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Prepared Witness Testimony The House Committee on Energy and Commerce
SARS: Assessment, Outlook, and Lessons Learned
Subcommittee on Oversight and Investigations
Dr. Barry R. Bloom Ph.D.
Mr. Chairman and members of the Subcommittee on Oversight and Investigations of Committee on Energy and Commerce, thank you for inviting me to appear before this Committee to share my thoughts about SARS, the general problem of emerging infectious diseases and how we can best respond to them. There are at least five reasons why SARS and emerging infections represent a serious threat to the health and security of Americans: 1. Epidemics of infectious diseases are by their nature unpredictable. 2. There is a continuing pattern of emergence of new infectious diseases into human populations. 3. Infections transmitted by the respiratory route are readily transmitted between humans; in the case of SARS some infected individuals are documented to have infected tens of healthy people and 5 travelers have exported the disease to five different countries. 4. Historically, respiratory infections against which we did not have vaccines or drugs killed vast numbers of people. I cite the 20-40 million lives lost in the 1918 influenza pandemic, the 90% mortality in Hawaii in the 19th century due to measles, and the 8 million cases and 2.4 million deaths due to tuberculosis last year. 5. SARS has already infected 6000 people and killed 6.7% of them. It has caused enormous economic losses --- an estimated $30 million per day in Canada, $16 billion in losses to the Asian economies and $30 billion to the world economy thus far. As the U.S. attempts to improve our capacity to protect against this major threat, I would suggest that we keep several factors in mind: 1. Infectious diseases do not respect national boundaries - global security depends on the competence of local responses in countries around the world. The security of the US increasingly depends on expertise around the world. 2. Honest and accurate information is essential to make effective policy. 3. Outbreaks are contained when they are detected early and the number of cases is small. When they are not, they become epidemics, which may require drastic state measures, as is currently the case in China, Taiwan and Singapore. 4. The CDC is pivotal to an effective global and national response, and the United States Government has been tragically shortsighted in cutting the CDC's budget and particularly that of the National Center for Infectious Diseases. 5. NIH research is critical to developing new tools, such as drugs and vaccines. 6. Engaging industry to develop products for emerging infections, where markets are unsure or limited, is a crucial challenge. 7. Creating Global Health Surveillance and Laboratory Networks must be given high priority. The best way to achieve that is to strengthen WHO, and the collaborations between CDC, WHO and national and regional health institutions through training and linkage. 8. US research institutions, including the Fogarty International Center at NIH and our great schools of public health and medicine should receive resources to collaborate with and train health scientists in countries around the globe. 9. Investing in global health, beyond just SARS or AIDS, would protect our country and every other, save millions of lives, and help to change the U.S. image from self-interest to human interest Mr. Chairman and members of the Subcommittee on Oversight and Investigations of the Committee on Energy and Commerce, thank you for inviting me to appear before this Committee to share my thoughts about SARS, the problem of Emerging Infections and the most appropriate response to them. It is the nature of epidemics to be unpredictable. Yet people want answers to some important questions: How serious is severe acute respiratory syndrome (SARS)? Will SARS be contained in Toronto, or Singapore, or China? How far will it spread and how rapidly? What can we in the US do to prevent and control SARS? And future epidemics of infectious diseases? Why is SARS a serious concern? Any infectious disease that spreads by the respiratory route on aerosol droplets has to be taken seriously, because one individual can infect many others in a relatively short period of time. Aerosol droplets spreading from ordinary speech.. Those able to penetrate into the lung are too small and too numerous to be seen in the photograph. The available data indicate that fewer than a dozen infected individuals were able to transport SARS from China into Hong Kong, Vietnam, Singapore, Canada, the US, Ireland, Australia and Germany. The major risk factor for acquiring the infection is ---- breathing. In the absence of an effective drug or vaccine, we know that some infectious diseases similarly transmitted by the respiratory route have wreaked havoc --- 20-40 million deaths from the influenza pandemic of 1918, the decimation of the population of Hawaii by the first introduction of measles, and the lingering epidemic of tuberculosis that afflicts 8 million people annually now. Even with good vaccines, 36,000 people died in the US last year from influenza, and even with good drugs for tuberculosis, over 2 million people died worldwide. The good news about SARS is that it is not the most rapidly spreading respiratory infection known, generally requiring close contact; the worrisome aspect is that it is among the deadliest. SARS is not an aberration, but a reflection of the continuing threat of nature from emerging infections. Emerging infectious disease will continue to challenge us, and the question is whether we remain vigilant and prepared. The question has been raised in the press that since there are more people dying from motor vehicle accidents and gun injuries in the US than from SARS, are we in this country overreacting? I would note that deaths from auto accidents and gun injuries are not increasing exponentially; whereas SARS has been in three countries. The highest priority in any epidemic is to stop transmission to healthy people. If people infected with SARS can be identified and isolated for several incubation periods, there is a real chance that the cycle of transmission can be broken. If we do not, there is a possibility that it will establish itself in communities and we will have to cope with SARS for a long time. In the absence of a specific diagnostic test, vaccine or drug, standard public health precautions are the only tool available ---- establishing a case definition so as not to miss cases, acquiring accurate and honest information, alerting the public to take precautions, implementing strict protections in hospitals to protect first line medical staff and patients, isolating individuals suspected of having SARS so that transmission of infection is limited, and quarantining people who have been in contact with known cases who might develop the disease. Voluntary isolation and quarantine are a great inconvenience for a lot of people, but they are currently our best tool to save lives. The key to containing an outbreak is to take action at the earliest possible stage, before the numbers get high. Vietnam did that, and WHO has lifted its travel alert; China did not, and there are now over 10,000 people quarantined, thousands of probable cases and more suspected cases, such that the medical capabilities are now under severe strain. But as long as SARS rages in any country, it threatens every country, with the potential for reintroduction by new cases. Because of the enormous economic and political impact of epidemics it takes great courage in public health to declare to the world that a country has an epidemic. When the World Health Organization (WHO) recognized in March, after one of their top infectious disease specialists was infected by SARS in Hanoi and died, that there were similar cases in Hong Kong and rumors of more cases in China, it declared a Global Alert for the first time in WHO history. That gave every country in the world time to get prepared for a potential global epidemic and served as an early warning. If public health really works well and a health problem is prevented, there is little evidence to show that something important was achieved. When public health officials don't act quickly enough, outbreaks become epidemics. We also know from history that fear of epidemics exacts a toll in both human and economic terms. The anticipated epidemic of plague in India in 1994 that ultimately spread to fewer than 1,000 people devastated tourism and trade, and cost India more than $2 billion. The cholera outbreak in Peru in 1996, though contained, cost the country $2 billion as well. And the swine flu epidemic of 1976 that didn't happen cost the director of the federal Centers for Disease Control his job. In the case of SARS the economic consequences are already enormous, particularly for Asia. Information compiled from the press indicates that: The stock market in China will decline from a projected 5% increase to a 5% decrease, and the country's economic growth is estimated to decline by 1.5-2%. Tourism is already reduced in China by 40% which represents a loss on an annual basis of $27 billion. In Hong Kong, retail sales are down about 50%, airline bookings are down by 85%. Hotel occupancy in Asia is reduced by 25%, visitors to Singapore are down by 61%. It is estimated that SARS has been costing Canada $30 million a day. One can project these numbers on the United States should SARS be imported and not be adequately addressed by the public health system. I recently visited the CDC, an agency at the epicenter of this country's and the world's response to SARS. Their staff has worked tirelessly day and night to get the best information available, make it available to the press and the public, provide help in protecting our country from importing SARS, provide guidance to emergency rooms and hospitals, the public and press, and carry out laboratory work on sequencing the coronavirus genome. It is inexplicable that the budget of the National Center for Infectious Diseases at CDC was cut in FY 2003 by $8 million, to which was added a recision of $2.5 million. It is no less shocking that the center of operations, the Situation Room at CDC, could not be provided by federal funds, but required the generosity of a private donor to bring the National Center for Infectious Diseases information handling and communications out of the Stone Age. That they are being asked to do more to protect our country and the most affected countries around the world with fewer staff and fewer resources in itself represents a threat to the security of this country. We don't have to go to Iraq to find real weapons of mass destruction --- emerging infections, if we are not vigilant, will find their way here. Our first line defenders, the emergency room and hospital staffs, and the public health system must receive adequate support. It is shameful that fewer than half the public health workforce in the US have had any formal training in public health. This country's public health infrastructure has been degraded for many years, and was chronically unprepared for emergent infectious diseases. Why then has SARS not exploded yet in this country? Part of the answer may be good luck. Yet I believe that since September 11, 2001 and the outbreak of anthrax on October 5, Congressional investments in bioterrorism preparedness have been crucial in beginning to strengthen our public health system, increasing awareness and disseminating best practices, not only important to provide protections from man-made threats, but from the deadliest threats of all, emergent infectious diseases, such as SARS. In my view, the wrong lesson to be taken from SARS would be to pass new legislation mandating narrowly targeted funding of SARS research and control in the United States, the Centers for Disease Control and Prevention (CDC) has had to put 300 people funded for other activities to work on SARS; the National Institutes of Health has new funding for infectious disease research, but much of it is highly restricted to research on a long list of predicted bioterrorist agents. It is clear we are going to need research on many aspects of SARS and other infectious threats: What is their origin? How can we prevent animal to human transmission, and human to human transmission of new infectious agents? How can we develop and, equally importantly, standardize and validate new molecular tests for diagnosis of SARS or other potential threats? How do we understand the pathogenesis of the disease, to learn the best approaches to ameliorating it and saving lives? How do we get a better understanding of the epidemiology of the disease, whether there are superspreaders or carriers, and why some cases transmit more than others? When is someone over an infection and no longer likely to transmit? How do we support development of new antiviral drugs or vaccines against infectious disease agents that are not currently major problems in the US, and do not represent commercial markets? And who will support research in risk analysis and risk communication to be able to learn how to motivate and empower the public, without terrifying them or causing hysteria or cynicism, to protect themselves and their communities, even at some personal sacrifice. Neither the CDC, nor the NIH, currently has the resources or flexibility to use its funds to allocate personnel and resources rapidly to meet ever changing emerging infections without neglecting other health responsibilities. Unanticipated outbreaks will continue to be a reality and the world must be ready to move in whatever direction is needed, and we would do well to provide maximum flexibility to the CDC and the NIH to move quickly to contain outbreaks and prevent them from becoming epidemics. Infectious diseases do not respect national boundaries. A vital lesson we must learn from September 11, 2001 and SARS is that the security of the United States increasingly depends on expertise around the world in identifying potential health threats, and in having the scientific capability to address those threats locally. In the 1980's it took 2 years to identify HIV as the cause of AIDS. WHO created an extraordinary network of 13 laboratories in 10 countries, including the CDC, which identified a previously unknown virus as the likely cause of SARS in 2 weeks and had its entire genome sequenced in 2 more. Those labs shared their knowledge in an extraordinary fashion, to the benefit of everyone. In a world that is increasingly distrustful of the United States, the lesson here is that it is important for our country with the most advanced biomedical and public health capability in the history of mankind to make a commitment to improving the health of people around the globe. There is an urgent need to train people in epidemiology of disease and infectious disease surveillance. For this our great universities and schools of public health should be engaged and supported. There is nothing so difficult for a university than to find the resources to train students from developing countries. We should be collaborating with WHO in strengthening global networks for disease surveillance and sharing information. Because of the enormous stakes in missing the emergence of a serious infectious disease or mistaking non-threatening infectious diseases as major threats, there is an equally urgent need to train people in laboratory capability in key regions and countries around the world. What would be the incentives for scientists to share information on internal health threats or to join such networks, where the risk of finding new disease threats would have major economic consequences within countries? One would be the creation of scientific linkages between health ministries and institutions around the world and in this country, including WHO, sharing in new technology and knowledge to protect all of us from emerging threats. Another would be to provide support to our schools of public health and medicine through the Fogarty International Center at NIH and through the CDC to train students from overseas, establish long-term linkages that allow the students to return to their home countries and yet maintain contacts with institutions here so that they have the opportunity to continue learning and improving. In return they should contribute knowledge to a global health network. The costs of investing in training globally are inevitably small compared to the costs of just a single infectious disease epidemic. Investing in training of experts in epidemiology and surveillance, strengthening laboratories in key regions and providing long term linkages with our schools of public health and medicine, and amply supporting CDC, NIH and WHO, would be the best investment we could make to protect our country and every other against global epidemics, save millions of lives, and help to change the image of the United States from self-interest to human interest.
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