Let me say this. The investigation has not been completed.
Senator YoUNG. It is obvious it is in violation of the law here.

Mr. Chairman, I am going to inquire why Mr. Gould, the owner, was not compelled to be here or at least some member? I hope that in the next meeting some people from that Gould home will be made to be here.

Did you talk personally with any doctor in the Gould home when you first went there?

Dr. SOLOMON. Our staff talked personally.

Senator YOUNG. Did you personally?

Dr. SOLOMON. Yes, as a matter of fact I personally talked.
Senator YOUNG. When was that?

Dr. SOLOMON. On Sunday when I was there.

Senator YOUNG. That was over a full week after.

Dr. SOLOMON. Yes. You see, I could not have talked before I knew about it.

Senator YOUNG. I ask you what you did, not what you learned from hearsay.

No one has been arrested as yet?

Dr. SOLOMON. The information has all been submitted to the attorney general of the State of Maryland and we are awaiting his guidance and counsel.

Senator YOUNG. I have no further questions to ask at this time but I do hope that at the next meeting, Mr. Chairman, we will compel some member of the Gould home to be here. We should have some people connected with that home if he is not here.

Senator Moss. I agree with you, Senator. I don't believe you were here when I read the letter from Mr. Gould.

Senator YOUNG. Yes, I was here.

Senator Moss. We will have a further hearing and Mr. Gould will appear before the committee.

There are many questions that need to be answered about this.

Dr. Solomon, on the 5th of August you are quoted as saying that based on the report and an inspection of the home you believe the Gould home had a poor understanding of the necessary dietary control measures and procedures for isolating persons with contagious diseases. Does the current evidence substantiate the view you stated then?

Dr. SOLOMON. That was based on the fact that, as I said, on Sunday I personally went to the nursing home and made an inspection and when I was there I noticed that there were two employees who were ill with signs and symptoms who were handling food. They were in the kitchen and I sent them home.

Now it also is clear that the investigation when completed will look very critically at this area.

Senator Moss. Was not one of the first things that you did on visiting the home to order that the patients be removed to a general hospital?

Dr. SOLOMON. On Friday, the 31st, when we rang the fire bell there were several things that we did. One, we said that the home would be closed to any future admissions. Two, we strongly suggested that the private physicians remove their critically ill patients to hospitals. But let me make it very clear that we in the State have no control in ordering a private physician to do what he thinks he should do with his patient and physician relationship, this is between the private

physician and the patient. We act in a cooperative manner with him. We made the suggestions and we found that the physicians by and large carried them out.

Senator Moss. Didn't it strike you as unusual that the private physicians involved and the nursing home itself didn't undertake to remove these elderly patients who were very ill?

Dr. SOLOMON. Let me again say that you would have to look at this on an individual basis of each physician and each patient involved because each one becomes a patient-physician relationship. I think in cases where they were critically ill and needed the types of services that could not be availed at the nursing home, the answer is, Yes, they should have been removed.

Senator Moss. Did you believe from your visit there that the Gould people didn't consider this a serious matter and that they were trying to remedy it without announcing it, hoping it would pass over? Dr. SOLOMON. As Senator Young said, that would just be speculation. I think what we really have to do

Senator YOUNG. You have done a lot of other speculation. Why not answer that question?

Senator Moss. I just asked you for your impression. Of course we cannot know positively.

Dr. SOLOMON. I believe that at the outset the severity of it was not realized.

Senator Moss. Even though at the time you visited there there were already some people who had died?

Dr. SOLOMON. Oh, by the time I visited there, and that was on Sunday, I believe that the severity of it was realized. It was realized Friday 5 minutes after that phone call was made.

Senator Moss. Were the patients removed on Sunday to general hospitals?

Dr. SOLOMON. The removal of the patients to general hospitals again was up to their own physician and what he thought was best for them. Patients were removed at various times depending on what their physician's feelings were.

Senator Moss. But the nursing home administration itself did not initiate any movement of that sort?

Dr. SOLOMON. No, this was entirely up to the physician.

Senator Moss. In recent press you have been quoted as tying the outbreak here with some type of food. Are you still of that opinion, that it was some food?

Dr. SOLOMON. Well, my deduction, if you go through the three possible routes, one would be person-to-person spread, contact and spread; second would be through a contaminated water supply; and third would be through contaminated food supply. It is difficult to envisage that 60 people would suddenly come down in an explosive nature on a person-to-person spread if one person would have to be around and spread it simultaneously to a minimum of 60 other patients. It also appeared that if it had been the water supply, since that water supply was a general water supply it would not have been confined to that particular area but would have hit the general area. This was not the case. So by deduction then you are left with the possible food, and the data certainly suggests that, although at the moment I do not have confirmatory data, the organism was found in the food.

Senator Moss. Is it not a fact that eggs are among the most frequent carriers of salmonella, particularly if the shell has been cracked prior to serving?

Dr. SOLOMON. This is a true statement, that eggs, especially if the shells are cracked in cases of salmonella, are a frequent carrier.

Senator Moss. Now assuming that the infection came in a food, was it most likely that it came at one of the Sunday meals? Is that your opinion?

Dr. SOLOMON. This would be what the data would suggest.

Senator Moss. Is it true, as the Baltimore Sun reported on August 6, that the evening meal at the Gould home that Sunday consisted of eggs? Did personnel from the Health Department obtain samples of this meal; and if so, on what date and in what form?

Dr. SOLOMON. That was done by the city health department who did that aspect of the investigation.

Senator Moss. Is Dr. Garber here?

Dr. GARBER. Yes.

Senator Moss. Would you come to the table just for a moment. I want to ask you about this. I am trying to pursue a line of questioning here to see if we can get some idea of where the infection might have come from.

Would you identify yourself for the record so that we have your full name and title.

STATEMENT OF DR. HOWARD GARBER, CHIEF OF COMMUNICABLE DISEASES OF THE MARYLAND STATE DEPARTMENT OF HEALTH

Dr. GARBER. Dr. Howard Garber, chief of communicable diseases of the Maryland State Department of Health.

Senator Moss. Thank you, Dr. Garber.

Did personnel from the health department obtain samples of the Sunday night meal?

Dr. GARBER. Well, Senator Moss, as Dr. Solomon and Dr. Tayback mentioned we were on the scene approximately 5 or 6 days after the genesis of this outbreak and, therefore, the foods left over from the Sunday meal which were deviled eggs and shrimp salad were not available at the time. However, samples were taken of frozen shrimp similar to that which had been served, at the Sunday night meal. Also samples were taken of eggs from an open crate, supposedly the crate from which the eggs used for the Sunday meal were taken.

Thus far, both the FDA district office laboratory in Baltimore and the State department of health bureau of laboratories have found no contamination of bacterial origin in either the eggs, which as I say were not actually the ones used during the Sunday meal, or the shrimp.

Senator Moss. The sample you took though were uncooked eggs, you didn't take any of the eggs served at the Sunday meal?

Dr. GARBER. They were not available, sir.

Senator Moss. They were not available at that time?

Dr. GARBER. That is right. They had all been utilized at the Sunday meal or thrown out.

Senator Moss. So at this point the health department does not have any opinion of the source of the infection?

Dr. GARBER. That is correct.

The other thing that I might add, sir, is that usually in instances where we cannot find the actual food substance to culture often we will take food histories from the individuals at risk to obtain some idea of which particular food was eaten predominantly by the people who were ill and see if the people who were not ill ate or did not eat these foods.

Unfortunately, it was extremely difficult to ascertain what types of foods the nursing home patients ate. One could not obtain a history from these patients and there were no records in their clinical histories of what they had eaten.

Senator Moss. These eggs that you found in the crate, was there anything unusual about them?

Dr. GARBER. No, sir. The eggs that we found in the crate and all the eggs that were on the premises were obtained through regular suppliers and there was no evidence of cracking.

Senator Moss. You didn't see any evidence of cracking?

Dr. GARBER. No, sir.

Senator Moss. Do the Baltimore nursing homes have a particular source where they obtain their eggs?

Dr. GARBER. They have suppliers for their eggs the same as all the other supplies that they used on the premise; meats, shrimp, et

cetera.

Senator Moss. But I wondered, do they all go to the same supplier so far as you know?

Dr. GARBER. For the eggs?

Senator Moss. Yes.

Dr. GARBER. In all the nursing homes?

Senator Moss. All the nursing homes.

Dr. GARBER. No, sir. They use a different supplier to obtain many different things. There is no one supplier that supplies all the nursing homes.

Senator Moss. There was a story that appeared in the press indicating that some 43 purchased all of their eggs from one supplier. I wonder if you had any confirmation of that.

Dr. GARBER. No, sir. I don't think this is an accurate statement. Senator Moss. Congressman Pryor, would you like to ask a question on this particular point?

Representative PRYOR. I would like to proceed a little further on the egg question, Senator Moss, if I may have that privilege.

Senator Moss. All right.

Representative PRYOR. Would your department or Dr. Solomon's department in its ordinary, normal investigations and inspections of the nursing home have reason to, say, check with the financial records of that particular home to see how much they were purchasing their eggs for and see what price they paid for those eggs?

Dr. TAYBACK. No, there would be no reason to check such records. There is an inspection made at least once a year in connection with sanitation matters, and in that regard the nature of the food that is within the institution and how it is being stored is subject to inspection. There are not less than three additional inspections made during the year. In the course of these three additional inspections some attention is given to food hygiene.

Representative PRYOR. That is all the egg questions I have right

now.

Senator Moss. Unless anyone else had something further, I have one or two more questions that I wanted to ask of Dr. Solomon.

Herbert Fritz in charge of the licensing of nursing homes released to the press the fact that since the Gould home was established in 1964 there have been nine inspections and each time they found sanitation problems in the Gould home. Dr. DeHoff gave a similar statement that these deficiencies were minor and that the nursing home was a darn good facility.

One of these reported deficiencies was that the hot water used for rinsing dishes was not hot enough, another suggested the need for better food handling procedure. What can you tell us about the record of the Gould home?

Dr. TAYBACK. These are proper observations of the findings. What happens is that in connection with licensure, annual inspections are made. As I have indicated, not less than three additional inspections were made during the year. If deficiencies of this type are found, orders are given to clean up. The licensure may be held up until the condition is remedied, and when the condition is remedied then the license is issued.

Senator Moss. But even though there were nine times in which there were sanitation problems noted, none of these called for suspension of license?

Dr. TAYBACK. The instances that result in observations of the type that you have described, Mr. Chairman, lead to orders. These orders are generally for correction, correction within a 30-day period of time. A subsequent inspection is then made. If the condition has been removed, then the condition is considered to have been appropriately taken care of.

Senator Moss. I understand there are still some 90 patients or patrons of the Gould home still there now. What protection is there for them on these food handling procedures?

Dr. TAYBACK. The protection has to do with the intensive medical investigations that have been made. These intensive medical investigations have brought decisions of the type that Dr. Solomon has indicated to you; that is, if a patient obviously is showing evidence of continuing diarrhea and dehydration the patient has been removed for care in the acute hospital. In the meanwhile the sanitation people from the city health department have gone over the kitchen situation in great detail and at the present moment I can say with certainty that the highest levels of food hygiene are being pursued in connection with the purchase, preparation, and distribution of food.

At the State level that is, in the State department of health and mental hygiene with which the three of us are associated-just 4 days ago we brought on board a consultant in food hygiene, an individual who has had more than 35 years of experience in this particular field. He is an expert in the whole matter of salmonella infection. This individual is now undertaking the most careful survey of food hygiene in the city nursing homes and throughout the State. This person will be reporting to us.

In the interim, concerning the adequacy of our current rules and regulations, we will seek to upgrade the rules and regulations as soon as this individual indicates to us that our standards, say, are too low.