Visit to the United States of America,
20-25 January, Principal Points Arising
1. The Committee visited a variety of institutions
in the United States between the 20 and 25 January. Members present
were Lord Haskel, Lord Oxburgh, Lord Soulsby of Swaffham Prior
and Baroness Walmsley. They were supported by the Specialist Adviser,
Professor Julius Weinberg and the Clerk, Rebecca Neal.
MONDAY 20 JANUARY
2. The Committee was accompanied by Deputy
Consul General, Steve Collier and Trade Officer Mark Borst.
3. The Committee met Dr Jeffrey Koplan,
Senior Advisor, South Eastern Center for Emerging Biological Threats
(SECEB) Dr Jyoti Somani, Dr James Steinberg, Faculty member of
the Division of Infectious Disease at Emory University, Dr Mark
Feinberg and Dr Jeffrey Dunbar, Senior Business Manager of the
Division of Infectious Disease at Emory University.
4. SECEB had recently been established to
co-ordinate and consolidate research and other activities in order
to improve the response to biological threats. It fostered links
with universities and state health departments to develop relationships
between academics and state health departments. The infrastructure
costs had been borne by Emory University.
5. In the far-ranging discussion the following
points were made:
(a) The National Institutes of Health funded
much research, including that relating to public health, and therefore
had a significant impact on the research agenda by setting funding
(b) in order to be able to address public
health threats effectively academic and public health institutions
needed to collaborate and carry out joint research;
(c) public health aspects of infectious disease
needed to be closely integrated both with clinical infectious
disease and microbiology and with the public health practice rather
than viewed as a distinct;
(d) social and political perspectives played
a significant role in establishing and the tackling of public
(e) rising debt amongst medical graduates
had impacted upon recruitment in public health as posts in this
area were less well remunerated than other medical specialities;
(f) new and more rapid diagnostic tools were
needed but no body had taken responsibility for fostering their
development. Perhaps governments should take the lead and provide
pump priming funds;
(g) constraints were being placed on medical
researchers by US data protection legislation;
(h) frequency, timeliness and quality of
disease reporting by local authorities was variable because of
the large and diverse number of paper based surveillance systems;
(i) the CDC was a purveyor and brander of
(j) there were 70-80 ID physicians in Atlanta
area; very few had laboratory management responsibility. An increasing
number of microbiology laboratories were managed by non medical
(k) there was a shortage of medical microbiologists
and laboratory technicians;
(l) many hospitals did not have on-site microbiology
laboratories but sent specimens elsewhere; for example an Atlanta
hospital used a Florida based laboratory;
(m) it could be useful to introduce public
health messages into the entertainment media. There had recently
been a story about the MMR vaccine on a popular TV show;
(n) medical students did not have significant
exposure to infectious disease medicine, with only about 10 to
20 per cent rotating through ID wards;
(o) infectious disease physicians would not
see every patient with serious infectious diseases. A consultation
with an ID physician depended on whether the lead physician called
in ID advice; and
(p) the PHLS was highly regarded by many
in the US.
Emory Vaccine Center
6. The Committee met Lillian Kim and Dr
Rama Amara and toured the purpose-built vaccine research centre
based at Emory University. The following points were raised:
(a) the centre brought together basic science,
pre-clinical and clinical science in one physical setting;
(b) there was significant value in having
a purpose built primate centre integrated with basic immunological
and applied vaccine research facilities;
(c) there was concern about the future of
vaccine development because of regulatory problems particularly
the safety requirements for new vaccines and an increasing amount
of anti-vaccine feeling in the US public.
TB Centre at Grady Hospital
7. The Committee met Dr Henry Blumberg,
an ID physician based at Emory University and an Epidemiologist
at Grady Hospital, and his colleague Dr King and went on a tour
of a TB ward. Grady was a public teaching hospital based in downtown
Atlanta with 1,000 beds.
8. The following points were made during
(a) about 25 per cent of all new TB cases
recorded in Georgia in a year (c125 cases) were diagnosed at Grady
Hospital and 35 per cent of these patients were co-infected with
(b) Grady had 50 isolation rooms, 26 of which
were respiratory isolation rooms. Ninety-nine per cent of patients
using these rooms had TB. This was probably the largest number
of isolation rooms in one hospital in the USA;
(c) it was important to have a social perspective
when treating patients with TB, most of whom were socially deprived
and often homeless. Social workers were based in the hospital
to assess patient needs. Patients with TB were often placed on
an outreach programme where they were provided with a free motel
room and food in exchange for completing anti-TB drug treatment;
(d) developing rapid diagnostic tests for
TB was important but no body was taking responsibility for this
(e) prisoners were a group of particular
concern. Although prisoners were screened on entering prison many
would not be there long enough to complete treatment, leaving
them infected and contributing to antibiotic resistance. Holding
jails did not screen inmates at all;
(f) there were some concerns about the lack
of infectious disease training for doctors, with very few general
medical students rotating onto TB wards. ID physicians only completed
one month of microbiology training;
(g) ID physicians did not necessarily see
all patients with TB. General physicians might and often did treat
simple cases themselves. At Grady a nurse saw all patients prior
to discharge in order to confirm that patients did not have TB
and that they had been correctly treated.
TUESDAY 21 JANUARY
Centers for Disease Control and Prevention (CDC)
9. The Committee was accompanied by Steve
Collier and Mark Borst.
10. The Committee met Dr Ken Castro, Dr
Nancy Cox, Mr Rob Cox, Dr Julie Gerberding, Dr Jim Hughes, Mr
Dennis McDowell, Dr Dixie Snider, Dr Dan Sosin, Ms Cathy Spruill,
Dr Steve Ostroff, Mr Tom O'Toole, Ms Kathryn O'Toole, Ms Wanda
Walton, Dr Charles Wells and Dr Melinda Wharton.
11. The Committee heard that the CDC was
a federal organisation based in the Department of Health and Human
Services. CDC had responsibility for developing and applying methods
of disease prevention and control. Much of the CDC's current surveillance
activity was driven by its response to the Institute of Medicine's
report, Emerging Infection, published in 1992.
12. CDC had an estimated $600 million annual
research budget. Some of this was earmarked research funding and
some was carved out of core funds.
13. The following points were made during
presentations and discussion.
Importance of collaborative work
(a) Effective infectious disease control
services required clinicians to understand about and work closely
with experts in public health.
(b) There should be strong links both between
laboratory scientists and epidemiologists and between experts
in human and animal infection.
(c) Surveillance should be linked to the
response capacity rather than operating in isolation.
(d) There was a need in the United States
to rebuild links between local, state and national surveillance.
This relationship had declined as a result of under-investment.
(e) The importance of collaborative work
had been highlighted by the recent emergence of West Nile virus
(i) this disease could perhaps have been
identified earlier had there been better communication between
the veterinarians and those with responsibility for human health;
(ii) there had been a significant number
of agencies involved in attempting to control the spread of West
Nile virus, creating uncertainty about which should take the lead;
(iii) counties, rather than federal or
state organisations, were responsible for deciding whether or
not to spray anti-insecticides, potentially leading to different
policies about spraying across the US.
Emerging threats and bioterrorism
(a) Systems that would enable the USA to
respond to bioterrorism effectively would also contribute to routine
public health activities ("dual use").
(b) Attention needed to be paid to developing
surge capacity in case of a sudden outbreak. For example there
was a shortage of entomologists (experts in insects) who were
crucial to providing expertise in cases of insect-borne disease.
(c) The CDC was fortunate with recent events
in having been able to call on extra support in academic departments
and the Department of Defense.
(d) The H5N1 influenza outbreak in Hong Kong
had revealed the lack of pandemic preparedness. In particular:
(i) effective response to a `flu pandemic
would require rapid characterisation of the virus and pilot production
and subsequent scaling up to industrial production of a vaccine;
(ii) despite developing candidate vaccines
and pilot lots there was limited global production capacity with
only two manufacturers in the US;
(iii) it would take four to nine months
to produce a vaccine and current global travel patterns could
mean that any epidemic were well established within this time.
Even current capacity of vaccine production would be inadequate
for the demand;
(iv) it was necessary to consider how
anti-viral treatment should be used in a `flu pandemic. Anti-virals
were expensive to produce and would have to be stockpiled;
(v) it would be necessary to have international
co-ordination of distributing both vaccines and anti-virals;
(vi) it was important to improve the
timeliness of recognising an epidemic. As there were concerns
that a `flu pandemic could develop in China, the WHO, with the
support of CDC and others, were helping the Chinese to develop
`flu surveillance systems.
(e) The UK was one of the few countries to
have had a formal national pandemic response plan at the time
of the H5N1 influenza outbreak.
(a) The CDC had an Epidemic Intelligence
Service (EIS), which required two years of formal training in
field epidemiology and attracted people from a variety of backgrounds
with different skill sets, including vets, physicians, PhD epidemiologists
and public health nurses.
(b) The EIS helped to create strong relationships
within the alumni who went into a variety of roles in the public
health and academic sectors across the USA. EIS Officers played
significant roles in preventing disease epidemics.
Information Technology and management
(a) The CDC was currently developing systems
for more effective information management, including capturing
data from within clinical settings. In particular, they were considering
possible uses of hand-held computerised devices.
(i) tap routine data wherever possible;
(ii) use both formal and informal sources
of data for example routine data as well as word of mouth, newspaper
(iii) collect only what was needed and
would be used;
(iv) have a single rather than multiple
input whenever possible.
(c) Whilst not all data required personal
identifiers some did in order to carry out effective disease control.
This was now difficult given data protection legislation.
(a) More press officers were currently being
appointed by the CDC in order to disseminate public health messages.
It was also currently training scientists in communication skills.
(b) The CDC was appointing communication
experts to run focus groups in order to establish public concerns.
(c) The CDC worked hard to build relationships
with the legislature through regular briefings about developments
in public health and medical science.
(d) It was viewed important to have a well-informed
media so the CDC carried out training for journalists.
(a) It was important to harmonise advice
about vaccine schedules and side effects from authoritative bodies
in order to avoid confusion in the physician community and panic
in the general public.
(b) The US had a no-fault compensation scheme
for recognised side-effects from vaccines. However this scheme
covered very few side-effects. There was on-going discussion as
to whether the burden of proof should be lessened.
14. Communicable disease was a global phenomenon
and therefore attempts to control it must also have an international
(a) In 1999 CDC was authorised by Congress
to engage in an international effort against tuberculosis and
there were now funding streams for people working abroad.
(b) TB provided a good example of the need
for an international perspective with a large proportion of people
in the US with TB being foreign born. One seventh of all new drug-resistant
TB cases in the US were from Latvia.
WEDNESDAY 22 JANUARY
15. The Committee was accompanied by Mr
Chris Pook, First Secretary (Science and Technology).
16. The Committee met Dr Eve Slater, Assistant
Secretary for Health and Head of Office of Public Health and Science,
part of the Health and Human Services Department, Adm. Ken Moritsugu,
Deputy Surgeon General, Bruce Gellin, Director of National Vaccines
Program and Frank Patzman, Office of the Assistant Secretary for
17. The following points were raised in
(a) The Health and Human Services Department
had recently been reorganised so that the heads of the National
Institutes of Health, Centers for Disease Control and the Food
and Drug Administration all reported directly to the Secretary.
(b) A key concern was integration between
federal and state activity and communicating federal priorities
to the states. One way in which this had been tackled was through
publishing public health targets (467) in Healthy People 2010.
These had been identified in consultation with states and federal
agencies. It was to be hoped that this would raise the profile
of public health.
(c) Information gathering needed to be improved
with the main barrier to improvement being shortage of resources.
(d) Data protection legislation had prevented
some public health research being carried out. The US intends
to introduce legislation to simplify data protection law.
(e) Whilst data could be made anonymous with
unique identifiers in some cases there would still be difficulty
with deductive disclosure, for example rare conditions in rural
THURSDAY 23 JANUARY
This meeting focused on the National Institute
of Allergy and Infectious Diseases (NIAID) tuberculosis and West
Nile virus research programs. NIAID is a component of the National
Institutes of Health (NIH).
18. The Committee was accompanied by Chris
Pook. The Committee met Dr John La Montagne, Deputy Director of
NIAID, Dr Caroline Heilman, Director of the Division of Microbiology
and Infectious Diseases, NIAID, Dr Christine Sizemore, NIAID's
Tuberculosis Program Officer and Dr James Meegan, NIAID's West
Nile Virus Program Officer.
19. NIAID supports a broad tuberculosis
research portfolio, which encompasses prevention and treatment
efforts. NIAID also supports research endeavours to address the
diagnosis and, prevention and treatment of West Nile virus. Issues
(a) NIAID's research program encompasses
infectious, immunological, and allergic diseases. NIAID's overall
budget for 2003 is the second largest among the institutes and
centers that comprise the NIH. Eighty-five per cent of the Institute's
budget goes to outside researchers through a combination of grants
and cooperative mechanisms, including contracts;
(b) research priorities are set through meetings
with the White House and Congress, scientists, the research community,
and other institutions, such as the Institute of Medicine;
(c) infectious diseases have a significant
economic impact and a global nature;
(d) the NIAID has a number of different mechanisms
for funding research. Of particular interest is the Small Business
Innovation Research (SBIR) program, which attempts to stimulate
research that may not otherwise be carried out because of its
unprofitable nature. Businesses were allowed to retain intellectual
property rights but were obliged to make every effort to deliver
a product to the market; and
(e) areas that need to be stimulated include
computer and mathematical modelling of infectious diseases, molecular
and genetic epidemiology and information technology.
Institute of Medicine
20. The Committee met Dr Rose Martinez,
Director of Health Promotion and Disease Prevention, Dr Mark Smolenski
and Stacy Knobles.
21. The Institute of Medicine aimed to influence
federal agencies rather than individual health professionals.
It was independent of government and the majority of its money
derived from contracts from agencies.
22. The following points were raised in
(a) the IoM would publish in March 2003 a
consensus follow-up review to its 1992 report, entitled Emerging
Infections: Microbial Threats to Human Health in the United States.
This would include examining the benefits of and concerns about
(b) it was difficult to standardise state-to-state
data exchange which led to variations in the nature and accuracy
of reporting. There was not a standardised system for reporting
(c) state public health laboratories generally
had effective relationships with CDC;
(d) research and development of rapid diagnostics
was an area of concern with no body taking responsibility for
this. Also these tests were often expensive; and
(e) there was a shortage of ID physicians
and insufficient ID training for physicians and there was concern
about the low numbers of microbiologists and entomologists.
Infectious Disease Society of America
23. The Committee met Dr John Bartlett,
Dr Henry Masur, Dr Thomas Quinn and Dr Mike Scheld of the Infectious
Disease Society of America. The following points were raised:
(a) the relationship between federal government,
the states, the CDC and other relevant organisations was key in
the fight against infectious disease but had improved recently.
This was particularly relevant for developing new antiobiotics
to deal with resistant microorganisms;
(b) the Government needed to make a clear
commitment to fighting infectious disease and attempt to stimulate
applications to become public health and infectious disease physicians.
These were both relatively low paid specialities and therefore
had traditionally had difficulties in recruiting;
(c) it was important to have one body taking
the lead in pushing the public health and infectious disease agenda;
(d) the majority of laboratories in the US
were not run by medical microbiologists but by PhD scientists.
Most laboratories are run by pathologists who often have little
knowledge of or interest in microbiology; and
(e) development of vaccines might be stimulated
by extending length of patents. However some issues could not
be solved by patent extension. These include the negative image
of vaccines by the public, low profits in vaccines and concerns
24. The Committee was accompanied by Leslie
Slocum, British Consulate.
25. The Committee met for dinner at the
residence of the Consul General, Sir Thomas and Lady Harris, Mr
Gordon Cameron, President, Acambis Inc.; Dr. Thomas Frieden, Commissioner
New York City Department of Health and Mental Hygiene; Dr Michael
Garvey, The Bobst Hospital, Animal Medical Center; Dr Luis Montaner,
Wistar Institute; Alice Pomponio, Vice-Consul, British Consulate-General,
Boston; Dr Lee Reichman, New Jersey Medical School National Tuberculosis
Center; Dr Stephen C Schoenbaum The Commonwealth Fund and Mr Mark
Sinclair, Consul, British Consulate-General, Boston.
26. A wide variety of issues were discussed
including collaboration between state and federal organisations,
international collaboration, vaccine development and control of
FRIDAY 24 JANUARY
New York City Department of Health and Mental
27. The Committee met Dr Marcelle Layton,
Assistant Commissioner for the Communicable Disease Programme,
Dr Sonal Munsiff, Director of New York City TB Control Program.
Tuberculosis in New York
(a) New York City had a programme to identify
individuals with latent TB. Physicians were required to report
TB and, if the Department requested, had to provide information
about those patients. The 1993 City Health Code allowed New York
City to involuntarily detain individuals in a hospital if they
were suspected of being infected with TB in order to prevent transmission.
It could not force individuals to take treatment;
(b) this programme was costly. It had however
proved to be very successful with rates of TB dropping to 20 per
cent of the 1993 figure. 1,000 individuals were currently on treatment
with only seven incarcerated;
(c) New York City and New York State had
needed to work closely together to implement and carry out the
(d) New York City carried out a significant
amount of Directly Observed Therapy (DOT). DOT increased from
30 per cent to 70 per cent of individuals with TB in NYC. NYC
also ran a TB shelter for men where patients could live during
(e) about half of all DOT was carried out
in the field rather than in clinics. Non-medics had been appointed
as outreach workers, each looking after 10 patients;
(f) there were significant side-effects to
treatments given for multi-drug resistant TB; and
(g) ideally there would be more outreach
workers and hospitals would provide clinic services rather than
admitting people with TB.
West Nile virus encephalitis
(a) patients had presented with peculiar
symptoms in the Queens area of New York. When the Department had
been informed they carried out extensive interviews with patients
and families, concluded that it could be a mosquito borne disease
and sent an entomologist to Queens;
(b) the response to this emerging disease
required significant co-ordination with the Sanitation Department,
which was responsible for spraying anti-mosquito agents and clearing
tyre dumps, which were a breeding ground for mosquitoes;
(c) there was a need for effective sharing
of information between those responsible for human health and
the veterinary authorities; Birds had been dying of strange illness
for three months prior to human infection with West Nile but this
was only investigated after human infection;
(d) preventative measures should be based
on surveillance of mosquito and bird populations rather than on
human surveillance; and
(e) the Department had been very pro-active
about informing the public as soon as it had been established
that the illness was mosquito-borne.
Model TB Center, Harlem Hospital
28. The Committee met Dr Wafaa El-Sadr,
Chief of Infectious Disease; Dr Paul Colson, Program director;
Dr Cyrus Badshah, Medical Director; Ms Linda Smith, Head Nurse;
Mr Bill Bower, Head of Education and Training; Mr Kenneth Holley,
Health Educator; Mr Mark Torres, Senior Health Educator.
(a) This was one of three model TB centres
in the US, the others being based in New Jersey and San Francisco.
It aimed to develop innovative ways of treating TB, education
and training health professionals, patients and the public.
(b) Harlem had historically a large incidence
of TB and significant numbers of patients who did not complete
(c) Aims of the Center were to:
(i) improve treatment completion rates;
(ii) manage latent as well as active
(iii) reach out to new patient populations
and develop relationships with new professional partners such
as community physicians, international medical graduates working
in Harlem and traditional healers;
(iv) conduct behavioural studies;
(d) in order for DOT programmes to work,
patients needed lots of support from staff and therefore the Center
had developed a "surrogate family" model of treatment.
This was clinic based; patients could drop in and "hang out"
in clinics. There was a sense of family with staff and patients
developing close relationships through regular contact. Group
incentives were also employed, such as celebrating birthdays and
public holidays together;
(e) more work needed to be carried out on
how to identify patients who were infected with both TB and HIV;
(f) there was an extensive community outreach
programme with workers attending street fairs, local churches;
(g) the Center was keen to employ peer workers
from within the community. There were staff, both who worked in
the center and in an outreach capacity, who had originally been
patients. This provided them with a useful insight into the difficulties
of completing often unpleasant and long courses of treatment;
(h) patients who attended the clinic for
DOT were provided with food vouchers and travelcards; and
(i) treating and identifying latent TB in
illegal immigrants provided a challenge as these individuals were
often very fearful of institutions.