to
see people becoming infected with any number of diseases, and
as our world continues to become smaller as a result of
globalization we will continue to be confronted with the
challenges of how to adequately deal with drug resistance that
may or may not be on our doorstep today, but might be tomorrow.
Thank you very much. I yield my time.
Mr. Smith. Thank you, Ms. Bass.
Mr. Meadows.
Mr. Meadows. Thank you, Mr. Chairman.
This is a timely hearing on an important issue. And, Dr.
Frieden, I appreciate your willingness to be here as well and I
look forward to your testimony.
Obviously drug-resistant diseases are a serious problem
everywhere. You know, our own healthcare providers are
struggling to stay on top of this issue on a daily basis, and,
you know, I firmly believe that to address this problem we must
first determine the scale of the problem, and, you know, we
need to make sure and ensure that we have the data necessary
both here and in the developing world to properly define the
problem.
These drug-resistant diseases, you know, they don't
recognize a political boundary. You know, in a globalized world
that we live in a threat anywhere is a threat here, and so,
therefore, we are bound to work on this problem wherever it
presents itself and that obviously creates challenges, as you
know. We know that developing countries may struggle with
sanitary practices, the use of nonprescribed antibiotics,
limited access to care, you know, and so on. And so I look
forward to hearing how we can address those challenges and
improve our knowledge of these severe threats.
And with that, Mr. Chairman, I yield back.
Mr. Smith. Dr. Bera.
Mr. Bera. Chairman Smith, thank you. And again thank you
for calling this hearing. It is extremely timely. And today I
will be a doctor as opposed to a Congressman because that is
really how I look at this issue, from the perspective of being
a doctor. You know, as the former chief medical officer for
Sacramento County we dealt with issues of drug-resistant
tuberculosis, but 5 or 6 years ago we had second and third line
medications that we could use judiciously and still deal with
these cases when we are called into consultation in the
hospital.
What keeps me awake at night and what I worry about is the
emergence of extremely drug-resistant cases of tuberculosis
that we are starting to see pop up in Africa and other nations
around the globe, and that is of critical concern not only to
those countries abroad in Africa, but clearly to our hospitals
and our patients here domestically. It is a real issue and it
is one that we have to take very seriously.
You know, I have seen it firsthand, having travelled to
South Africa a few years ago with a group of doctors to
evaluate how they were caring for the HIV epidemic there. You
are seeing the devastating effects of these cases and the
limited resources in the arsenal.
The other thing that keeps me awake at night, and I saw it
firsthand this past weekend when I was back home and rounding
with a group of doctors at Mercy San Juan Hospital, seeing what
was happening there. If I am not mistaken, the nurse
administrator who was rounding with us suggested that close to
50 percent of the patients that they are admitting now have a
history of MRSA, or methicillin-resistant staph aureus. So
there is a real concern of the efficacy of antibiotics that we
are using and starting to run out of those tools in our arsenal
as physicians.
That leads me to another body of literature that really is
emerging. As we incent our pharmaceutical companies to come up
with the fourth generation of antibiotics, we really have to
extend the life of these medications. And I have been a doctor
for over 20 years and for years we could use penicillin and so
forth. But now, as we get into our first, second, third
generation of cephalosporins and antibiotics, the lifespan of
these drugs are increasingly shorter and shorter. And part of
that is the ease of access of antibiotics in third world
countries, the ability to just buy them over the counter, and
there is no guarantee that they are being used in an
appropriate manner.
So we have to work with industry to make sure, as we come
up with the next generation of antibiotics, we are very
judicious in how they are used, not only here domestically, but
also abroad in other countries. And I would be interested in
hearing your testimony on all of these issues, what we can do
proactively here in Congress, as well as our medical community,
to address that next generation of tuberculosis resistant, but
then also how we work with industry as we develop the fourth
generation of antibiotics and make sure we can extend the lives
of these medications.
And with that, Mr. Chairman, again, thank you for this
hearing, and I yield back.
Mr. Smith. Thank you, Dr. Bera.
Mr. Weber.
Mr. Weber. I will yield back.
Mr. Smith. Okay. Thank you. Thank you.
I would like now to extend a very special welcome to Dr.
Frieden. Tom Frieden, medical doctor, M.P.H., who has been the
Director of the Centers for Disease Control and Prevention
since June 2009, has controlled both infectious and chronic
diseases in this country and globally. From 1992 to 1996, he
led New York City's program that controlled tuberculosis and
reduced multidrug-resistant cases by 80 percent. Dr. Frieden
then worked in India for 5 years, helping to build a
tuberculosis control program that has saved nearly 3 million
lives.
As commissioner of the New York City Health Department from
2002 to 2009, Dr. Frieden led programs that reduced illness and
death and increased life expectancy substantially, including
programs that reduced adult and teen smoking dramatically and
eliminated artificial transfats from restaurants, and the
department eliminated racial/ethnic disparities in colon cancer
screening and began the country's largest community-based
electronic health records project.
As CDC Director, Dr. Frieden has intensified CDC's 24/7
work to save lives and protect people, including through more
effective response to outbreaks and other health threats at the
local, State, Federal, and global levels. New programs have
prevented infections from food and healthcare, helped Americans
quit smoking, reduce childhood obesity, and save lives of teens
and others from car crashes, and extended lifesaving treatment
and disease prevention in more than 50 countries.
A graduate of Columbia University's College of Physicians
and Surgeons and School of Public Health, Dr. Frieden completed
infectious disease training at Yale University and CDC's
Epidemic Intelligence Service. The recipient of numerous awards
and honors, Dr. Frieden speaks Spanish and has published more
than 200 scientific articles, and we welcome him back.
And the floor is yours, Doctor.
STATEMENT OF TOM FRIEDEN, M.D., DIRECTOR, CENTERS FOR DISEASE
CONTROL AND PREVENTION
Dr. Frieden. Thank you so very much, Chairman Smith,
Ranging Member Bass, and the other members of the committee,
both for your support for global health issues and for this
opportunity to speak with you today about such important
threats that we face and the important work that the CDC does
in this country and around the world to protect Americans 24/7.
CDC's work is critical to addressing antimicrobial
resistance and other global threats. What I would like to do
here is briefly outline what the problem is, what we are doing
about it, and what more needs to be done in three broad
sections. Obviously, any one of those three could take a lot of
time, so I will just give you some of the highlights. And I
would really agree with all of what was said in the
introductory comments from the chair, the ranking member, and
the panel. This is a critical problem for us. If there is one
basic concept, it is that we are inevitably interconnected as a
world, and whether we like it or not, whether drugs are used
correctly all over the world affects what happens to people in
our communities.
I think we are facing essentially a perfect storm of
vulnerability. There are four trends that are combining to make
us in some ways at greater risk than we have ever been in the
past. The first is the emergence and spread of new microbes,
things like SARS and H7N9 influenza, which I can speak about
later if you would like.
The second is globalization of travel, where people just a
plane ride away can bring new organisms and resistant organisms
from one part of the world to another, and also globalization
of our food and medical supply. We are increasingly
interconnected.
The third and the main topic of this hearing is the
inexorable rise of drug resistance. We now face an increasing
rate of resistance in many different types of organisms. To
mention just three, we have tuberculosis strains--and
tuberculosis is an area that I worked in for many years--that
are resistant to virtually all antibiotics. We have strains of
Gram-negative organisms, a group, a problem referred to as CRE,
or carbapenem-resistant enterobacteriaceae, basically very
dangerous bacteria that are now resistant to most or even all
antibiotics and are spreading in our country. And third,
malaria. We are now beginning to see resistance to the last
best drug we have treated on an outpatient basis, the
artemisinin drugs and that class of drugs.
There are about 12 million Americans a year who go visit
malarious areas, areas where they are at risk for getting
malaria. If these resistant strains spread, the risk to people
in this country will be substantial, in addition to the number
of deaths and the amount of suffering and economic hardship
that that will cause around the world.
The fourth risk is the potential of people, either
intentionally or unintentionally, to create dangerous organisms
and then to release those into the environment, either
intentionally or unintentionally. Unfortunately, that has
become easier as we have had technological advances.
Poor quality treatment, whether of tuberculosis or of
pneumonia in the hospital, anywhere in the world, in Asia or
Africa, can and in fact has become a nightmare in communities
in the U.S. Today in many communities, most likely each of the
communities that you represent in this country, there is
someone in a nursing home or a hospital who is fighting for
their life against an infection that doctors have limited or no
tools to treat. And as we saw, for example, in Colorado, where
there was an outbreak recently, the indexed patient had just
come from Asia and undoubtedly had brought that organism with
them through no fault of the individual and unavoidably.
Given the four big challenges that we face, I think there
are two broad areas that give me a great deal of hope for being
able to tackle them in the future. One is, frankly, political
and one is technological. On the political side, I think we
have more commitment to addressing this in more countries than
we have ever had before. The SARS outbreak cost the world more
that $30 billion. H7N9 Avian influenza in less than a month has
cost China more than $2 billion. So I think countries get that,
in addition to the human suffering, there are strong economic
incentives to address health threats more effectively.
In addition, we have global commitments through things like
the International Health Regulations which require countries of
the world to find, report, and stop disease threats, and we are
getting reporting from an increasing number of countries. We
are nowhere near where we need to be, but we have the political
framework to provide the support and assistance so that the
world can be safer because each of the countries around us is
safer and each of the countries in the world is safer.
And also, in terms of the commitment, we have success
stories, and I will go into some of them, but we have seen that
when we work with China or Thailand or Brazil or many, many
other countries and help them see what needs to be done, they
invest their own resources, their own substantial talent, their
own capacities in doing that, so that we end up with a true
partnership to reduce health risks both for their country and
for the whole world.
The second broad reason for optimism is the advances in
both laboratory work and informatics. They are breathtaking. We
are able to do things in the laboratory now that we could not
have even dreamed of even just a few years ago. When I started
at the CDC as an Epidemic Intelligence Service officer, we were
just beginning to do genetic sequencing of tiny parts of the
genome and to use that to figure out how tuberculosis and other
organisms were spreading and to stop them sooner. It took a
large room, months of work, a lot of very difficult comparison
by hand sometimes of different patterns. Now much more
information can be obtained in just 3 or 4 hours.
In the President's budget for fiscal 2014, there is an
initiative called Advanced Molecular Detection. This initiative
would allow us to go to this next generation of tools, find
outbreaks that we are missing now, find them sooner, stop them
more effectively, and figure out how they are spreading so we
can prevent more of them. This is our single highest priority
for the 2014 budget at CDC. And in addition, there are really
exciting bioinformatics developments where we can look at huge
amounts of data and begin to make sense of it. So I think we
have real reasons for optimism.
In terms of what CDC is doing today, Ambassador Carson, the
recently retired former Ambassador to Africa, said to me CDC is
the 911 for the world, and we are happy to play that role, but
we are even happier that we are now teaching countries to do
that for themselves. And we are doing that in critical ways and
with important platforms, and I want to thank the chairman,
ranking member, and all members of the committee for your
steadfast support for the PEPFAR program over the years. PEPFAR
is really changing the world. There are more than 5.3 million
people alive today who would be dead or dying otherwise. Last
year alone a quarter of a million babies were born without HIV
because of PEPFAR.
And in order to do what we have done with PEPFAR, with the
leadership of the State Department and the Global AIDS
coordinator, in order to have those results, we have also used
PEPFAR as a platform. We have come in under budget and ahead of
schedule, but we have also used PEPFAR as a platform to
strengthen laboratories for HIV and for other conditions, to
strengthen diagnosis, to strengthen maternal and child health.
And what we have seen with that, for example, is strengthening
through PEPFAR, and also through the Global Disease Detection
Program, which is a CDC program that is a platform to find and
stop outbreaks. We have seen strengthening of laboratories,
which are crucial, of epidemiologists or disease detectives who
are essential to finding and stopping problems and of
prevention measures.
And just to mention a few of them, through the laboratory
work, we now have created an African Society for Laboratory
Medicine. Hundreds and soon thousands of laboratories
throughout Africa will be certified so doctors and patients can
rely on accurate results. Do they have an infection or not? Is
it resistant or not? Is treatment working or not? Right now,
without good laboratories, you can't answer those questions in
far too much of the world.
We are also expanding influenza surveillance throughout
Asia and Africa so that we can get a better handle on where it
is emerging, how it is happening. We know that a risk anywhere
can be a risk everywhere, and though we have worked with 50
countries on influenza surveillance, we were taken off-guard by
H1N1 which emerged in Mexico. We have expected new influenza
strains to emerge in China and Southeast Asia, as H7 is now,
but H1 took us by surprise. And that emphasizes a key point,
which is that a blind spot anywhere is a risk to all of us. But
our laboratory work at CDC has strengthened work throughout the
world so that there is much more accurate diagnosis.
I will give you one example of this that CDC is doing with
Uganda right now. Our CDC lab in Fort Collins, Colorado, came
up with a new way to diagnose plague. Plague is often fatal,
but with a simple $1 dipstick test, we are determining whether
patients have plague.
CDC is working with local traditional healers. We are
working with the medical care system, and CDC is also working
to see what treatment is best for plague. As a result, in just
the past few months, we have diagnosed people who would likely
have died otherwise and treated them before they have spread
plague to others, and we are transferring this technology to
Uganda so that they don't need for us to do it in the future,
as we have done with Ebola as an example. We have taught them
how to control it, how to diagnose it, so instead of the large
outbreaks that we saw a decade ago, we are seeing isolated
cases or smaller outbreaks now.
The second key area is epidemiology, disease detectives,
and this is so crucial to what we do, figuring out where
disease is spreading, what the threats are, how to stop them,
and whether our efforts are working. Our flagship program in
epidemiology at the CDC is the Epidemic Intelligence Service.
What we have done with more than 30 countries is help them
start similar programs, called Field Epidemiology Training
Programs. In the next year or 2, we will graduate the 3,000th
disease detective. It is a 2-year, intensively mentored
program. Eighty percent of the graduates stay in their home
country, often in leadership positions, finding and stopping
health threats. We also do epidemiologic investigations, and we
start on average one of these a day in this country and on
average, with our partners, one a day around the world to
identify and stop a new threat.
And third is prevention, and we do this in important ways,
including vaccination. After all, if you vaccinate and prevent
an infection from happening, it won't be resistant, and we are
seeing that with, for example, pneumococcal infections now,
with vaccination resistances less of a concern in that one
organism.
And of course we are closer than ever to the finish line in
polio eradication, and the work of Rotary International and so
many partners with CDC as the spearheading partner for this
country has brought us to this point from 1988, when there were
more than 350,000 children affected by polio in that year
alone, to last year, when there were 222, the lowest number
ever in the history of humanity as far as we know. We are also
active in quarantine, identifying passengers who are ill and
helping to reduce risks of people who come here from other
countries.
That is some of what we at CDC are doing. In terms of what
more is needed, I have to say, frankly, that we are not keeping
pace with the threats. Microbes evolve and emerge rapidly, and
we need to keep pace with that evolution. What we are faced
with is a need to accelerate progress in three specific areas.
The first is detection. We need to fund and implement the
Advanced Molecular Detection program. I brought for you a
remarkable thing. This is a chip. It is one company. It fits
very easily to carry. There are about five different companies
that make something like this. But this chip in less than 4
hours can sequence the entire genome of not just one, but many
different microbes, and with advanced supercomputing, we can
then take--there are actually more than 10 million individual
wells on this chip. We can take the fragments of DNA, and with
a supercomputer put them back together like a jigsaw puzzle
with tens of thousands of pieces to figure out where the
connections are, whether it is resistant, how it is spreading,
and whether it is becoming more virulent. We are using this
technology now to track H7N9, and this is the kind of thing
that we need to invest in more to make an even bigger
difference going forward. We have too many blind spots.
Second, we need to improve our ability to respond to
infectious disease and other threats. At CDC, we have an
Emergency Operations Center, and if any of you are ever passing
through Atlanta, please come by and spend an hour or 2 with us
to see what we do there. We track what is happening around the
world. We have an information system. We have a communication
system. We respond rapidly. Ideally every country in the world
should have some system like that. They will be safer and we
will be safer.
And third, we need to increase our ability to prevent,
through better vaccines, through antibiotic stewardship,
through better supply chain control in terms of antibiotics.
So I will be happy to get into specific issues that you
have raised. I don't want to take too much time with my
introductory statement. But I do want to conclude with one
simple thought, which is that a safer United States and a safer
world is within reach if we invest in it, if we work with
partners, if we take advantage of the unique opportunities that
both the commitment of countries around the world has and this
very exciting technology that we have to bring to bear on
longstanding threats to our health. Thank you so much for your
interest.
Mr. Smith. Thank you so very much, Doctor.
[The prepared statement of Dr. Frieden follows:]
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Mr. Smith. And without objection, your full written
statement will be made a part of the record, as well as that of
Ranking Member Eliot Engel.
Let me just ask you a couple of opening questions.
Artemisinins, the power of these very important drugs to help
cure people with malaria, may be thrown a huge curveball in, as
I said earlier, in Cambodia, Burma, and particularly along the
Thai border. And my question is, you know, there are 104
malaria-endemic countries. Obviously, and you know it, because
you have been a part of this, we went from a $100 million in
the year 2000 to $1.8 billion worldwide in 2012, certainly
below what the target was if we wanted to really look to
eradicate this horrible disease.
But how concerned are you and CDC about this problem? I
know WHO talks about containment and trying to ensure that this
does not spread to other places, particularly Africa, where it
would be even more catastrophic. If you could spend some time
on that, I would appreciate it.
Dr. Frieden. Thank you. Thank you very much. And thank for
your support for the President's Malaria Initiative. I have
seen, as you have, this program in action in Africa and
elsewhere and it is breathtaking. I have gone into communities
that previously had extensive amounts of malaria. CDC has
documented that in some of these communities, one out of every
four medical visits of children was for malaria. One out of
every two units of blood used for transfusion was for malaria.
And in communities where they have implemented good control
measures, we have seen essentially zero cases of malaria with
good control and zero deaths. So we know that tremendous
progress is possible.
We are quite concerned about artemisinin resistance. We
have seen areas, as you say, in Cambodia and elsewhere where as
many as 30 percent of patients have evidence that their
particular strain of malaria is responding much less well to
the artemisinins. This is our last hope for good malaria
control. We have to preserve this drug.
I think you can think of drug resistance and prevention of
drug resistance as something that we owe the world, we owe our
children, that these antibiotics that we have been bequeathed
by people who worked so hard to come up with them are preserved
and can be used to protect lives for many years going forward.
What we think is possible is, first, to understand better
what has happened and, second, to contain as well as possible,
through a comprehensive approach to vector control, that is
stopping the mosquito, treating effectively, diagnosing and
treating well. And I think overall with malaria, we are quite
reassured by the overall amount of progress that is happening.
The challenge with malaria is the challenge of persistence.
We have seen big progress with malaria before, we let off our
guard, and it came roaring back. That is exactly what we have
to avoid. We have to intensify our work in Southeast Asia to
understand and contain artemisinin resistance. At the same time
we have to scale up the core malaria control interventions in
Asia and Africa, especially so that we can reduce the number of
deaths and the burden of illness.
There is still a lot we know that we are not doing and we
need to scale up that net use and high quality diagnosis and
treatment. There is still certain things that we don't know
that we need to understand better about the malaria parasite,
about the best tools to control it.
Mr. Smith. And isn't it true that about half of those who
should have bed nets have it, but we are running into the
problem of the bed nets now losing their efficacy to keep the
mosquitos out? So we need a replacement effort as well.
Dr. Frieden. CDC scientists have looked at this carefully.
The life of a bed net is not an easy one. They get embers put
on them from the stove, they are worn out. And so having the
first set of nets out was great and knocked down child
mortality enormously. We have documented at CDC overall
reductions, not malaria specific, but overall reductions in
child deaths of 25 percent just from the malaria control
program. But exactly as you say, Mr. Chairman, the nets now
need to be replaced, and that requires resources.
Mr. Smith. You know, in terms of drugs that are actually in
the pipeline, you know, we know that newer orders of new types
of antibiotics are few and in between. On tuberculosis, without
objection, we are including testimony from Dr. Adrian Thomas
from Johnson & Johnson. And he points out that Janssen is
bringing forward a new medicine specifically indicated to treat
a drug-resistant form of tuberculosis. It is called Sirturo. It
seems to have gone to the next stage, although it is not used
yet.
My question on that drug specifically and other drugs that
are or not in the pipeline, particularly as it relates to
malaria and multiresistant tuberculosis.
Dr. Frieden. I think a key concept is that the development
of new antimicrobials, new antibiotics is a necessary but not a
sufficient condition. Now, for those two conditions
particularly, we are very encouraged. It is the first new anti-
tuberculosis drugs in decades. We think at this point it should
be reserved for people for whom other drugs are not available.
The CDC has convened national experts to look at what is the
optimal way of using this new drug. We will need to have some
clinical trials and the FDA moved very quickly to approve it so
that patients could get it and their lives could be saved.
There are some other drugs for tuberculosis that are in the
pipeline that are somewhat encouraging, but what we know is,
unless we improve our treatment system, we will lose those
drugs as well.
In terms of malaria, the situation is perhaps a little less
encouraging because virtually everything in the pipeline is
either an artemisinin-related product, a synthetic artemisinin,
or something that has the same resistance mechanisms as the
artemisinins appear to have. So if we lose the artemisinins, we
may lose the new drugs before we even get them.
I think this comes back to one of the core concepts of
antimicrobial resistance. Resistance develops because of poor
quality programs. It is very straightforward. If you have a
good quality program, you will not get lots of drug resistance.
And in tuberculosis, which I worked in for many years, one of
the core concepts is that a poor quality program can create
multidrug resistance faster than a good program can treat it,
no matter how many resources you have. And it is critically
important to stop resistance from emerging and then to stop it
from spreading.
We documented in New York City in the early 1990s that as
many as half of all of the multidrug-resistant tuberculosis
patients had actually caught it in the hospital. So hospitals
can become an amplification point for drug resistance. That is
why in our work in this country and our recommendations to
other countries we have advocated a program called Detect and
Protect. Detect and Protect. It is a simple concept: Find the
patients that have the resistant organisms, protect them from
harm with it, and protect other patients from getting it from
them. And one of the things that we are encouraged by is the
amount of progress in things like methicillin-resistant staph
aureus where since 2005 we have documented a more than 50
percent reduction in the serious infections with that highly
resistant organism.
This is not a problem for which we have no solution. We
know what to do. It is a question of doing it. We also need
some new knowledge, but what we can do now is a much better job
at reducing the risk of detecting it, so we find the patients
who have it and are protecting others from them and protecting
them from the organism.
Mr. Smith. Dr. Frieden, you made a very strong appeal to
Congress to include in its budget what is in the Fiscal Year
2014 President's budget for the Advanced Molecular Detection
initiative. As you point out, it combines two powerful
technologies, molecular sequencing and bioinformatics. Could
you perhaps elaborate on exactly how that works, and if you
could also--and then I yield to my colleagues for their
questions--speak to the area of labs, which you made reference
to. How much connectivity is there with CDC and those labs? Are
they at a basic level?
When I travel, I always ask about the labs myself. As a
matter of fact, we had hearing in the last Congress with CURE
International and the magnificent work they are doing with the
infection-based hydrocephalic condition. And they have cured
over 5,000 children in Uganda alone with a simple intervention
that does not require any stents, it doesn't require, you know,
the kind of follow-up that we often would need here. But it is
infection based, they believe, and I watched one of the
operations myself. The lab you mentioned in Uganda, I am not
sure if that lends itself to the kind of detection that they
need to do on this, but the labs. Where are they? Particularly
in Africa, but elsewhere in the world, how do we grow those
labs, as well as their sophistication and their connectivity to
you?
Dr. Frieden. Thank you very much. The Advanced Molecular
Detection initiative would give our top-quality disease
detectives the cutting-edge tools to find problems and stop
them sooner. We have terrific scientists at CDC. We have a
mandate within this country and abroad to detect and stop
problems. But our hands are in some ways tied because we can't
look into the microbe's genome in the way that technology
actually allows us to today.
To give you just one example of that. With H7N9 influenza,
which we can talk about more a bit later, we are very concerned
to see will it develop the capacity to spread easily from
person to person. So far we are confident it hasn't. If it
does, it has major implications for all of us and for every
country.
We think we could learn more if we could go into clinical
specimens and sequence the entire genetic material in those
specimens. What happens when you grow an organism is that one
particular strain grows very well and you can analyze that in a
laboratory, but that is not exactly what is happening in the
patient's body. What is happening in the patient's body is that
there are many different--an assortment of different sub-
strains or what are sometimes called quasi-species of that
organism, and by sequencing from there you can figure out what
is going to happen. You can skate to where the puck is going,
not where the puck is.
AMD (advanced molecular detection) would allow us to do
that, not just for influenza but for other organisms as well.
It is a critical tool in helping us not only avoid problems,
but prevent them in the future.
The laboratories, we are very encouraged by the progress
around the world. I think there are two broad areas where we
are going to see more progress. The one is what are called
point-of-care tests, things that a doctor or nurse or other
health worker can do at the patient's bedside or at the
patient's hut side. Things that use a dipstick, as we are using
in Uganda with plague now. So these are great technologies
because they take not much time, they are highly accurate. It
is how we are diagnosing HIV and malaria now in the field.
The other are the high-tech things where we can go in and
look at a specimen, and there are now technologies which can
look at two dozen different organisms to say in this one
specimen of blood or sputum, which of these organisms are
present. We have already use this on an experimental basis, for
example, to look at an outbreak that we couldn't figure out
what was causing it, and to our surprise it was a yellow fever
outbreak, and because of that, we were able to do control
measures. So there is the ability to bring these new
technologies to bear on laboratories throughout the world.
The African Society of Laboratory Medicine, which PEPFAR
helped to start, has made really progress by leaps and bounds.
In fact, the Ethiopian Government has given them, the African
Union has given them free space. Countries all over Africa are
doing more with that. In Africa they are being very willing to
do regionalization so that not every country needs to create
everything. It is not efficient. They can work regionally very
effectively. Our polio labs, our measles labs, our influenza
labs, our foodborne labs are a global network where all of us
are safer if every country can do a better job finding and
tracking it.
Mr. Smith. Before I yield to Ms. Bass, is there an
inventory of all of those labs that could be made a part of the
record and give us a better sense of--and also would be a place
that when we do travel, we will visit.
Dr. Frieden. We will certainly get you what we have in
terms of an inventory. I will also mention that Congress
requested that CDC do summaries of CDC's laboratory work last
year and this year, so we have two reports on laboratory work
that CDC does in this country and around the world, and we
would be delighted to share those as well, as the global
laboratory network information.
Mr. Smith. Thank you so much.
Ms. Bass.
Ms. Bass. Thank you.
Once again, thank you for your testimony. And I do look
forward to, I was saying to the chairman, I would love to go to
Atlanta and to see the CDC. So I hope to do that in the future.
You know, I wanted to ask you to address two areas, and one
is, especially, you know, you said that internationally you
thought there were good news on the political framework, so a
couple of international issues I would like for you to address
as to how countries are dealing with the unregulated sale of
antibiotics, I mean, you know, you can get them over the
counter in a lot of different countries, and how you are
relating to countries and trying to get them to stop that
practice.
The other thing is on counterfeit drugs and how prevalent
do you think that is. You know, I have heard it is only
anecdotal, though, but I have certainly heard that there is a
lot of countries, countries in Africa and also many other
countries around the world that are buying medications that
they think are legitimate and they are not.
Dr. Frieden. Both of those problems are big problems, and I
don't think we have great news in terms of what is happening
today to address them, but we do have a pretty clear pathway to
get there.
On the unregulated sale of antibiotics, fundamentally this
is a question of strengthening governmental public sector
capacity to do core things that we take for granted in this
country. We take for granted in this country that you can't go
to the local pharmacy and pick up the latest antibiotic because
you think maybe you need it. There is control over the use of
antibiotics.
I think many countries are not in that world yet, and one
of the things that we do at CDC and the FDA does as well is to
work with partner governments, both the public sector and the
private sector, to strengthen their capacity to do those core
governmental capacities that they need to have and it will
protect them and us. As an example, the Government of India has
recently passed rules outlawing an inaccurate test for
tuberculosis that was being used very widely in India and very
misleadingly. So people were being told they didn't have TB
when they did and that they did have TB when they didn't. They
have also ruled that you can't get TB over the market.
Well, it is wonderful that they have taken those steps to
have those rules so that people would need a prescription and
you would have an accurate test. The next step is get them
implemented effectively, and that is something that with any
country we are willing to partner to help them get it right
because that helps them and it helps us.
In terms----
Ms. Bass. Could I ask you a little bit, just one question
about that? How about Mexico? You know, living in Los Angeles,
I am just 2 hours from the border and a lot of times people do
go across the border to get antibiotics and bring them back. We
also had a problem in Los Angeles, frankly, with people selling
them over the counter at swap meets and different places. What
is our relationship with Mexico?
Dr. Frieden. We have a longstanding relationship with
Mexico. We have, at CDC, binational programs, especially for
some of the border areas. Mexico has a very robust public
health system. In terms of antibiotic availability, I would
have to find out and get back to you.
Ms. Bass. Okay.
Dr. Frieden. In terms of counterfeit drugs, I don't think
we have a good sense of the scope of the problem. We know it is
a risk. We are very concerned about counterfeit artemisinins
which we have seen and we are very concerned about the
continued sale of monotherapy with artemisinin. One of the
great ways to protect antibiotics is to the give them in pairs
or groups of three or four. This makes a huge difference
because it reduces the risk that if you develop resistance it
will spread. This is one of the key lessons from tuberculosis
and from HIV, that by using multiple drugs together you can
cure patients more effectively and prevent the emergence of
drug resistance.
So the sale of monotherapy artemisinin alone is just a
terrible thing. It should never happen. And one of the things
that we need to do more of is work with WHO, work with other
international organizations, work with individual countries on
reducing both counterfeit and irrational drug formulations on
the market.
Ms. Bass. So then do you think the counterfeiting of drugs
is not that big of a problem? I mean, it is talked about huge,
and I don't know if it is playing that big of a role in drug
resistance.
Dr. Frieden. I think what I was trying to say is I don't
think we know how big of a problem it is.
Ms. Bass. Oh, okay.
Dr. Frieden. We know that there are many problems of which
that is one, and the FDA has some new technologies that they
are looking at which may help countries to identify counterfeit
drugs more easily. A lot of this involves strengthening
national regulatory authorities in other countries. That may
sound like something, why would we want to do that? But we want
to do that because we don't want people anywhere getting drugs
that they shouldn't be getting or drugs that are ineffective
when their resistance will soon be just a plane ride away from
us in the U.S. We have already seen this happen with patients
from Asia coming here and creating outbreaks of disease.
The answer to this isn't to try to say we are going to keep
all microbes out. We are a globalized world, whether it is in
our food supply, whether it is in our medications, whether it
is in the travelers from the U.S. who go abroad and come back
or people who come here, and in the case of tuberculosis, may
have been here for decades and then develop an infection or an
active infection with tuberculosis.
Ms. Bass. Thank you.
Mr. Smith. Mr. Weber?
Mr. Weber. Wow, where do I start?
I think you might have answered it, Doctor. You held up the
chip, and you said the chip was instrumental, I think, in the
detection of H7N9? And then you mentioned it had, oh, I don't
know how many pieces of information on it. Would you go back
through that again, please?
Dr. Frieden. Sure. And if you would like, I will also talk
some about H7N9 at some point.
Mr. Weber. Okay.
Dr. Frieden. But this chip allows you to take either a
culture that you have in a laboratory or a patient's specimen,
blood or urine, and then to isolate the DNA and put it in these
wells and then, through testing, figure out what DNA is in it,
so what organism it is, whether the DNA encodes for resistance
genes, whether, when we learn more, whether it is related to
other organisms. So two people may have the same species
infection, but they may be totally unrelated or they may have
gotten it one from the other.
That kind of information can come from this kind of
technology, but we need to learn more about it, we need to
invest in it, we need to study the genome of many of the
organisms that are causing human illness.
Mr. Weber. Does that give us the ability to look at that
DNA and say some strings of DNA are more resistant to drugs
than others?
Dr. Frieden. Yes, it would allow you to say which of the
strains are more dangerous. I should give the caveat that this
is only effective if it is done along with a lot of our
traditional tools of laboratory work and what we call shoe-
leather epidemiology, going out, asking people questions,
figuring out who is sick, figuring out who is resistant, and
who had contact where with who.
Mr. Weber. Okay. So this gives the ability to predict, for
lack of a better term, I think the phrase you used was to skate
not to where the puck is, but is going to be.
Dr. Frieden. That is what we hope it will do.
Mr. Weber. Yeah. Wayne Gretzky he said over here.
Dr. Frieden. That is right.
Mr. Weber. Okay. I didn't know he was a doctor.
So what does that look like? I mean, are you anticipating
strains evolving? What do you mean by that?
Dr. Frieden. So we could see within an individual patient
with influenza, in our current way of doing it, we can only see
one dominant strain. With the new technology, we would actually
see many strains that are in their body and making them sick.
Some of those strains may be drug-resistant. Some of them,
in the case of H7, may have picked up the ability to spread
person to person. We don't know that yet. That is something we
will be tracking very, very closely as H7 progresses and as we
learn more about it.
Mr. Weber. And then you do what? You skate to where the
medicine that he or she needs?
Dr. Frieden. We might, for example, use a different drug to
treat that patient. We might change the way we create the
vaccine so that the parts of the vaccine that are active are
active against a different strain of the virus or a different
type of the virus. So it would help us to both find it and stop
it and prevent it.
Mr. Weber. So when you do that, when you have this data--
and I forget how many pieces you said was on there, hundreds of
millions, I am sure--are you able to get that into a database
that says, okay, we can share this and we know--at some point,
somebody named the H7N9. And so at what point do you determine
that a particular strain is wide and it gets a name? Who
determines that, and when does that happen?
Dr. Frieden. So, for influenza, we have really a wonderful
global partnership. We work with more than 50 countries, we
work with the World Health Organization. And after the SARS
epidemic in China, the Chinese got very interested in improving
their system. So we have worked very closely with them to set
up systems to track influenza, to help them develop their
laboratory abilities to be able to detect it and to do the
genetic sequence of influenza.
And, in fact, we helped them become a World Health
Organization collaborating center on influenza. And that is
important, because, as a collaborating center, they are
required to post on the Internet the entire gene sequence of
every new influenza organism that they sequence, and they are
happy to do so.
So, within days of receiving the first sample, the China
CDC, which is the collaborating center there, had sequenced the
genome in ways that we had helped them to do and then posted
that on the Internet. We brought that sequence down and used
the sequence to create a test to see if someone has this
organism.
We have already had about two dozen people in this country
coming back from China with severe illness who we have tested
in our laboratories. None of them have had this. We don't think
any have had it yet, of the ones that are still pending. But,
in addition, we have already begun through what is called
reverse engineering to make a vaccine against H7 based on this
information from the Internet.
That is all great, but there is actually a next generation
of genetic work that can be even more powerful and allow us to
see in advance--we only saw this once it had made a bunch of
people sick. It has now made over 100 people sick in China----
Mr. Weber. Well, and that is my question. How do know over
here in this country? How do you get that word out? At what
point do you know that these people--do they have a common
theme? They have been overseas, I guess.
Dr. Frieden. So for the H7N9, if I can just address that
for a moment, influenza is, of all of the infectious diseases,
the one that can kill the most people. During the 1918
pandemic, more than 50 million people around the world died.
The death rate among people who got the virus in 1918 was
around 1.7 percent.
Now, in an average flu year in the U.S., average seasonal
flu year, about 20 percent of people, 60 million Americans, get
the flu. So if a virus could be that severe and infect that
many people, it would be of enormous risk.
Mr. Weber. Knock out 6,000 people, basically, if you went--
and more than that at 1.7 percent of 60 million.
Dr. Frieden. So that is why flu we take so very seriously
and we track it all around the world. In fact, the Southern
Hemisphere tends to get flu before we do, and we use the
pattern there to decide which strains of flu to put into the
virus for the coming year, and they use for the next year what
happens here. So it is really a global collaboration on
influenza.
H7N9 is a new scenario. We have never seen anything quite
like this before in China. And there are aspects of it that are
reassuring, there are aspects that are not reassuring, and
there are things that we are specifically doing.
I will tell you the most reassuring thing about the bird
flu in China now, the H7, is that it is not spreading from one
person to another efficiently. And we are quite confident in
that. The Chinese Government has checked more than 2,000
contacts of people with flu, and they have found only a very
small handful of secondary cases, whereas with a usual flu we
might expect to see as many as 20 or 30 percent of those people
sick. So we are not seeing spread. And we are seeing most of
the cases had contact with birds--ducks, pigeons, quail, or
chickens.
So what is reassuring is we are not seeing person-to-person
spread. We are also seeing very good collaboration with the
Chinese authorities. In fact, the head of our flu program is
there now on a World Health Organization delegation and getting
great collaboration. The Chinese Government has asked us to
send them three of our top experts in flu to work with them for
weeks and months to come so that they can do everything
possible to get ahead of it. And for 10 years we have been
increasing our preparedness for threats and working better
across the U.S. Government. That is the good news.
The not-so-reassuring news is that this particular strain
of bird flu, H7, is severe. So, of the 100 people or so who
have gotten it, about 20 have died, and many of the remaining
are quite sick. We also don't see birds getting sick from it.
Now, you might say that is a good thing, but it is not, because
with H5N1, another bird flu that we have been tracking for 10
years, with H5, the birds get sick and the country culls the
flock and it stops spreading. Here the birds aren't sick, so
you can't cull the flock. You don't have that marker.
And H5, the other bird flu, spread all over the world in
years. So it started in Asia and soon was all over the Middle
East and Africa. And for H5, it took about 18 months between
the time the first case came and we had 100 cases. H1 was
recognized on April 1st of this year, and we already have 100
cases.
So there are things that we are very concerned about in
what the genome looks like, and creating a vaccine is
particularly challenging for these types of virus. But our plan
for addressing the flu basically uses four pillars that the
Department of Health and Human Services coordinates. The first
is tracking so we know what is happening. The second is
mitigation, figuring out how we can reduce damage if it comes
by treating people and helping them survive flu, by good care
in hospitals. Third is vaccine development. Vaccine development
in influenza takes at least 6 months, and for H7 it is likely
to require probably two doses and maybe an adjuvant because the
human body doesn't respond well to this. And communication. We
are very up front. We have a fundamental rule: Tell them what
you know when you know it; tell them what you don't know and
how you are trying to find out. And that is our approach to
this.
The bottom line with H7 is that, currently, it is not
spreading person to person. If it does not gain that capacity,
it will not cause a pandemic. But I cannot predict if it will
and, if it does, if it is going to be tomorrow or in 10 years.
Mr. Weber. Sure.
Let me ask one final question, if I may, Mr. Chairman.
In your remarks, you said there were four trends, and your
fourth trend was the potential for folks to intentionally or
unintentionally create dangerous organisms and release them,
which got my attention, because in all this talk about, you
know, biological warfare, for example, with all of these
databases up on the Web you talked about, where they identify a
strain, they are supposed to post it as a member of the WHO, do
you guys, for national security reasons, work with the branch
of government that would track something like that?
And I don't know if you can really go into it. How do you
identify that strain, if you will? And how do you know who is
working on it?
Dr. Frieden. So within this country, within the United
States, CDC operates something that looks at what are called
select agents, things that could be used for terrorist purposes
or could be dangerous if they got out of the laboratory. There
are currently about 354 laboratories in this country that work
with one or another toxin or select agent.
We are generally not a regulatory agency, unless you want
to import or work with plague or something like it in your
laboratory, in which case we will do the regulation. And for
each of these laboratories, we do on-site visits and we oversee
them. And we ensure that both the workers there don't get
infected, because if they got infected, they could bring it
outside and they could be very sick, and we do everything
possible to minimize the risk of spread.
Mr. Weber. Well, I am not too concerned about the
laboratories that are here. I was concerned about your example
or, for example, other foreign countries posted their stuff
online. If they find something that is so bad that there is
really hardly a cure for it, what would keep them from just
sending it over to our country? That is really my question.
Dr. Frieden. Yep. The risk of biological warfare is real.
Mr. Weber. Do you all track that?
Dr. Frieden. We do. And we also retain under our
jurisdiction the strategic national stockpile. It is
countermeasures for a natural or manmade disaster that we can
deploy to anywhere in the U.S. within 12 hours.
Mr. Weber. So if you see a country that is hostile to
America--of course, they probably aren't going to post that on
the Web. That is the catch-22. If they come up with something
like that, there is no good way for us to have a preventative
vaccine in place without foreknowledge.
Dr. Frieden. Well, we look at all the potential risks. So
we have scientists at CDC who are essentially the world's
experts in just about all of the threats that could be faced.
We know, for example, that smallpox is something that we
have been very concerned about someone reintroducing in the
world. CDC, working with World Health Organization, eradicated
smallpox from the world, but we have been concerned that
someone might bring it back as a terrorist agent. We have in
the stockpile enough vaccine to vaccinate the country. So we
have essentially taken that risk off the table.
Mr. Weber. Okay.
Dr. Frieden. Not all risks are that amenable to our
intervention, but we both track and think of how to prepare.
And I would mention that the advanced molecular detection
allows us to do very specific fingerprinting of strains which
would help us in identifying the source of it. So that it is
something that has additional benefits, as well.
Mr. Weber. Okay. Thank you.
Thank you, Mr. Chairman. I yield back.
Mr. Smith. Thank you very much, Mr. Weber.
Mr. Bera?
Mr. Bera. Thank you, Mr. Chairman.
And my apologies, Dr. Frieden, if you have been asked this
question. But in my opening statement, I talked a little bit
about how we come up with the next generation of antibiotics
and certainly extend the life of those antibiotics.
Part of the challenge that we face is, as our domestic
pharmaceutical companies and global pharmaceutical companies
look at making those investments and the amount of research
that goes into developing that next generation and then the
return on that investment, many of these companies are making
those cost-benefit analyses and realizing, you know, the costs
of prohibitive. So, clearly, the Federal Government has a role
in making sure we are providing adequate resources and funding,
creating that partnership between industry and academia to do
this research and develop the next generation.
But the critical question here is, as we are making those
investments, we certainly want to extend the life of these
therapeutics. And we are seeing--I was reading my home medical
journal, the Annals of Internal Medicine, in this latest issue,
and they were touching on the increasing incidents of CRE and
the impact that is having and potentially will have in the
future.
What are some thoughts that you might have as we come up
with this next generation to both protect and extend the life
of these discoveries here domestically? But then also, we talk
about the ease of obtaining antibiotics overseas in third world
countries. What are some creative things that we can do here in
Congress, working with industry, to, again, extend the life?
Dr. Frieden. I think everything you say is a critical
issue. We need to figure out how to preserve the antibiotics we
have now and ensure that, as new antibiotics come on line,
which we anticipate and hope they will, we don't lose them as
quickly as we have lost some of the current ones.
The amount of antibiotic usage in the U.S. is actually
astonishing. CDC just published data on this within the past
week, I believe. There are more than a quarter of a billion,
``B,'' quarter of a billion courses of antibiotics prescribed
in this country each year, about 8 courses of antibiotics for
every 10 people in the country. And in some parts of the
country, it is 12 for every 10 people.
So I think we really have to work on antibiotic
stewardship, making sure that when people need antibiotics,
they get them, and when they don't need them, they don't get
them. And CDC has sponsored some antibiotic stewardship
programs which have been shown to save money for facilities.
They require an investment; you have to have staff doing them.
But they pay off. And this is something that is really quite
important.
In terms of the pipeline of how to get new antibiotics, the
NIH is critical in that regard, and the FDA as well. It is
figuring out ways to help companies bring products to the
market sooner and at lower cost so that we can address this
gap, because we don't have a lot of great antibiotics in the
pipeline.
In terms of preserving antibiotics, I talked briefly before
about the new antibiotic for tuberculosis, which we are trying
to do just that with, saying, let's just reserve this for the
patients for whom there are no other options while we figure
out the best mechanism for it.
As you know as a doctor, Dr. Bera, if you use antibiotics
correctly, you won't get drug resistance. A lot of the things
that we need to do are fairly simple and straightforward:
Getting healthcare workers to wash their hands, removing
urinary catheters and intravenous lines very promptly and only
using them when essential, getting patients off ventilators as
rapidly as possible, reducing healthcare-associated infection.
And CDC's healthcare-associated infection program does that
in this country. Other countries, particularly low- and middle-
income countries, are not doing much in that area. And that is
an area we would like to expand work on, but we are unable to
for lack of resources.
Mr. Bera. You have touched on a couple areas. I am
astonished at the number of courses of antibiotics. I realized
there was a lot being prescribed; I didn't realize it was that
high.
Are there best practices that we can make sure physicians
around the country are utilizing that have been shown to be
effective? So for years we have been talking about appropriate
antibiotic prescriptions and prescribing habits. Are there best
practices that you have seen and effective models?
Dr. Frieden. Yes, we have seen antibiotic stewardship
models that really make a difference. We have a program at CDC
called Get Smart About Antibiotics. And we think it is
important to involve both the clinicians and the community.
Because the clinicians will say to us, you know, the patient
came in and they demanded antibiotics, and they said if I don't
give them to them, they are going to go to the guy down the
street.
Mr. Bera. Right.
Dr. Frieden. So I think it is important to get more
awareness that antibiotics--no medicine is without risk. So
things should absolutely be taken when they are needed but not
be taken when they are not needed. And I think that is the
essence of the best practice.
We have often seen that getting nondoctors involved in the
system--pharmacists, nurses, allied health workers--can be very
important.
And the other thing that has been very effective is to
track the prescribing trends of different doctors, not as a way
of criticizing someone, but providing feedback, and if there
are outliers, providing them that information and education so
that they can do a better job.
When I worked in tuberculosis control, we were able to
standardize treatment for tuberculosis across an entire city,
an entire country, using outreach workers to reach out to
doctors, private doctors, in case the prescription wasn't
appropriate or rational, and just provide them with education
and information so we could improve the quality of care.
Mr. Bera. Great.
You know, just one last question. My colleague, Mr. Weber,
touched on the threat of biological agents and so forth and the
imminent threat here locally, or domestically. You know, in the
full committee, we have certainly had a few hearings on Syria,
a country that increasingly looks like it is going to fall and
a country that we know possesses some of these biological
agents.
You know, as we prepare ourselves for, you know, all
threats and so forth, is there anything that you would like to
see from this body in terms of helping the CDC make sure that
we are fully prepared for----
Dr. Frieden. Well, at CDC we work 24/7 protecting Americans
from threats, whether they are natural or manmade, whether they
are infectious or environmental, whether they are from this
country or abroad.
What we do, frankly, is dependent on the resources we are
provided. So when we have fewer resources, that means the
resources that we provide to State and local entities to detect
and respond to problems are less, that means the resources we
have to work globally are less.
Sequestration has had broad and serious impacts on CDC's
ability to detect and respond to a wide variety of problems. We
understand that we are in fiscally constrained times. We have
done a lot to be more efficient, to make sure that as much of
our money that we are entrusted goes out for direct program
services. But we are concerned that our ability to respond is
really at the breaking point in some of our programs.
Mr. Bera. Right. Thank you.
Mr. Smith. Thank you.
Mr. Meadows?
Mr. Meadows. Thank you, Mr. Chairman.
And thank you for your illuminating testimony.
And one of the areas that I want to broach is, Dr. Bera and
I actually have had a lead letter together where we had Dr.
Collins come in with NIH, National Institutes of Health. And he
was sharing some of the groundbreaking, exciting research that
they have been doing, particularly in influenza.
And so what kind of correlation or partnership has there
been with that group? And what can be learned from that
partnership?
Because as he was sharing, you know, right now we treat,
and he described it, it is kind of like a mushroom. And, you
know, every year you get a flu shot, and, you know, it is a
different strain, and we are coming up with that, and that
there is a hope that one day we will be able to, in the not-
too-distant future, just have one shot for that stem that, from
a DNA perspective, helps us address that.
And so are you working with them, and in what ways?
Dr. Frieden. We work very closely with NIH, with FDA, with
other parts of HHS. In fact, in the H7N9 response, we are
having twice-weekly coordination calls to make sure we are
perfectly aligned.
What we are finding--really, what NIH is working on we
really hope will work out.
Mr. Meadows. Right.
Dr. Frieden. They are doing the basic research to try to
come up with a universal, long-lasting flu vaccine.
Mr. Meadows. Right.
Dr. Frieden. This would be phenomenal. Right now, our flu
vaccine works okay. It doesn't work as well as most of our
vaccines. You have to take it every year. Sometimes we have a
mismatch, and it doesn't----
Mr. Meadows. Right.
Dr. Frieden [continuing]. Meet the strains. If you look at
something like H7, it doesn't work particularly well. You have
to give two doses and maybe an adjuvant.
Mr. Meadows. Right.
Dr. Frieden. So we have real challenges, and we ardently
hope that they will succeed.
But our job really is to take what is existing knowledge
and turn it into practice. That is the CDC space----
Mr. Meadows. Okay.
Dr. Frieden [continuing]. Take what we know how to do and
get it happening as broadly as possible to protect as many
people as possible.
And we are able through our laboratory, for example, to
accelerate and improve some of the current vaccine development
techniques. We are able through our laboratory to cut a month
off vaccine production time through a new technology that we
have developed.
So it really is a partnership across the system.
Mr. Meadows. All right. So you mentioned the FDA. And,
obviously, there is this, where you are analyzing and seeing
the issue and identifying the problem, so to speak. And then we
have to figure out a way, how do we deal with the problem. And
so there are a number of components there. One would be the
FDA; the other would be pharmaceutical companies.
What are the barriers that you face right now with either
sharing that information or speeding up the process? You know,
if you are identifying the issue, how do we make sure that as
quickly as possible that we see the enemy and that we know how
to fight it, with drugs or whatever? What are the barriers that
you are seeing there?
Dr. Frieden. I think within the Federal system, we are very
well-aligned. I honestly might not have said that a few years
ago, but that----
Mr. Meadows. So that is part of the government that is
working well, is what you are saying?
Dr. Frieden. Yeah.
Mr. Meadows. Okay.
Dr. Frieden. Just to take food safety as an example, we
have weekly reviews with both USDA and FDA on every potential
cluster and investigate those that make sense.
On influenza development, we are really very tightly
aligned between FDA, USDA, NIH, and ourselves. So, for example,
if we go forward to make vaccine for H7, even trial vaccine----
Mr. Meadows. Right.
Dr. Frieden [continuing]. It would be part of HHS that
contracts for that, it would be NIH that does the clinical
trials, it would be FDA that licenses it. So I think that is
going well.
There are at least two areas where we face real challenges.
One of them is, as I have mentioned, our limitation in being
able to do some of the advanced molecular work that would open
doors and make things visible that are currently invisible to
us.
Mr. Meadows. Right.
Dr. Frieden. The second are sometimes some of the
incentives. The private sector is a crucial partner in this
work, but for some of the work they don't have the incentive to
do what might do the most good, either because a product
wouldn't pay or because the market isn't necessarily there. If
we don't have an H7 pandemic, there will be no market for the
vaccine. So there are areas where the government needs to step
in because there is no natural incentive for it.
New antibiotics are an area where we are trying to get the
incentives right, because it does cost so much money to develop
a new antibiotic. How do we make sure that, if they do get one
to market, it is preserved and they can get a return on their
substantial investment to bring it to market?
So I think those are two of the issues that we are looking
at more.
Mr. Meadows. All right. And so let's look at that
prioritization, because I think you have come up and you have
said, okay, you know, we have fiscal constraints, we have, you
know, a priority on where we are in terms of our investment on
these.
How would you look at those areas and prioritize them? I
mean, I have a number of friends that have worked for the CDC.
I mean, they come up to the mountains of North Carolina to get
away, and so I get to see them on a regular basis. And all of
them are very dedicated, capable individuals.
I still at times, though, see the CDC, what I believe, may
have mission creep in terms of getting into areas that
tangentially maybe have to do with disease. For example, I
mean, I was real surprised to see some of the advertising done
by the CDC with regards to gun control. You know, there was an
issue there that came up, and I was just blown away that there
would even be anything there.
And so, how can you--or who is the best person to
prioritize those things for us?
Dr. Frieden. Well, first, I am not aware of any advertising
CDC has done on gun violence. So if there is any example of
that, I would like to see it.
Mr. Meadows. I will get you a copy of it.
Dr. Frieden. I think the bottom line for us is a return on
investment, return on investment both in terms of health and in
terms of dollars.
So with influenza as an example, we are looking at what
will be the return on investment from a better vaccine. Now, we
hope we will come up with a universal vaccine. It might or
might not happen. But we know that if we can increase----
Mr. Meadows. Right.
Dr. Frieden [continuing]. The use of existing tools, we can
tamp down the impact of influenza.
For many of the vaccines, we know that if we got to higher
vaccination rates, we would have less disease in the future. In
fact, vaccines are a great example of that. For every $1 we
spend on vaccines, we get $3 back in healthcare savings and $10
back in societal savings.
So I think, for me, the key concept is the return on
investment. It is not something we do because it makes us feel
good or we think----
Mr. Meadows. Oh, no, no. And I realize that. And I guess my
question becomes, how do we share the issue of how concerning
these issues are without creating panic and yet, at the same
time--because, you know, funding becomes--you know, you only go
to the doctor when you know you are sick. And a lot of these
issues are here, that are out there, that, quite frankly, the
average person on Main Street has no idea that the threat
exists.
So how do we share that information where we build, you
know, public consensus and yet, at the same time, not create a
fear, you know, where everybody is running around on Main
Street with masks on their face?
Dr. Frieden. So, right now, for H7 as an example, there is
nothing for people to do differently. As a family member, as a
parent, there is nothing that I am advising my family to do
differently.
Mr. Meadows. Because of the contagious nature that you
talked about earlier.
Dr. Frieden. That is right.
Mr. Meadows. Okay.
Dr. Frieden. For 10 years, we have told people, if you
visit China, don't go to live markets. That was to protect you
against SARS and avian influenza and other things. And that
remains our advice, and that is----
Mr. Meadows. Sure.
Dr. Frieden [continuing]. Essentially the only thing
different.
For us at CDC, it is different. We have activated our
emergency operations center. We are tracking it 24/7. We are
sending teams out to look at it. We are working with State and
local governments. We are working with neighboring countries.
So there is a lot that we are doing.
I think the issue of building consensus is a challenging
one, and it really gets to the heart of this hearing, I think,
which is, how do we ensure that there is a widespread
recognition that in terms of global health threats we are
inevitably interconnected, that a risk anywhere is a risk
everywhere, that a blind spot anywhere puts us all at risk? And
that is something that I think all of us can think together on,
how to convey that most effectively.
Mr. Meadows. So you think the Federal answer--and this is
my last question, Mr. Chairman--you think the Federal answer to
that would be to prioritize those, identify those areas, as we
did with smallpox when there was a potential risk with smallpox
after 9/11, and identify those areas that may not have a
pharmaceutical payback, so to speak, and say that is where the
Federal Government needs to get involved, and on the others
leave it to the private sector?
Dr. Frieden. Yes, in general. I would say that it is not an
either/or. There are very important public-private partnerships
where, say, take the example of the cell-based flu
manufacturing capacity that the public sector invested in but
Novartis also invested in.
Mr. Meadows. Right.
Dr. Frieden. So I think there are partnerships possible
there.
In terms of the gaps, we have talked about the advanced
molecular detection. We have also talked about the global
health security and the need to have that network around the
world, because if any country is weak, we are all at higher
risk. And, ultimately, things like vaccines can take diseases
off the table but require more investment or, where we have the
vaccine, investment to get it into people.
Mr. Meadows. Okay.
I thank you, Mr. Chairman, and I yield back.
Mr. Smith. Thank you very much.
Dr. Frieden, you have been very generous with your time. If
I could just ask you a couple of final questions, and perhaps
any other colleagues who would like to ask a final question as
well.
You mentioned drug-resistant gonorrhea. If you perhaps
could speak to how prevalent that is, that we saw strains,
``we'' being the government, detected in Asia, and now it has
been observed around the world, including the United States.
On MRSA, is that something that is multiplying globally,
and at what rate, perhaps?
I, on one trip to Korea, met with a number of people, but
one of them was a priest who was doing work in Pyongyang to
help multiresistant TB and XDR TB-affected patients, who are
unbelievably sick, and yet he was allowed in. In that case, Kim
Jong Il welcomed him because he was doing such a great
humanitarian initiative.
When you have a country like North Korea, or perhaps Iran
or Eritrea, or some other country where human rights abusers
are in power, like China and even Vietnam, they welcome,
thankfully, the collaboration to try to mitigate and stop
disease spread, but in a country like North Korea, that is not
happening. Do you have any recommendations on what could be
done, you know, to build that bridge? Because, obviously, I am
sure CDC would love to be there helping to eradicate something
like--or help people with drug-resistant tuberculosis.
Let me also just ask you briefly if you can comment on the,
maybe you might not want to, but the $236 million in last
year's budget for Fiscal Year 2012 will be cut by $45 million
in the President's budget for TB to $191 million. I mean, yes,
these are hard times, but it seems to me that that money,
minimally straight-lining it, if not increasing it, is--every
dollar well-spent.
And, finally, back in the early 1980s, during the child
survival revolution, Jim Grant and all the others at UNICEF,
and of course our Government was pushing hard for it, David
Stockman came along as OMB Director and zeroed out in its
second year the child survival emphasis on vaccines or
rehydration therapy and the like. I offered the amendment to
double it, to double down and say not only should we not end
that money, we need to increase it.
And I travelled to El Salvador and many other places when
vaccination days were called. And pertussis, diptheria, and
other killers of children, kids were vaccinated against it.
Now, this is obviously several decades later, and I am
wondering, are we hitting all the diseases? Are any of those
diseases, like pertussis or diptheria, morphing into something
that becomes drug-resistant?
We thought we were on our way to eradication and universal
immunization, but obviously they keep rearing their ugly heads.
I mean, we need to redouble our efforts on the child survival
effort as well.
If you could speak to that.
Dr. Frieden. Thank you so much.
On drug-resistant gonorrhea, we have seen an increasing
proportion of strains in this country and around the world that
are resistant to cephalosporins. So, earlier, just a few months
ago, we issued new treatment guidelines to use two drugs for
patients, not one, because, again, using two will reduce that
emergence.
We know that it is a problem globally and we will have to
address it globally. There is a lot of global transmission. And
what we have seen is the need to have that kind of action. We
have worked very actively with the World Health Organization to
track it.
In terms of MRSA, I think there is very limited evidence or
knowledge about where it is globally. So that is one of the
things that we would like to work with other countries on to
further develop. But we do know that in this country we have
been able to substantially reduce invasive MRSA through some
commonsense, low-cost ways of reducing infections in hospitals.
I agree with you completely that health is often a great
way to foster collaboration. I mean, look at the partnership,
steadfast partnership, over the past 10 years with China on
influenza and other infectious diseases, regardless of what
else may be happening. Or if you look at smallpox eradication,
that was done when the Soviet Union still existed. There was a
partnership between the CDC, the U.S., and the Soviet Union for
smallpox eradication.
So health can be a safe space. And the days of tranquility
that you mentioned of James Grant and UNICEF were a very
inspiring example of that, where people actually stopped the
war to vaccinate kids.
I can't comment on the budget on TB. I believe that is the
USAID budget that you are referring to.
In terms of the child survival revolution and what is
happening now, vaccinations remain one of the great
accomplishments of all time in humanity. Take measles alone.
There are about 10 million children who would be dead who are
alive today because of measles vaccinations. Low cost, it is
highly effective.
We know that there are limits to vaccines. For example, our
pertussis vaccine doesn't work as well as we would like. Many
countries are not using the vaccines that we know work. So
rubella vaccines have to be used at a high rate or you actually
can do more harm than good. So the vaccine work is very
important.
One thing that has been very encouraging is GAVI, the
Global Alliance for Vaccines and Immunizations, which is
funding and creating an incentive for companies to sell at a
reasonable price vaccines around the world. And the vaccine
manufacturers have been wonderful partners in this. The result
of that is that new vaccines against rotavirus, something that
CDC helped develop; against pneumococcal disease, which killed
lots of kids last year; and against haemophilus are being
introduced around the world.
We still have much further to go to make sure that every
child in the world can have the potential of receiving those
vaccines. And there are some new vaccines that we are hoping to
see developed in the coming years. But right now we have kind
of a full plate getting these scaled up.
We have worked in Haiti, for example, to help that country
implement new vaccination programs at a higher rates for three
of leading killers that they were never vaccinating against
before post-earthquake, so rotavirus, pneumococcal, and
haemophilus. Major killers, at least probably 10,000 deaths per
year per pathogen. And those are getting introduced last year,
this year, and next year in Haiti.
So I think it is a great example of how much can be
accomplished in global health. And I really thank the
committee, the chairman for how much you have done in this
area.
At CDC, we also have searing memories of the zeroing out of
the child survival revolution, because we were expanding
vaccination. And lot of children could have had a fuller,
longer life if that program hadn't been stopped.
Mr. Smith. Doctor, is there anything you would like to say
in conclusion?
Dr. Frieden. Only to thank you again for your attention to
these issues and to emphasize that, despite all the problems,
despite all the threats, despite all of the risks, I remain
fundamentally optimistic. We have commitment and we have tools,
we have great people, we have will in this country and around
the world. There is a broad consensus in this country and
around the world of what needs to be done. And I am confident
that we will make even more progress in the future.
Mr. Smith. Thank you so very much for your great testimony
but, more importantly, your leadership. It is making a huge
difference and deeply appreciated by this committee. Thank you.
Dr. Frieden. Thank you very much.
Mr. Smith. The hearing is adjourned.
[Whereupon, at 4:44 p.m., the subcommittee was adjourned.]
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Material submitted for the record by the Honorable Christopher H.
Smith, a Representative in Congress from the State of New Jersey, and
chairman, Subcommittee on Africa, Global Health, Global Human Rights,
and International Organizations
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Material submitted for the record by Tom Frieden, M.D., director,
Centers for Disease Control and Prevention
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