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Be prepared, be very prepared, says Centers for Disease Control chief

– The woman at the center of the nation's response to severe acute respiratory syndrome (SARS), not to mention anthrax and other bioterrorism agents, stepped out of the limelight on Tuesday to talk to an overflow crowd at UC Berkeley's School of Public Health.

Julie Gerberding, director of the national Centers for Disease Control and Prevention (CDC)

Julie Gerberding, director of the national Centers for Disease Control and Prevention (CDC) and a 1990 MPH graduate, flew in for the day to receive the school's Alumna of the Year Award. After two days of testimony before Congress, she seemed relaxed in front of the audience in a Warren Hall lecture room she had last seen as a student.

"The last time I was in this room I was in jeans and Birkenstocks," she quipped.

Stephen Shortell, dean of the School of Public Health, presented her with a crystal bear and an orange Cal T-shirt — an allusion to her talk, "Beyond Orange Alert" —that she promised to hang above her desk at the CDC in Atlanta.

"She (Gerberding) told me that this colloquium is one of the most important things she wanted to do this year," Shortell said. "The fact that she is coming to UC Berkeley, despite her intensely busy schedule, shows her commitment to the school and university."

Though revealing little new information about SARS, Gerberding did lay out her plans to improve the CDC's emergency response, learning from the agency's experience with the 2001 anthrax scare and bioterrorism how to better deal with public health crises.

While acknowledging the importance of SARS and bioterrorism, she emphasized that these are just two of many health issues the CDC focuses on. She pointed out that chronic health problems, in particular obesity, are the country's major threats.

Because of the serious nature of chronic illness, the Department of Health and Human Services will launch next week a "steps to a healthier U.S." initiative, plowing $120 million into chronic disease prevention of obesity, diabetes and asthma.

"That's more than we've ever, ever gotten for chronic diseases," said Gerberding. Gerberding's tenure at the CDC, which she first joined in 1998 after leaving UC San Francisco and San Francisco General Hospital, has, in many respects, been a trial by fire.

Before her appointment as director, Gerberding was head of one of the CDC's 12 divisions, the National Center for Infectious Diseases, where she played a major role in leading the CDC's response to the anthrax bioterrorism events of 2001 and 2002.

Then, shortly after her appointment as director in July 2002, birds began dropping dead throughout the South, heralding the arrival of a disease new to the U.S. — West Nile virus. As humans began to catch the disease through mosquitoes, she saw her own husband come down with a mild case, contracted in their own backyard.

As the virus spread throughout the summer and fall, she began preparing for mass vaccinations against a feared smallpox terrorist attack. With much revision of her initial plans, the CDC finally began offering a vaccine to health care workers and emergency responders, only to have a large number of people, and even entire states, balk at the risk. She had to halt the program briefly when several people died of heart attacks after being vaccinated.

Then, on March 15, the CDC went to the media and the public with warnings about an unusual flu-like illness spreading through Asia and, via travelers, reaching into America and Europe. Despite unprecedented response from the World Health Organization (WHO), the number of cases worldwide continues to rise, with an estimated 148 cases in the United States as of April 8. Gerberding revealed Wednesday that the first health care worker in the United States has come down with probable SARS, a not unexpected development, since health care workers have been among the hardest hit in China, Hong Kong and Vietnam.

"I don't know where we are with the SARS epidemic," Geberding admitted. "The picture in the U.S. is promising in that we have had very little secondary infection, but we may just be lucky. We have to be very vigilant about this."

Vigilance and preparedness were her themes on Tuesday evening, as she warned Californians, for example, to "pay attention to West Nile virus; it's moving West." Three dead birds reported from Louisiana this week shows that the virus is still around.

"We need to think in the context of a public health security system to mobilize the existing health care system," much the way the Department of Homeland Security plans to approach terrorism. "Other problems are imperiling homeland security and need the same amount of investment," she urged.

Such funding by the federal government would help the CDC prepare for general health emergencies, whether bioterrorism or emerging infections.

Gerberding is already making progress. The CDC completed its first-ever emergency operations center (EOC) on March 14, the day before it activated the center and put out an emergency health alert about SARS. The EOC has been instrumental in coordinating response to SARS, with the help of CDC staff on the ground in Hanoi and Guangdong Province in China, scouring case records and interviewing virologists about the mysterious flu-like disease that originated there late last year.

"We don't know the whole situation in China, but we're concerned about it being more widespread than they report," she said. "There are reports (of illness) from other provinces, even though cases are decreasing in Guangdong itself. If it is spreading, we will be in for a very long race."

In this country, the CDC's efforts are "proving to be amazingly effective," she said. More than 300,000 health alerts have been handed out to travelers arriving at airports and other entry points, cautioning them to be aware of SARS symptoms — fever, mild respiratory symptoms, dry cough or trouble breathing — and to see a doctor if any appear.

The WHO also has sprung into action, she said, issuing advice to countries involved. The biggest challenge, though, is one Canada has dealt with admirably but other countries have fallen short on —screening passengers before they board an airplane.

As the world watches and hopes the spread is slowing, the CDC is working full-time with researchers to pin down the cause. It has called a meeting of virus experts next week to reach a consensus about whether a coronavirus can be confidently identified as the cause of SARS, thereby triggering a full-court press to develop a vaccine. New techniques based on PCR (polymerase chain reaction) are under development to allow quick detection of the virus, as are other tests to detect antibodies showing a person has been infected.

"There's a peculiar phenomenon with SARS: not all people transmit the disease efficiently, and it appears that some people are particularly infectious," she said, referring to the so-called "superspreaders." "Plus we don't understand transmission — there is more than aerosol transmission, possibly environmental transmission."

She said that, so far, there is no evidence for spread via insects or other animals.

Although Gerberding said SARS "is taking a lot of our energy and attention," bioterrorism and questions surrounding smallpox vaccinations continue to dog her and the CDC. One member of the audience challenged her about the diversion of scarce public health funds to deal with the perceived bioterrorism threat. While expressing her concern that state public health agencies were strapped for funds even before bioterrorism became a major national issue, she denied that CDC funds have been diverted from other projects. Last year she said, Congress actually appropriated extra funds to help states deal with bioterrorism preparedness and added an extra $240 million to the CDC budget for intramural programs. This will continue in future budgets, she said.

Regarding chronic illness, Gerberding noted that obesity is approaching tobacco as the top risk factor for disease in this country, with 21 percent of all Americans labeled as obese. Obesity is defined by the CDC as a body-mass index (ratio of weight to square of height, measured in kilograms per square meter) over 30.

"Some people have said that is a really bad definition of obesity, that by that definition, Arnold Schwarzenegger would be obese," she said. "That's probably true, but open your eyes in a public area, and you can see we have a problem.

"As far as I'm concerned, if asked to identify the two most important health issues in the country today, I would say obesity and the consequences of obesity. While we are very concerned about where the SARS epidemic is going to take us, we are very aware of these other priorities for CDC."

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