Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 24 - Evidence
OTTAWA, Wednesday, October 22, 2003
The Standing Senate Committee on Social Affairs, Science and Technology met this day at 3:45 p.m. to study the infrastructure and governance of the public health system in Canada, as well as Canada's ability to respond to public health emergencies arising from outbreaks of infectious disease.
Senator Michael Kirby (Chairman) in the Chair.
[English]
The Chairman: Senators, we have with us today from Atlanta, where it is significantly warmer than the barely above freezing that it is here, Dr. Hughes, who is the Director of the National Center for Infectious Diseases of the Centers for Disease Control and Prevention.
Dr. Hughes, while the SARS outbreak was going on in this country, the CDC was getting laudable press coverage virtually every day. You are regarded very much as the world's experts in the kind of work that you do. We know your busy schedule. We appreciate you taking the time to be with us today to talk about what you do, what Canada ought to do or any new things we ought to put in place, so that the next time SARS or its equivalent appears, we would be in a better position to handle it.
Thank you for appearing. I know you have a statement that you would like to make. If you want to turn to that, we will then ask you some questions.
Dr. James Hughes, Director, National Center for Infectious Diseases, U.S. Centers for Disease Control and Prevention: For the sake of time, I do have a prepared statement here, but I would be willing to forego that and go to the questions, if you prefer. The statement I have is a shortened variation on the written testimony that we submitted. I am happy to do it either way.
The Chairman: I would like to make maximum use of your time to respond to questions, since you did submit a statement.
At the broad level, you would have had experience in the case of SARS, in particular. By the way, the intent of our work here is to be constructive. It is not to find scapegoats or to be blaming anyone. We are trying to find ways to improve the system for the future. What are your perspectives on what Canada ought to add to its existing system, or even subtract if there are some things we do not need, in order to be able to respond in the future to another SARS- type outbreak? I say that because there seems to be a general consensus that while we do not know if it will come back, we must be prepared if it does.
Dr. Hughes: That is the bottom line. SARS is an excellent example of a global microbial threat. It is the best example until we encounter the next pandemic of influenza, which does lie out there. We know that will occur; however, we simply do not know when. Many of the lessons from SARS are certainly applicable to pandemic influenza preparedness and bio-terrorism preparedness. It is important that we, you and other countries take this seriously and learn from it.
In terms of some of the obvious lessons, there is the importance of vigilance, the importance of transparency by all countries. I think the unfortunate global experience with SARS might have been entirely avoided, or at least mitigated, with earlier recognition of and effective response to the outbreak that was occurring in South China. We know that we live in a global village, and once these problems occur, we know that diseases can spread rapidly around the world. In all the years I have been responsible for infectious diseases here at CDC, the most stunning thing I have seen is the Hotel Metropole experience: the Chinese physician spending 24 hours on the ninth floor there and infecting about 16 people, which moved that virus rapidly around much of the world. These things can happen in modern society and it truly is a global village. Therefore, we have to pay attention to problems in other countries. We have to support the World Health Organization in their efforts to strengthen global surveillance and response capacity and also in their interest in encouraging governments to be transparent when they encounter problems of potential global significance.
Rather than saying what needs to be added or subtracted, let me share a few thoughts about things that need to be in place.
First, there must be effective disease surveillance, supported by modern public health laboratory capacity. The public health world needs to be closely linked to the clinical world. I do not know about Canada, but in the United States, there often remains a gulf between the world of clinical medicine and the world of public health. Emerging infections generally, antibiotic resistance and organism problems, as well as SARS, absolutely demand we focus on ways to improve the linkages and the communication between the clinical world and the public health world.
Similarly, there is a bigger gulf between human medicine and public health on the one hand and veterinary medicine and public health on the other hand. SARS is an excellent example of a zoonosis: a disease transmitted from animals to people. Many of the recent emerging infectious diseases have fallen into this zoonotic category. Therefore, it is important that we take steps to improve linkages, cooperation and communication between the human health world and the veterinary world.
It is important that we continue to work hard to improve cooperation between epidemiologists and laboratories. A recurrent theme is the important linkages that need to be developed, in some cases, or strengthened in others. A final thought is the importance of communication within a country between the local level, the state or provincial level, and the national or federal level.
Second, there is a need, when dealing with a public health emergency such as SARS, to be able to rapidly develop and frequently update new information and to make that available in usable fashion to clinicians, laboratory scientists, the public and policy-makers.
Those are some general principles. If I had gone through the prepared statement, you would have heard a little more detail about each of those themes, but I think that cuts to the bottom line.
The Chairman: I will ask a follow-up question on an issue with which we have struggled. In order to close the gaps or to put in place the linkages that are now missing, someone must be in charge. One of the difficulties that we have in the Canadian context — and you have in a different way in the United States — is that health care is delivered by provincial governments rather than the federal government. Yet, an epidemic that crosses provincial boundaries is of national and therefore federal interest.
Given all the chiefs that are found in this milieu, do you have any thoughts on what structures the U.S. can use to pull all of them together so that they are coordinated?
Dr. Hughes: That is an excellent question that is difficult to answer in these sorts of emergencies, namely, who is in charge? We have learned many lessons from our anthrax attack two years ago. In responding to that, we created a new Department of Homeland Security here in the United States. We in the Department of Health and Human Services work closely with the Department of Homeland Security. What we have done here at CDC is actually construct an emergency operations centre that allows us to be in instantaneous communication with the emergency operations centre in the Department of Health and Human Services, in Secretary Thompson's immediate office in Washington, D.C. From that centre, we can link with the Department of Homeland Security, as indicated, and to WHO in Geneva. During the early days of the SARS response, we had several video conference links with not only Secretary Thompson's command centre, but also the command centre in WHO.
Beyond that, we need to reach out to the clinical community in the United States as well as the public health community at the state and local levels. As part of our bio-terrorism preparedness, we have put in place several systems that greatly facilitate rapid dissemination of information not only to public health officials, but also to clinicians. That is using a system that we call the Health Alert Network, which is an open, Internet-based system that links all state health departments, and now most local health departments, to CDC. We have an additional system called Epi-X that has secure communication and less wide distribution, but is linked to all state public health departments. On that system, we can rapidly disseminate information of a more sensitive nature.
Using the Health Alert Network, we are also able to reach out to clinicians. We have several clinician-based sentinel surveillance networks, but beyond that, we are able to work with the American Medical Association and others to link up to members of large professional societies and provide Internet information directly to them in a timely way. This is a good example of the dual utility we have seen in some of our bio-terrorism investments here over the past few years.
The Chairman: From that, I infer that over the last few years you have put significant capital investment into communications technology. That is your way of not only being able to hook into WHO yourselves, but also allowing all the states and most of the major local governments to do so. I assume that means you have, effectively, a standby communication system that is activated quickly?
Dr. Hughes: That is right. It is as a result of bio-terrorism investments that much has been put into place.
The Chairman: One does not automatically think of this when one thinks of the health care system, but you made a significant investment in communications technology in order to be able to handle the communication side of the business.
Dr. Hughes: Yes, that is correct. To elaborate on one more point that occurs to me in this context, it does not have to be all Internet based. The WHO held daily telephone conference calls involving the laboratory network that they assembled, as well as an epidemiology network and a clinician network. Similarly, within the U.S. we had frequent telephone conference calls with our state epidemiologists, our lab directors and people involved in infection control aspects. We would not want to throw the telephone away; it was valuable as well.
Senator LeBreton: I want to follow that same line of questioning. I will use the SARS example because it is the most recent one. This follows, in Canada, from the lack of coordination between the federal government and the provinces. You stated that there were a total of 344 suspect and 74 probable cases of SARS. Would you elaborate a little on that? Are the states obligated to immediately notify the Centers for Disease Control? I would like to know the line of authority. Also, do you have to provide resources, human and financial, to assist? How would you have handled what happened in Toronto?
Dr. Hughes: Let me appear to digress slightly and make another comment that would have been in the oral testimony and that I think is important because it gets both at the federal/state relationship issue as well as the reporting issue.
In the United States, there is quite an informal network within the public health system. Back in the early 1950s, Dr. Alexander Langmuir formed the Epidemic Intelligence Service, or EIS. That is a two-year training program in applied public health epidemiology that held its first class in 1951. Part of the rationale in putting this together was the threat of biological warfare during the Korean War. It is interesting that we have come full circle here. Young people, primarily physicians, have been trained in a two-year practical public health experience for more than 50 years now. When they finished the training, the vast majority of these people elected to stay in public health. Many now work at CDC and in state and local health departments.
There is an alumni component of this group that is quite active. There is quite an informal network of people who have been working together for a long time and who know each other pretty well. I would not say that it is always smooth or that everyone is always in agreement; that is not the case. However, it is clearly an advantage for us in bridging some of the tensions between the federal, state and local levels.
In terms of your question about reporting, I am a big believer in alert clinicians who knows how to reach their counterparts, the alert public health officials, at the local or state level by telephone when something unusual happens, and then having the alert state public health officials know how to reach individuals at CDC if they think they are dealing with an unusual, complex or very challenging problem.
You hear about syndromic surveillance systems and large investments in improving our ability to monitor syndromes, which is important, but the alert clinician played a critical role in recognizing the first case in our anthrax attack, in the introduction of West Nile encephalitis into New York City and our recent experience with monkeypox. Honourable senators will know the critical role that Dr. Carlo Urbani played in Hanoi in recognizing this unusual syndrome. It is important that clinicians know how to reach their public health counterparts and that the information flows back and forth in a timely way.
In terms of what is reportable, I would take a minute or two to explain that to honourable senators, because it is important to understand how this works in the United States. Many people think that we at CDC simply determine what diseases are reportable at the national level. However, it is the umbrella organization of the state epidemiologists, called the Council of State and Territorial Epidemiologists, or CSTE, that actually makes the determination, through discussion and, hopefully, consensus-building with the membership, of what diseases are nationally reportable. Requirements for the reporting of diseases at the state level are set by local and state laws and regulations that CDC does not influence.
A month or two into SARS, once the virus was recognized and the diagnostic tests were in development, there were discussions with CSTE about making SARS nationally reportable. As a result of the discussions, there was an agreement to do that, but we obviously did not wait for that to happen before beginning to get the phone call reports going back to March 15 of the suspect or probable cases of SARS in the U.S.
Senator LeBreton: On the resources side, is CDC obligated to assist or does the state have to request funds? What is the financial status of reporting requirements?
Dr. Hughes: Back on March 14 and 15, we were not being asked for money, but before too much time went on — and you are very familiar with the incredible burden that SARS put on the clinical and the public health community — we had suspect SARS cases reported from virtually all of our states and probable cases reported from the majority of our states. There was a great deal of effort going into investigation, isolation and control strategy implementation as well as dealing with all the communication needs at the state and local level.
In our country, and in Canada, I suspect, these are the same people who are trying to deal with smallpox preparedness and are worried about pandemic influenza. It is a small group of people involved in public health aspects of infectious diseases in most state and local public health departments. They do have resource needs and we can help in several ways. One is by sending people to assist them. We only do that when invited to do so. It is often these EIS officers whom I have mentioned who go out and provide that assistance.
In addition, we provide laboratory support here once specimens come to us. We then work with the administration and with Congress to identify emergency resource needs. The good news on SARS was that there was, with the support of the administration, a supplemental Congressional appropriation to CDC of $16 million, which we used to cover many of our expenses for this investigation. Also, we were able to make awards through a standing cooperative agreement mechanism called the Epidemiology and Laboratory Capacity Program that we have with all of our states, six large cities and Puerto Rico. We have a mechanism in place so that, in an emergency, we can mobilize the funds; we can rapidly move those funds to the states and to the biggest cities. That was a real asset to us and, I believe, something for honourable senators to be aware of.
Senator Robertson: We are struggling, as you are probably aware, with designing something that will include, has to include, the provinces. The provinces have jurisdiction over our health system in Canada. I am particularly interested in structures and how we can proceed to break down the barriers that exist between so-called competing units.
CDC is under the supervision of the Secretary of Health and Human Services, I believe. What is CDC's relationship with the U.S. Surgeon General? How do these two entities interact in pursuing their missions? What was the relationship there in dealing with SARS?
Dr. Hughes: As honourable senators can perhaps see, I am wearing my public health service uniform. I am an assistant surgeon general. I am one of the flag officers, of which there are approximately 50, who relate to our Surgeon General, Richard Carmona.
The line of authority at the moment is from the Secretary of the Department of Health and Human Services, Secretary Thompson, to the Director of CDC, Dr. Julie Gerberding, and then into the institutes and offices at CDC. As the Director of the National Center for Infectious Diseases, I report to Dr. Gerberding. The second line of reporting would then be to Secretary Thompson.
There are discussions in progress with respect to the Commissioned Corps of the Public Health Service. There are efforts underway to transform that. The officers in the Commissioned Corps of the Public Health Service, as a uniform service, are available 24/7. We are ready, willing and able to respond to emergencies as they occur.
The Surgeon General, as the leader of that corps, is a primary person in these emergency response situations. Again, the line of authority comes from the secretary through the agency head to the operating units.
Senator Robertson: That is most interesting, because we have been looking at a position something like your Surgeon General. We are almost starting from scratch in many ways as far as cooperative delivery goes, and that is a big concern to us.
You talked earlier about the jurisdictional issues, such as CDC, the federal agency. Do you have any advice on how to overcome the resistance you might find to cooperation and breaking down the barriers at the state level?
Dr. Hughes: There are many barriers. This federal, state or provincial, and local one is certainly one of them. I gave honourable senators some of our older history that maybe suggests some of the reasons why the problem is not as bad here as it might be.
Both the umbrella group of state epidemiologists and another important group that I have not mentioned, the umbrella group of state public health laboratory directors, called the Association of Public Health Laboratories, have an annual meeting. We make it a point to participate both in the program and by attending their annual meetings, because those two groups do not always communicate as well as they might. We like it best when they hold a joint annual meeting, which they do every three or four years.
We try to maintain a presence at those meetings. Through the EIS program that I mentioned, many of the new EIS officers are assigned to state and local health departments. The state and big city epidemiologists come to CDC for an annual conference that we host to present scientific and public health updates of the past year. At the same time, the recruiting venue is used to determine the assignments of the EIS officers, who begin their service three months after the conference.
There is a significant amount of give and take and a certain amount of collegiality that develops as a result of these frequent opportunities to build relationships.
On the laboratory side, we have responded over the past 10 or 11 years to some of these emerging infectious disease issues by putting in place, in collaboration with the Association of Public Health Laboratories, an applied public health laboratory training program that is modeled to some extent on the EIS program that I mentioned to honourable senators. We started in 1995 with a class of about 20 people. We have been able, over the subsequent years, to expand that now to about 50 people a year. They come into this program either at the bachelor or master's level for the broader track or the smaller doctoral-degree track.
These people are assigned to work in either CDC laboratories or in state or big city public laboratories. It is another collaborative arrangement that we have with people at the state level that is focused on training. It helps us to not only develop the next generation of people that we need, but also to stay in touch with each other.
Senator Robertson: That is very helpful. I wish to switch topics here somewhat. In terms of your relationship with international agencies, you have already alluded to the World Health Organization. What lessons have you learned about the ability of the World Health Organization or other international agencies to detect and respond to outbreaks such as SARS?
Dr. Hughes: First, WHO really deserves to be commended for their outstanding leadership in responding to SARS. Once the problem came to public attention and was reported to them, they responded in a really admirable fashion, I believe, by mobilizing and dispatching teams to a number of impacted countries. We were fortunate to be able to participate as members of many of those teams.
WHO very quickly put a laboratory network together that was absolutely central to the rapid identification of this previously unrecognized corona-virus. They put a secure Internet connection in place that initially linked 11 labs in 9 countries. They then added two additional laboratories as time went on.
These labs had frequent conference calls and a secure Internet site on which they could post new laboratory information as it developed. This network was critical to the communication among the lab groups that led to the simultaneous isolation in three different laboratories of what is now known to be the SARS corona-virus.
Similarly, they put together networks of physicians and epidemiologists to discuss findings as information was developed. They also moved into emergency operations centre mode, and they had the video links about which I talked.
We help them whenever we can because they are very limited in their resources in the communicable disease area. They do a significant amount of work with a small core staff, supplemented by consultants whom they either bring to Geneva or mobilize and send into the field.
Also, they did a very good job with their Web site and with their press interactions. We were very much stretched to our limit here. I know that they were stretched even more.
Senator Cordy: Dr. Hughes, your prepared statement commented on the Laboratory Response Network. I am wondering how this works. Are you affiliated with private labs?
I am also wondering whether this is an informal partnership for times of emergencies, or whether it is a more structured relationship or partnership whereby you would communicate regularly. Could you explain this to me?
Dr. Hughes: The Laboratory Response Network dates from the year that we received the initial bio-terrorism preparedness funding at CDC. That was 1999. The network is a tiered network of laboratories around the country that are put together at three levels.
At the base of the pyramid, there are the clinical laboratories in hospitals and in free-standing laboratories. Those are the first level of laboratories where clinical specimens will be sent when a hospitalized patient has diagnostic work done for infectious diseases.
The first recognized case in the anthrax attack was the unfortunate gentleman in South Florida who presented with meningitis caused by the anthrax organism. His blood cultures and spinal fluid were sent to one of these clinical laboratories. That is where the work began that led to its referral to what at that time was still the relatively new mid- level of the Laboratory Response Network.
That mid-level is the public health laboratories, most of which are at the state level. In that case in Florida, the clinical lab got some isolates about which they were concerned and rapidly transported them to one of the Florida state public health laboratory branches, where additional work was done that suggested that this was related to anthrax.
That lab talked to us over a period of time and sent diagnostic material to Atlanta, where we were rapidly able to confirm their diagnosis. That example actually shows you how the Laboratory Response Network works.
At the mid-level, there are a little over 100 laboratories currently participating in the network. All the state public health labs are in it. A number of our big city laboratories and a number of other federal agency laboratories are in it. Some of the U.S. Department of Agriculture and Department of Defence laboratories are members of it.
I have not told you yet that at the pinnacle of the pyramid are the two national reference laboratories, the two multipurpose, bio-safety level 4 laboratories in the U.S. that are able to work on human specimens. One is the laboratory here at CDC and the other is in Fort Dietrich, Maryland, and is run by the U.S. Army. These are the three tiers.
There are thousands of clinical laboratories. We are currently in much better shape in terms of our linkages with the public health laboratories, the mid-level, than many of them are in terms of their linkages with the large number of clinical labs within their jurisdictions. I do not want to present this in any way as a fully developed system. Having said that, it has come a long way. Honourable senators will see, I hope, how it worked in regard to anthrax.
The impetus for this was bio-terrorism preparedness. These mid-level labs are equipped and trained to recognize the so-called category "A" bio-terrorism threat agents. We are working on the category "B" agents with them now.
They are linked through a secure Web site. Protocols for the testing that is indicated for these organisms are available to them.
They are able to order reagents electronically, which we are able to send to them to keep them working. It is a formal system. You have to be admitted to it and you have to jump over some hurdles to qualify.
At that mid-level and the top level, it is formal and mostly fully developed, although there is a need to expand its capacity. It was important in SARS because as we got the antibody testing and some of the molecular PCR testing, we were able to move those tests out to these public health labs — the PCR testing, in particular — into the laboratory response component. They had the modern equipment required to do real-time PCR testing. Again, that is a good example of the dual utility of these investments, but it does take money, people and commitment to make this sort of thing happen.
Senator Cordy: Following on from that, you talked about the possible cases that you had in the U.S. As you came up with a clear definition, as a result of the laboratory testing, that number dropped dramatically. You also mention in your report that prompt reporting is essential in dealing with whatever the disease is in a rapid manner. You talked about establishing the definition for the country. Is it a standard definition? One can do that more easily within a country, but one of the things that you mentioned in your report is that key among these lessons learned is the importance of strong national and international partnerships.
I am wondering about the standard definition of a disease. How do we determine internationally what actually is a disease? You can do that within your country, but do you work through the WHO, and exactly how does this come about? Certainly, if countries have different standards as to what is a disease, then we have some difficulty with people travelling and those kinds of things.
Dr. Hughes: I mentioned to honourable senators some of the history of how we worked with CSTE to make SARS reportable. Let me speak to the situation within the U.S. for a minute and then go to the broader context that you raised.
Within the U.S., from day one, we developed a suspect case definition and a probable case definition. We tried to keep those congruent with WHO definitions, but we were not 100 per cent successful.
As you move forward with the development of the laboratory testing, one of the things you want in a surveillance case definition — if at all possible, of course — is a laboratory component. It took a couple of months before we had the tests available for the states to use. We were fortunate that we developed tests for internal use much more quickly, but it took some time to get those out to the state health departments. However, when we developed the formal case definition for national reporting, it did have a laboratory component to it.
As to how to work with the WHO and others, again, it really comes down to communication. It also gives me a chance to make another point about something that worked well, I think, in the SARS response. We were fortunate from the very early moments to have a Health Canada person here in Atlanta working with us on a daily — in fact, hourly — basis. Similarly, they asked us to send a liaison person to Health Canada to work in Ottawa, which we did. That was extremely valuable in terms of staying on the same page, if you will, in terms of breaking information and cutting down on the number of surprises.
We had a person working in Geneva at the WHO on antibiotic resistance, interestingly — another important issue for us all — when the SARS outbreak began. Pretty quickly, we realized the need to have a liaison person with the WHO in Geneva, so we moved him from working on drug resistance to SARS. He related directly to our associate director for global health here, who used to work at the WHO.
Again, it comes down to nurturing some of these personal networks and ensuring that you have senior people in strategic locations to facilitate this communication and, as much as possible, keeping everyone up to date, number one; and number two, doing whatever we could to be sure that everyone was delivering a consistent message.
Senator Cordy: You talked about some of the collaborations that were strengthened during your work on SARS. Some of the agencies you mentioned were in private industry — like airline unions, for example. How do you work with private industry? It is extremely important in a national emergency.
Dr. Hughes: This is another very good, important question. We are fortunate here at CDC to have the National Institute of Occupational Safety and Health — NIOSH, we call it. It is a prominent part of CDC and has been for a number of years. It has a number of people with a lot of expertise in dealing with occupational health issues and they also have a lot of contacts with both labour and management. One of the things that you have to try to do in this kind of emergency situation is get the communication going with both labour and management. The NIOSH people were extremely helpful in doing that. As a result, we were able to have conference calls and some face-to-face meetings in order to open up these communication channels.
Obviously, these are not groups that necessarily work together on a daily basis. However, when the next global epidemic of influenza occurs, this need to relate to people involved in the transportation industry will be very apparent. Anything we can do now to set the stage for that, we should do.
Senator Fairbairn: You have given us a significant amount of information about connection and communication. To go back to the subject of SARS, what was your first point of communication or information when this was developing in China and then in Hanoi? Did you get it through the Hanoi connection, or through the WHO in Geneva?
Dr. Hughes: There is an electronic list serve system called ProMED that provides people around the world who are interested in infectious diseases with the ability to communicate, and many of us subscribe to that. There was a report on that system, back on February 10, of some unexplained respiratory illness occurring in South China, with some deaths. There was speculation about what this might be.
One of the things we always worry about — and you should, too, when you hear about unexplained respiratory illness in that part of the world — is the possible emergence of a new strain of influenza. Historically, new strains have come from there, and conditions favour their emergence.
We were concerned at that time that there might be evidence of a new strain of influenza circulating. We heard that the Chinese thought this might be due to Chlamydia pneumoniae. It did not sound like that was probably the case to us.
The next day, the Chinese government did officially report this outbreak to the WHO.
We have good, close working relationships with colleagues in Hong Kong, in part as a result of the 1997 avian influenza problem there. There were 18 cases and 6 deaths due to an unusual flu strain that had never infected people before, and we were afraid it might be the beginning of the next worldwide influenza epidemic. We assisted them and the WHO at that time in their investigation. Since that time, we have had good working relationships with them.
We were rapidly in communication with them to see if they thought that this problem in South China might be flu. Because they have excellent influenza surveillance in Hong Kong, they were evaluating respiratory illnesses in their residents and found several cases of H5N1 influenza in two members of a family who had recently returned from South China.
Again, we were concerned that this might be flu. As a result, we were able to send one of our people, along with a WHO representative, to Beijing to talk with them about whether this might be flu. Once we got on the ground there, of course, we began to hear more about what was really going on.
We really owe Dr. Urbani in Hanoi the bulk of the credit because he was reading the same information and was aware that there had been issues in South China. He saw an individual who had recently come to Hanoi from Hong Kong and was severely ill with an unexplained respiratory syndrome and he wondered whether it might be connected, which of course it was. It is good sometimes to be lucky. One of the other things we put in place in the U.S. is a series of what we call Emerging Infection Programs. We have 11 of those now based in state health departments. Several years ago, we decided to try to export that model to another country, and we picked Thailand because of a longstanding history of collaboration with the Thai Department of Health. We had a small group of people in Bangkok as part of this International Emerging Infections Program who got in touch with Dr. Urbani and were very helpful when he first arrived in Bangkok. I believe they were able to help minimize the risk of transmission of the virus in Bangkok. That group became involved in sending people to participate in several of the WHO international teams in the region.
Again, to some extent, it is part of that informal network, but we were certainly grateful to have alert people in the right places at the right time.
Senator Fairbairn: Just to get the picture clearly in my mind, when you picked up the information through your informal network, would that have been transmitted to Canada in any way?
Dr. Hughes: Could it have been transmitted to Canada? We certainly were in communication with the WHO. I would have to look back at the history of the earliest communications with Health Canada.
I will say that we have had a longstanding, close working relationship with them. Paul Gully, who is one of their senior officials, sits on our board as a scientific counsellor. We have regular communication with them. I do not know off the top of my head when the first communication from CDC to Health Canada took place.
That is a good point. We share common interests and common borders.
Senator Callbeck: Dr. Hughes, I wish to ask you a question about the management of an outbreak. The first line in outbreak management is at the local and then the state level. As I understand it, the CDC has to be asked to come in and help out. Does the CDC have any authority to go in on its own?
Dr. Hughes: In a massive, interstate kind of catastrophe, I am sure that the secretary or the director of CDC could declare an emergency and have us immediately engaged. In fact, the way it works, as you said, the problems are recognized at the local level and the state level. If they are thought to be severe or unusual beyond the capacity of the local level, or if the disease has special significance, like anthrax, they will immediately let us know. We will then offer assistance.
Depending on the nature of the problem, as honourable senators will understand, often the local and state jurisdictions rightly feel that they can handle it themselves. We get into a little negotiation with them, if you will. The ease with which we obtain our invitations varies with the gravity and nature of the problem. Suffice it to say that in a real, perceived emergency, they are generally only too happy to have us there as quickly as possible.
Senator Callbeck: Is it correct that you have never met with resistance in a serious outbreak?
Dr. Hughes: I would not go that far. The local and state jurisdictions do have trained people. Many things occur that we never hear about. That is as it should be.
Sometimes we get a problem that looks as if it has interstate implications. Then, frankly, it takes some negotiation. We can twist arms and have people call other people. In a real, perceived emergency, they are generally very happy to have us.
We would not just barge in because we would be unable to work effectively. We have to go in with their concurrence, which sometimes might be a little reluctant, but generally is reasonably enthusiastic.
Senator Callbeck: On another subject, I see that this year the budget of CDC totals $7.2 billion. Does that money come from the federal government? Does any of it come from the states? What about international organizations such as the World Health Organization? Do they contribute anything?
Dr. Hughes: The World Health Organization does not contribute to CDC except possibly very minimal amounts in the context of some of the collaborating centres that we have that support the WHO. In fact, we contribute money to WHO. I commented earlier that we recognize the problem of their limited resources, so we do try to help them to the extent that we can.
The vast majority of the CDC budget is made up of funds appropriated by Congress. However, we do have a CDC foundation that was established eight years ago that has been effective in raising money from other sources for some CDC programs that are not well supported by appropriated funds. That is a very small portion of the overall CDC budget.
To my knowledge, the states do not provide CDC with funding. We provide states with funding.
Senator Callbeck: Is a percentage of your budget spent on international cooperation with respect to health promotion and protection?
Dr. Hughes: Yes. I am not able to tell you what that percentage currently is. On that point, the roots of CDC are in an agency of the U.S. government that was in place during World War II called "malaria control in war areas." It was located in the Southeast because malaria was a problem at that time in many of the military recruit training camps down here.
It is interesting that CDC's roots are obviously in a global infectious disease that is still one of the leading killers worldwide.
From its very beginning in 1946, CDC had a commitment to dealing with international problems. For many years, though, that was not something that necessarily resonated in Washington. Although CDC has always had an international profile, presence and commitment, the funding has often not been substantial. There has, therefore, been a certain juggling act involved in keeping some of the international programs going.
However, in recent years, people have begun to appreciate the global village and the implications that problems in far away places can have for us. Therefore, I must say that both as a result of emerging infections and global microbial threats as well as the threat of bio-terrorism, the interest of the administration and Congress in supporting more international activity here at CDC is apparent. Although we do not have our budget for next year yet, there is reason to be hopeful that we will get an increase in funding to support some of our international work, which we think is very appropriate.
Senator Roche: Dr. Hughes, I want to follow up on the World Health Organization, to which senators have previously referred.
You have said that the CDC supports the World Health Organization and, for example, during the SARS epidemic, you had daily telephone conference calls with them. I think you said that from time to time, CDC contributes money to the World Health Organization.
I take it from that that there is a sort of ad hoc relationship between the CDC and the World Health Organization. I am struck by your own words in one of your concluding sentences, in which you said that the SARS experience reinforces the importance of global collaboration, global surveillance and prompt reporting that is linked to adequate and sophisticated diagnostic laboratory capacity.
It is clear from what I heard this afternoon that the CDC has a very sophisticated capacity, and I wonder if you think that the World Health Organization does not, because of its limited resources, as you said.
Is there a way in which something beyond an ad hoc relationship can be established, whether by the CDC and the World Health Organization or, I am thinking, particularly in Canada? If infectious disease is now a global problem, do we not need a strong, globally centred organization with a sophisticated capacity to deal with this?
Dr. Hughes: Yes, we do. If you visited WHO headquarters in Geneva and our headquarters here in Atlanta, you would see one obvious difference right away. WHO is in an office building. We are in office buildings that include laboratory buildings. The WHO does not have any in-house laboratory capacity. Therefore, they rely on networks of WHO collaborating centres of laboratories around the world. One example that is relevant, because its work is apparent every year, is the influenza collaborating centre network, of which there are four principle reference labs, one of which is here in Atlanta. That is the way WHO works. Rather than having the in-house laboratory capacity, they maintain relationships with laboratories that they have designated as collaborating centres.
Your National Microbiology Laboratory in Winnipeg participates as a collaborating centre in some of those laboratory networks, so you are supporting the WHO's efforts much as we do. We have a large number of WHO collaborating centre laboratory networks here, and because, as I mentioned, WHO does not have the funds, they rely on us to provide that service. Over the past few years, we have been fortunate to be able to target some of our emerging infections funding to rebuilding some of these laboratories and strengthening their capacity to support the WHO.
WHO has also established a Global Outbreak Alert and Response Network. I apologize for all the acronyms, but they refer to that as GOARN. That is a network of epidemiologists and laboratory scientists in many countries around the world, including people from the U.S. and Canada, who work very closely with them to try to track reports of infectious disease outbreaks of potentially international concern. Health Canada has been a very prominent participant in that.
Another good thing that Health Canada has done to help WHO is develop a global public health information network that is an Internet-based approach to daily scanning of news media to try to pick up local reports of infectious disease outbreaks around the world in a timely way. That was a Canadian initiative.
Senator Roche: Is there a serious influenza outbreak coming this fall and winter?
Dr. Hughes: I wish I knew. I cannot answer that for certain. That is why we have public health surveillance, and that is why we try to track influenza strains, working with this influenza network around the world.
In the U.S. so far this year, we have seen early activity in Texas, and we have seen that some of the viral isolates have drifted a little from what is in the vaccine strain. We learn more about this literally every day and we have to stay tuned to the magnitude, but it is time to get our influenza vaccine for this year. If you do not remember anything else from this, remember that.
Senator Fairbairn: Obviously, Dr. Hughes, I think it is fair to say that this situation certainly shook not just Ontario and Toronto, but also the country, and there is a lot of ongoing discussion about how to plan ahead. Would you welcome the creation of a full-blown Canadian form of a CDC in this country?
Dr. Hughes: Certainly. We value our current collaborations with colleagues in Health Canada, and we would look forward to working even more closely with them or with a new component, if that is the way you decide to go. Maybe the earlier question about when we first communicated with Health Canada is germane to that. However, we have found with these international issues over the years that it is good for us to be in communication and to have a consistent approach vis-à-vis Canada and the U.K., as well as, obviously for us, with Mexico. We will work with you regardless of how you determine to proceed.
The Chairman: To that extent, you would see pursuing greater integration or greater collaboration through the Global Public Health Intelligence Network as a critical piece of this detection process?
Dr. Hughes: Yes, through what WHO likes to refer to as a "network of networks," and there are many components. The more we can collaborate and communicate, the better.
That gives me a chance to make a final comment. One of the advantages you have over us right now is that you are fortunate to have your human disease reference laboratory and veterinary disease reference laboratory co-located in the same facility in Manitoba. You remember my comment about the human health world and the veterinary world being different. I wish we had a similar situation. I think you are better positioned than we are to deal with some of these zoonotic disease issues.
The Chairman: It is disconcerting for humans to discover that diseases that are causing trouble are coming from animals, because in a sense we are inclined to think that the vets do their thing and the doctors do theirs. I do not how you would even go about getting that kind of collaboration, because one of the gaps you talked about was that between veterinary medicine and clinical medicine, and they are usually two such totally separate worlds. Have you put in place any special processes to begin to close those gaps?
Dr. Hughes: We are trying. It is taking more time than I wish. There are public health veterinarians, people trained in public health veterinary science, and we have a number of them here at CDC. They are dispersed within our organization. There is no focal point for veterinary public health leadership here, which is critical in terms of reaching out to the broad range of professional groups. Veterinary medicine and public health is every bit as complex as human medicine and public health. There are many different areas of specialization, sub-specialization and focus. We are working to identify a senior person to come and work with us — I am not sure what we will call him, but maybe chief veterinary officer, for example — to provide leadership, because it really is a full-time job to make something like that happen, and we are not there yet.
The Chairman: As a matter of curiosity, is a veterinary public health officer trained as a doctor or a vet?
Dr. Hughes: By definition, a veterinary public health officer is trained as a vet.
The Chairman: Is the focus on animal diseases that impact on humans?
Dr. Hughes: Yes. I do not want to leave you with the impression, incidentally, that all of these emerging problems come from animals, because they certainly do not, but it does seems that the ones that have gained the most notoriety in recent years have tended to. There is a message there, telling us that we need to continue to try to get our act together better at that important interface.
The Chairman: Dr. Hughes, thank you for taking the time to be with us. It has been very helpful.
Dr. Hughes: I have enjoyed the opportunity. You have asked excellent questions. I hope I have been helpful, and if subsequent questions occur to you we can try to be responsive.
The Chairman: Honourable senators, because Dr. Hughes did not read his prepared document I need a motion to append it to the record.
Hon. Senators: Agreed.
The Chairman: Second, we will not try to go through the document tonight. Let me talk about the process here for a second and work backwards from the need to release our response to the Naylor report before what people keep telling us will be a prorogation.
The document that everyone has is a second or third draft. The steering committee went through the document before it was circulated, but people need time to read it. Can I suggest we do the following, because we would like to table it two weeks from today? Could we schedule a meeting at six o'clock next Tuesday? I would like to meet then, rather than Wednesday afternoon, because it buys us an extra 24 hours. In advance of that, if you have editorial changes, please give them to Odette and Howard.
How many people could make it to a meeting from 6:00 to 7:00? We have to find the time to get it done. That is my problem. I am not here Monday, and I am not sure if a couple of others will be back. I am not sure if Senator Morin will be back from Rome.
It could be a relatively short meeting, but could we try that at 6:00?
Senator LeBreton: The Agriculture Committee sits at six o'clock in that room.
The Chairman: Does anyone want to suggest another time? How about first thing Wednesday morning, because our national caucuses do not matter much these days?
Senator LeBreton: You have not been at ours.
The Chairman: Yours do, sorry.
Senator Fairbairn: Early Wednesday.
Senator Cordy: That is worse for me because I would like to go to the regional caucus meeting.
The Chairman: Will we leave it at our regular time, Wednesday afternoon, then?
Senator LeBreton: What did we have next Wednesday afternoon?
The Chairman: We did not have anything booked.
Senator LeBreton: Well then, we should use that space.
The Chairman: However, can we have a motion? If we want to meet on Wednesday it has to be at 3:30, even if the Senate is sitting, and we will not try to get a motion through the house.
Therefore could I have a motion that would essentially delegate to the steering committee the authority to approve the final text? That way, when we meet at 3:30 next week, it will be technically a steering committee meeting, even though we will all be there, and you can have a steering committee meeting even if the Senate is sitting. We then get around the problem of not being able to have a committee meeting when the Senate is sitting, because it is technically a steering committee meeting involving all members of the committee.
Senator Fairbairn: I have one point. You might want to contact the Agriculture Committee, because our report — we are working on one, too — was pretty much dealt with today and we might not be meeting on Tuesday.
The Chairman: Yes, but the Fisheries Committee is at the same time.
First, can I have a motion to delegate it to the steering committee, recognizing it is designed to get around the rule? Therefore, we will meet at 3:30 next week.
Hon. Senators: Agreed.
The committee adjourned.