I ask further unanimous consent that all witnesses be permitted to include their written statements in the record. And without objection, so ordered.

At this time, we will recognize our first panel. We have two panels. Our first panel is Dr. David W. Fleming, Deputy Director for Public Health Science, Centers for Disease Control and Prevention; and Dr. David Tornberg, Deputy Assistant Secretary of Defense for Clinical and Program Policy, Department of Defense.

Gentlemen, as you know, we swear in our witnesses, all our witnesses. If you would stand, raise your right hands, and then we will take your testimony.

[Witnesses sworn.]

Mr. SHAYS. Note for the record that both our witnesses have responded in the affirmative.

I should have asked, is there anyone else that might help you respond that might have to say something publicly? If so, we will swear them in.

We will start with you, Dr. Fleming, and then we will go to you Dr. Tornberg.

Let me just tell you what we do. We do a 5-minute, and then we roll it over for the next 5 minutes. Stop sometime between the first 5 minutes and the second 5 minutes. Please don't go over the second 5-minute.

I've never figured out what would happen if you did.
Dr. FLEMING. I don't want to be the first. Thank you.

Mr. SHAYS. I'm using a little poetic license. It's happened once or twice.

OK.

STATEMENTS OF DAVID FLEMING, M.D., DEPUTY DIRECTOR FOR PUBLIC HEALTH SCIENCE, CENTERS FOR DISEASE CONTROL AND PREVENTION, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES; AND DAVID TORNBERG, M.D., M.P.H., DEPUTY ASSISTANT SECRETARY, HEALTH AFFAIRS, U.S. DEPARTMENT OF DEFENSE

Dr. FLEMING. Mr. Chairman, members of the subcommittee, I'm Dr. David Fleming. I'm the Deputy Director of CDC for Public Health Science. Good afternoon. On behalf of CDC, thank you for inviting us here today. We very much appreciate your leadership and attention to the issue of public health surveillance.

You know, this weekend when I was preparing my testimony, my 10-year-old asked me what I was doing. And when I told her I was working on a talk about public health surveillance, she said, Wow, I didn't know anybody was interested in that. And, you know, she had a point. Public health surveillance isn't an issue that most people know they should care about; and for that reason, we doubly appreciate your interest in this issue. And in some ways it's funny. Mr. SHAYS. Given her great insight, would you give her full name for the record.

Dr. FLEMING. Sure. Absolutely. Her name is Whitney Lynn Fleming.

Mr. SHAYS. Well, she gets it.

And it's funny, because I think all of us would be fairly concerned if we walked into our personal doctor's office and he or she suddenly started treating us without taking a history or without doing a physical or without doing any diagnostic testing.

For public health, our patient isn't a person, it's the community. And just as clinicians need to know about blood pressure and about blood chemistries to diagnose the patients, public health practitioners must have the eyes and the ears and the tools to get the information that's needed to diagnose what's going on in their communities.

Although the range of information that's needed to monitor community health is broad, today we are focusing on one piece, the piece that's needed to respond to a biologic threat in a community, to detect an epidemic or a bioterrorist event. And the problem here is that in the early phases of an outbreak, affected people don't turn to public health because no one realizes there is an epidemic. Rather, one by one, affected people seek health care for their symptoms. And to overcome this problem requires a system that, first, recognizes and diagnoses cases as they occur; second, transfers information about those cases to the public health system, where, third, it's analyzed, investigated, and acted on.

Now, in this country this critical function is performed by our reportable disease surveillance system. Every physician, every laboratory in this country is required to report specific diseases and conditions to their public health authorities. And, you know, remarkably this system generally works. Thousands of disease reports are initiated each day and investigated each day, resulting in the detection of routine and exotic epidemics.

This is the system that identified the anthrax attacks, and odds are it's the system that will identify the next bioterrorist attack on this country. Is it perfect? No. It is the best in the world. But not all reports are complete, not all are timely, and not all are appropriately acted on. It is, however, the core of our detection capacity, and it is the one to work on to make us more prepared.

And there is good news here. The bioterrorism resources recently appropriated for building public health capacity have strengthened the system through a wide range of activities, such as increased provider training, improved laboratory diagnostic capacity throughout the country, better linkages between the clinical system and the public health system, and improved public health department 24/7 ability to receive and investigate reports. And these investments are paying off. Our remarkable success in detecting and responding to West Nile last summer and SARS right now are good examples.

In addition to these general improvements, let me just mention three specific enhancements that we are working on, and all of them capitalize on the fact that we are at a critical moment of opportunity regarding the use of information technology.

First, our current system emphasizes that providers recognize an event so that they can report it. In today's electronic age, there is a new potential that some of you have already alluded to, to use preexisting electronic data bases like nurse call lines or pharmacy records to check for clustering of events that might indicate an un

syndromic surveillance, and it can supplement our existing disease reporting system. It holds promise for potentially detecting some kinds of events sooner and for providing a richer set of information to monitor and respond to any recognized problem.

Second, we are working to improve the transfer of information from providers to public health. Though our National Electronic Disease Surveillance System [NEDSS], program, CDC is moving to move reporting from a paper system to an electronic system by establishing secure connectivity, by agreeing on those critical data standards, and by developing public health expertise that is necessary to make this system work.

And, third, we are working on our ability to integrate real-time information from a wide range of sources. You know, our detection methods have to be sensitive, but the price for that is the potential for false alarms. Creating the capacity to rapidly look across a range of inputs to see if one is confirmed by the others is an increasingly critical capacity. And the scope and speed with which a bioterror event could evolve also puts a premium on our ability to monitor the emergence of an epidemic and the response capacities that are needed to fight it.

I know the committee is also interested in surveillance at the international level. Let me just quickly say that the detection and tracking of SARS is an example of the international system working right, particularly given the resources that are available in most of the affected countries, and particularly given the fact that the very basics that we are beginning to take for granted here, like laboratory diagnostic capacity and personnel trained in case investigation and response are the rate-limiting need in most of the developing world.

So, in conclusion, public health surveillance is as critical to public health as clinical information and diagnostic testing is to the practicing physician. The basic elements of our system to detect a bioterrorist event are operational and increasingly robust as a result of the recent investments that we have made. More can be done, however. In particular, enhancements with a strong information technology component, accessing existing electronic data bases, facilitating electronic reporting, and improving our ability to rapidly analyze a wide range of information sources, once only dreams, are now possible. The challenge now is to make them a reality.

Thank you very much. And I would be happy to answer questions.

Mr. SHAYS. Thank you, Dr. Fleming.

Testimony

Before the Committee on Government Reform,
Subcommittee on National Security, Emerging
Threats, and International Relations,
United States House of Representatives

CDC's Public Health
Surveillance Activities

Statement of

David Fleming, MD

Deputy Director for Public Health Science.
Centers for Disease Control and Prevention
Department of Health and Human Services

CDC

SAFER. HEALTHIER⚫ PEOPLE

Good morning, Mr. Chairman and Members of the Subcommittee. I am Dr. David Fleming, MD, Deputy Director for Public Health Science at the Centers for Disease Control and Prevention (CDC). Thank you for the opportunity to update you on CDC's public health surveillance activities. I will describe the function of our current surveillance systems, update you on recent efforts to build surveillance capacity in state and local health departments, and discuss the status of our global disease surveillance activities.

As the nation's disease prevention and control agency, CDC has the responsibility on behalf of the Department of Health and Human Services (HHS) to provide national and international leadership in the public health and medical communities to detect, diagnose, respond to, and prevent illnesses, including those that occur as a result of a deliberate release of biological agents. This task is an integral part of CDC's overall mission to monitor and protect the health of the U.S. population. The ongoing response to the outbreak of Severe Acute Respiratory Syndrome (SARS) demonstrates the crucial importance of watchfulness to detect problems and control the spread of disease.

Public health surveillance is the ongoing collection, analysis and dissemination of public health data related to disease and injury. It is a crucial monitoring function for CDC and its partners, both domestically and internationally. These ongoing data collection and analysis activities help us detect threats to the health of the public. Without our public health surveillance systems, we might not identify outbreaks or other important problems in time to prevent the further spread of disease. We cannot investigate problems, identify their causes, and implement control measures if we have not detected them. Recent events, including the SARS outbreak, have underscored this essential role of public health surveillance. For most of our surveillance data, the initial source of information is provided by health care professionals; a physician's ability to recognize, for example, a suspected case of SARS and his or her responsibility for reporting it to the state

CDC's Public Health Surveillance Activities

May 5, 2003