I think he makes a very good point that the restrictive provisions of the Medicare and Medicaid legislation now pending in the Senate Finance Committee will have an adverse and retrogressive effect, and I assure him that as far as I am concerned, I am opposed to that.

I would like to ask Dr. Solomon this question. Do you feel that you had any lack of authority under Maryland law? Were you lacking any legal tool that could have been given to you by the State of Maryland which would have been helpful in dealing with this particular case?

Dr. SOLOMON. I can't really say that I was but I would have the reservation that at the public hearings we will really develop what happened and who has the authority-the city, State, what is the delegation of authority here. You see, the primary responsibility for inspection of food and this sort of thing falls with the city health department, not the State health department. So in answer to your question I would really want to wait until the public hearing fully developed this.

Senator MATHIAS. Let me ask Dr. Garber, do you feel the State of Maryland and the city of Baltimore gave you all the tools you needed to deal with a situation of this sort?

Dr. GARBER. I think, Senator Mathias, that my part in dealing with this problem was investigating the communicable disease aspects of it. I would say that the State of Maryland regulations dealing with communicable diseases may be slightly lacking as Dr. Tayback has mentioned. We are reviewing these regulations to tighten them up with regard to reporting. However, in this particular instance once we get on the scene and once the outbreaks are reported, we are lacking in no specific legal requirements.

Senator MATHIAS. Will you make that review, however, prior to the next legislative session in Maryland?

Dr. GARBER. Senator Mathias, we started that review as a matter of fact 9 months ago. I have been in my current position a little over a year and in the last 9 months we have begun a review of the regulations.

I would also mention to you, too, that in the previous 6 months we have been working on a notification system for the reporting of foodborne diseases. We hope this will unscramble the real maze that exists in the reporting of foodborne outbreaks between the Federal, State, and city jurisdictions. There is an overlap. There are problems in communication that we are trying to work out on a local level, sir. Senator MATHIAS. This kind of bureaucratic overlap and inefficiency is one of the causes of this very hearing today. It must be rooted out and exposed. Every level of government must be given a chance to eradicate it.

Dr. GARBER. I would say that in this particular investigation the cooperation exhibited by all the Federal agencies, not only the Center for Disease Control but also the FDA and the USDA as well as our Department of Mental Health and Hygiene and City Health Department to my way of thinking has been outstanding and exceptional. Senator MATHIAS. One final question, Mr. Chairman, one of interest to the whole community of Baltimore. The investigators doing the investigation of the tragedy at the Gould nursing home are reported to have said that they were unable to detect traces of chlorine in the water supply. Dr. Solomon, what was the source of water there?

Dr. SOLOMON. I beg your pardon?

Senator MATHIAS. What was the source of water at the Gould nursing home?

Dr. SOLOMON. It was the city water supply.

Senator MATHIAS. Is it true that the investigators made such a report?

Dr. SOLOMON. Yes. The city investigators did say that they could not find a trace amount, residual amounts of chlorine in that area. Senator MATHIAS. Is that a public health concern?

Dr. SOLOMON. Well, it is a public health concern. Yes, it is. I have asked the city health department whose jurisdiction this falls under to look into this and report to us on this.

Senator MATHIAS. Could this jeopardize not only the patients at the Gould nursing home but anyone in that particular area serviced by the water system?

Dr. SOLOMON. Now you have to be very careful when you try to translate what does it mean to have a residual amount of chlorine in the water to disease potential. This is not an easy relationship.

Senator MATHIAS. But you have taken this up with the city health department. Has the department reported back to you?

Dr. SOLOMON. They are looking into this. We will have this developed fully.

Senator MATHIAS. Will you supply the committee with the report of action on it? *

Senator Moss. Thank you, Senator Mathias.

Thank you, gentlemen. We have kept you here at the table a long time and have asked many questions. We appreciate your response. I have some more questions but I think I will forgo them because we have other witnesses that we must hear. We do appreciate your coming to testify before us.

Thank you very much.

My questions will have to be rather rhetorical. I have wondered why so many died in this salmonella outbreak in the Gould home when the usual incidence is 1 in 500. I wondered why this sign of "No Visitors" was up and yet no one at the nursing home had made any kind of report, whether the registered nurse was available that would do that. I wonder if the apathy that was mentioned in the testimony would have been as great if this outbreak had happened in a general hospital or whether apathy is endemic in nursing homes. All of these things are ponderables that we must keep in mind as we look into this matter that we have before us.

We now will be privileged to hear from Dr. Jesse L. Steinfeld, the Surgeon General of the Public Health Service, and Dr. David J. Sencer who is the director of the Public Health Services Center for Disease Control in Atlanta, Ga.

Would those two gentlemen come to the table. We would appreciate it very much.

We are pleased to have you here. We kept you waiting all morning but now we look forward to hearing your testimony.

See appendix 1, p. 797.

STATEMENTS OF JESSE L. STEINFELD, M.D., SURGEON GENERAL, PUBLIC HEALTH SERVICE; AND DAVID J. SENCER, M.D., DIRECTOR, FEDERAL COMMUNICABLE DISEASE CENTER, ATLANTA, GA.

Dr. STEINFELD. Thank you, Mr. Chairman.

I have been asked by your staff to review the salmonellosis question but I think you have touched on most of the major aspects of it already this morning.

Salmonellosis is a disease caused by members of a specific group of bacteria-the salmonellae. The disease may assume several forms, but most frequently appears as simple gastroenteritis. A typical case is usually self-limited, has an incubation period of 12 to 48 hours, and a duration of 1 to 4 days. Symptoms most frequently include fever, nausea, vomiting, diarrhea, and abdominal cramps. Severe cases may require hospitalization, intravenous fluids, antibiotic therapy and, on rare occasions, may involve extraintestinal sites.

Salmonellosis is an important economic problem in the United States, with an estimated yearly cost of $300 million. Bacteria are isolated in approximately 20,000 cases, as reported to the Center for Disease Control (CDC) each year. In fact, the actual number of yearly clinical cases probably exceeds 2 million in the United States. This estimate is based on the fact that in the large outbreak in Riverside, Calif., in 1965 only about 100 of some 16,000 cases were reported. Approximately 50 percent of all cases occur in children below the age of 5. There is an equal number of cases among males and females, though the incidence is higher for males under 20 and females over 20, perhaps reflecting the preparation of food by the female in our culture. The disease occurs more frequently during the summer months than during the winter.

It is extremely difficult to calculate mortality rates because of the uncertain actual number of cases and the difficulty of assigning the cause of death in individuals with multiple diseases. However, between 1962 and 1969, 238 outbreaks were reported with 20,361 cases. There were 53 deaths associated with these outbreaks with a combined case fatality rate of 0.26 percent. The great majority of deaths due to salmonellosis occur among the very young or very old.

Salmonellosis may be transmitted in several ways, though it is most likely to be the result of eating contaminated foods. Foods may be infected at any point on their way to consumption. Individuals also may be infected by direct person-to-person contact, and this means of transmission most often occurs in a hospital setting. Pets have also served as a source of salmonellosis-baby turtles, baby chicks and baby ducks given to children who may develop a very severe case of salmonellosis as a result of handling the pet. It is very unusual fof salmonellosis in this country to be spread through municipal water supplies, although spread through private water supplies has occurred. The only case since World War II is the outbreak in Riverside, Calif., in 1965 as we have indicated.

In 1969, a total of 8,877 nonhuman cases, confirmed by isolation of the bacteria, were reported to the CDC. Fifty-four percent of these were derived from food animals, with turkeys, chickens, and swine being most often reported in that order. Other human dietary items.

account for 6.3 percent of the nonhuman isolates, egg and egg products comprising about half of this category. Animal feeds contributed another 21 percent of last year's nonhuman reported isolates.

I would like to supply for you and the staff a copy of CDC's Salmonella Surveillance Report. The annual summary for 1969 has just been published and I would like to read the section on outbreaks since there have been several questions. It is a very short section.

Senator Moss. That will be received as an exhibit and referred to in the text of the hearings so that we may refer to it.

(The document, Salmonella Surveillance, was marked exhibit A, and may be found in the files of the subcommittee.) Senator Moss. You may proceed.

Dr. STEINFELD. Thank you, Mr. Chairman.
I am now reading the section "Outbreaks."

In 1969, 19 outbreaks involving 1,023 individuals were reported in the Salmonella Surveillance Reports. Of nine food-borne outbreaks, seven were traced to a specific contaminated food, including three caused by turkey, one by chicken, one by beef, one by spaghetti and meatballs, and one by muktuk (whale skin and blubber). In two foodborne outbreaks, the specific food could not be identified. Three outbreaks involving four individuals were traced to household pets infected with the same serotypes. Although it could not be firmly established in all instances that the pets caused the human illness and not vice versa, the circumstances of these outbreaks favor the former explanation.

Six outbreaks involving 137 individuals occurred in hospitals or nursing homes. Person-to-person contact was the primary mode of spread in one of these outbreaks. The source of infection in the five S. infantis outbreaks could not be determined.

An outbreak of typhoid fever involving four individuals was traced to a S. typhi carrier employed by a restaurant.

Although the etiology of all outbreaks was confirmed bacteriologically, many of the 1,023 ill individuals were never cultured and are not included as reported isolations in the national surveillance data. Thus only a very small fraction of the total of 21,413 isolations of salmonellae in 1969 were from reported outbreaks. This suggests that many outbreaks are never investigated.

The alleviation and eventual eradication of the salmonella problem is a very difficult and expensive undertaking. Vaccines are not available for these varieties of salmonellosis, and the number of varieties of salmonellae is so large as to make this technique not feasible. Eradication would require the development of salmonellafree herds and flocks; the production of salmonella-free feeds; and improved practices in abbatoirs and meat and poultry processing plants. Public education to improve personal hygiene and food handling techniques would be essential.

The Public Health Service conducts a surveillance program to identify known and new varieties of salmonellae. The CDC also conducts seminars for the training of health workers; thus, continuing education of health professionals is critical to protection of public health since there is no known means of prevention of salmonellosis. The major natural reservoirs for salmonellae are poultry, fish, and swine. Clean environment and handling practices must characterize the production, distribution, and preparation of food if public health is to be protected.

The American people can protect themselves from salmonellosis through careful food preparation. People should not buy dirty or socalled "checked" (cracked) eggs; clean, uncracked eggs are unlikely to be a problem. Salmonellae do not change the taste or smell of food;

therefore, we cannot emphasize too strongly that the only protection available from salmonellosis is the careful selection and preparation of foods.

Dr. Sencer and I would be pleased to attempt to try to answer any questions.

Senator Moss. Thank you. I might ask one or two questions before we have Dr. Sencer.

Did you indicate that cracked eggs are a rather common carrier, or likely carrier, of salmonella?

Dr. STEINFELD. Yes, sir; before the shell is put around the egg is permeable to salmonella, so salmonella may be present in eggs in relatively small numbers. When the salmonella begin multiplying and so be likely to produce disease much more quickly, they may cause the egg to crack. So a cracked egg is one that has a much higher probability of containing a significant number of salmonellae and, therefore, probably causing disease in man if he eats it.

Senator Moss. Well, how much of a crack would it require in an egg to so indicate?

Dr. STEINFELD. I would say any crack.

Senator Moss. Any crack at all?

Dr. STEINFELD. Any crack.

Senator Moss. So there is a danger in the purchase of so-called checks?

Dr. STEINFELD. Yes.

Senator Moss. In eggs where they are cracked in the shell?

Dr. STEINFELD. Yes, sir.

Senator Moss. You indicated there are many other carriers of salmonella. I have an article here that I would like to read one statement from and ask you about. Dr. Kelly of Stockholm said that drugs contaminated during the production in pharmacies or pharmaceutical factories could infect the patient in the hospital, and he described an outbreak of dysentery caused by salmonella bacteria that affected 200 Swedish patients who had swallowed contaminated thyroid pills imported from the United States. He also said that bacterial contaminated eye medicines have caused some patients to lose their sight. This is a hazard, but is this common at all?

Dr. STEINFELD. I hope it is not too common. We have in this report and Dr. Sencer has in the previous report those instances in which drugs are contaminated with salmonella. A certain dye made from ground up beetles, may also be contaminated so this is also a source. This presumably should have been prevented by appropriate cultures by the Federal or other regulatory agencies.

Senator Moss. Well, thank you, Dr. Steinfeld. You can remain at the table. I think we will hear from Dr. Sencer, Director of the Federal Communicable Disease Center, and then maybe we will have questions for the two of you.

Dr. Sencer.

STATEMENT OF DR. DAVID J. SENCER

Dr. SENCER. Mr. Chairman, I have no prepared statement to make this morning. Dr. Steinfeld has covered most of what I would care to say and I think the earlier statements, particularly your opening statement, preempted what we would have said about the disease. I will answer any questions.