<DOC> [105 Senate Hearings] [From the U.S. Government Printing Office via GPO Access] [DOCID: f:50357.wais] S. Hrg. 105-516 Part II THE SAFETY OF FOOD IMPORTS: FROM THE FARM TO THE TABLE--A CASE STUDY OF TAINTED IMPORTED FRUIT ======================================================================= HEARING before the PERMANENT SUBCOMMITTEE ON INVESTIGATIONS of the COMMITTEE ON GOVERNMENTAL AFFAIRS UNITED STATES SENATE ONE HUNDRED FIFTH CONGRESS SECOND SESSION __________ PART II __________ JULY 9, 1998 Printed for the use of the Committee on Governmental Affairs ----------- U.S. GOVERNMENT PRINTING OFFICE 50-357 CC WASHINGTON : 1998 _______________________________________________________________________ For sale by the Superintendent of Documents, Congressional Sales Office U.S. Government Printing Office, Washington, DC 20402 COMMITTEE ON GOVERNMENTAL AFFAIRS FRED THOMPSON, Tennessee, Chairman WILLIAM V. ROTH, Jr., Delaware JOHN GLENN, Ohio TED STEVENS, Alaska CARL LEVIN, Michigan SUSAN M. COLLINS, Maine JOSEPH I. LIEBERMAN, Connecticut SAM BROWNBACK, Kansas DANIEL K. AKAKA, Hawaii PETE V. DOMENICI, New Mexico RICHARD J. DURBIN, Illinois THAD COCHRAN, Mississippi ROBERT G. TORRICELLI, DON NICKLES, Oklahoma New Jersey ARLEN SPECTER, Pennsylvania MAX CLELAND, Georgia Hannah S. Sistare, Staff Director and Counsel Leonard Weiss, Minority Staff Director Lynn L. Baker, Chief Clerk ------ PERMANENT SUBCOMMITTEE ON INVESTIGATIONS SUSAN M. COLLINS, Maine, Chairman WILLIAM V. ROTH, Jr., Delaware JOHN GLENN, Ohio TED STEVENS, Alaska CARL LEVIN, Michigan SAM BROWNBACK, Kansas JOSEPH I. LIEBERMAN, Connecticut PETE V. DOMENICI, New Mexico DANIEL K. AKAKA, Hawaii THAD COCHRAN, Mississippi RICHARD J. DURBIN, Illinois DON NICKLES, Oklahoma ROBERT G. TORRICELLI, New Jersey ARLEN SPECTER, Pennsylvania MAX CLELAND, Georgia Timothy J. Shea, Chief Counsel and Staff Director David McKean, Minority Staff Director Pamela Marple, Minority Chief Counsel Mary D. Robertson, Chief Clerk C O N T E N T S ------ Opening statements: Page Senator Collins.............................................. 1 Senator Levin................................................ 3 Senator Cochran.............................................. 5 Senator Lieberman............................................ 6 Prepared statement: Senator Cleland.............................................. 43 WITNESSES Thursday, July 8, 1998 Dr. Stephanie A. Smith, Investigator, Permanent Subcommittee on Investigations, Committee on Governmental Affairs, U.S. Senate. 9 Dr. Jeffery A. Foran, Cyclospora Case Patient, and Executive Director, Risk Science Institute, International Life Science Institute...................................................... 13 Dr. Stephen M. Ostroff, Associate Director for Epidemiologic Science, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, accompanied by Dr. Barbara L. Herwaldt, Medical Epidemiologist, Division of Parasitic Diseases............................................. 16 Alphabetical List of Witnesses Foran, Dr. Jeffery A.: Testimony.................................................... 13 Prepared Statement........................................... 161 Ostroff, Dr. Stephen M.: Testimony.................................................... 16 Prepared Statement........................................... 165 Smith, Dr. Stephanie A.: Testimony.................................................... 9 APPENDIX Exhibit List for July 9, 1998 Hearing * May be found in the files of the Subcommittee. Page 1. Chart prepared by the Permanent Subcommittee on Investigations, ``1996 and 1997 Cyclosporiasis Outbreaks, Areas Affected In The U.S.''......................................... 44 2. Chart and photographs prepared by the Permanent Subcommittee on Investigations in conjunction with statement by Dr. Stephanie A. Smith--Flow Chart ``Fresh Raspberries From Farm to Table'' and photographs of Guatemalan Raspberry Farm (Photograph 1-3), Sorting Table (Photograph 4), Sorting and Classifying (Photograph 5), Raspberry Flats (Photograph 6), and Port of Entry (Photograph 7)................................... 45 3. Publications submitted by Centers for Disease Control and Prevention: a. FoodNet, CDC/USDA/FDA Foodborne Diseases Active Surveillance Network, CDC's Emerging Infections Program, 1997 Surveillance Results.................................. * b. Addressing Emerging Infectious Disease Threats, A Prevention for the United States, 1994..................... * 4. SEM Surface Structure of Raspberry and Blackberry, 1mm and 100mm.......................................................... 53 5. Charts prepared by the Centers for Disease Control and Prevention: a. The National Molecular Subtyping Network for Foodborne Disease Surveillance....................................... 55 b. Burden of Foodborne Diseases............................. 56 6. Statement for the Record, Guatemalan High Level Commission for Food Safety: Berry Production in Guatemala................. 57 7. Pamphlet, ``Guatemalan Berries, Spring-Summer 1998'' prepared by the Guatemalan Berry Commission.................... 62 8. Memoranda prepared by Don Mullinax, Chief Investigator, Stephanie Smith, PhD, Investigator, and Mary Mitschow, Counsel, Permanent Subcommittee on Investigations, dated July 6, 1998, to Permanent Subcommittee on Investigations' Membership Liaisons, regarding ``PSI Hearing On The Safety of Food Imports: From The Farm to The Table--A Case Study of Tainted Imported Fruit''............................................... 70 9. Supplemental Questions and Answers for the Record, Dr. Stephan M. Ostroff, Centers for Disease Control and Prevention. 150 10. Supplemental Questions and Answers for the Record, Dr. Jeffery Foran, Executive Director, Risk Science Institute, International Life Science Institute........................... 152 11. Supplemental Questions and Answers for the Record, Dr. Stephanie A. Smith, Investigator, Permanent Subcommittee on Investigations................................................. 154 12. Comments for the Record, Fresh Produce Association of the Americas....................................................... 156 THE SAFETY OF FOOD IMPORTS: FROM THE FARM TO THE TABLE--A CASE STUDY OF TAINTED IMPORTED FRUIT--PART II ---------- THURSDAY, JULY 9, 1998 U.S. Senate, Permanent Subcommittee on Investigations, of the Committee on Governmental Affairs, Washington, DC. The Subcommittee met, pursuant to notice, at 9:31 a.m., in room SD-342, Dirksen Senate Office Building, Hon. Susan M. Collins, Chairman of the Subcommittee, presiding. Present: Senators Collins, Cochran, Levin, Lieberman, and Durbin. Staff Present: Timothy J. Shea, Majority Chief Counsel and Staff Director; Mary D. Robertson, Chief Clerk; Don Mullinax, Chief Investigator; Eric Eskew, Investigator (Detailee, HHS- IG); Lindsey E. Ledwin, Staff Assistant; Kirk E. Walder, Investigator; Dr. Stephanie A. Smith, Investigator (Congressional Fellow); Beth Stein, Counsel to the Minority; Brian Benczkowski (Senator Domenici); Butch Burke (Senator Stevens); Pam Muha (Senator Specter); Michael Loesch (Senator Cochran); Maggie Hickey (Senator Thompson); Felicia Knight and Steve Abbott (Senator Collins); Kevin Mulry and Marianne Upton (Senator Durbin); Antigone Potamianus (Senator Levin); Doug O'Malley and Kevin Landy (Senator Lieberman); and Lynn Kimmerly and Donna Berry (Senator Cleland). OPENING STATEMENT OF SENATOR COLLINS Senator Collins. Good morning. The Subcommittee will please come to order. Today the Permanent Subcommittee on Investigations holds its second in a series of hearings on the safety of imported food. Food safety is a serious and growing public health concern. The escalation in the number of foodborne illnesses at a time when food imports are soaring prompted the Subcommittee to focus its investigation on the safety of imported fruit and vegetables. At the Subcommittee's first hearing in May, the General Accounting Office reported that as many as 81 million cases of foodborne illnesses and more than 9,000 related deaths are estimated to occur in the United States each year. The medical treatment and lost productivity resulting from foodborne illnesses costs billions of dollars a year. We also learned that the system intended to protect Americans from tainted imported food is not effective. The General Accounting Office told the Subcommittee that ``Federal agencies cannot ensure that the growing volume of imported food is safe for consumers.'' Specifically, the GAO reported that agencies have not targeted their resources on imported foods posing the greatest risks and concluded that the limited resources available to the Food and Drug Administration and the U.S. Department of Agriculture must be more efficiently deployed to better protect Americans from unsafe imported food. In its report to the Subcommittee, the GAO also found that ``weaknesses in controls over food imports enable entry of unsafe products.'' In other words, even if Federal inspectors discover tainted food, controls are not in place to prevent unsafe products from entering the marketplace and ending up on the dinner tables of America. For example, during one U.S. Customs Service special operation, 70 percent of the food shipments that the FDA had ordered destroyed or re-exported because they were unsafe actually entered into the American marketplace. As a continuation of the Subcommittee's investigation into the safety of imported food, our hearing today will examine a case study of tainted imported fruit. We will look at the food import system from the farm to the table and hear how a microscope organism made thousands of Americans sick in 1996 and 1997 from eating tainted raspberries. In the spring of 1996 and 1997, as the chart before you shows,\1\ people from Maine to California, in a total of 23 States and the District of Columbia, became sick. They experienced symptoms of foodborne illness. Many of these victims ate food at common events. This common link led public health officials to mobilize resources in an effort to determine the case of these illnesses. --------------------------------------------------------------------------- \1\ See Exhibit No. 1 which appears in the Appendix on page 44. --------------------------------------------------------------------------- We know the probable source of the 1996 and 1997 outbreaks because of the scientific traceback investigation conducted by public health officials, Federal regulatory agencies, and the Centers for Disease Control and Prevention. It is this fascinating and painstaking process--the traceback of a foodborne illness from the patient back to the source of contamination--that we will examine in the hearing this morning. The Subcommittee's inquiry will focus on the following critical questions: How is fresh fruit produced and then imported into the United States? What are the ways in which produce can become contaminated? And how do the CDC and other public health agencies investigate outbreaks of foodborne illnesses to determine the source of contamination? To assist the Subcommittee, we are fortunate to have a distinguished group of scientists here this morning. First, we will hear from Dr. Stephanie Smith. Dr. Smith is a food scientist by training and is currently working with the Subcommittee on a 1-year fellowship. As a Subcommittee investigator, she traveled to Guatemala to observe first-hand the production and exportation process for raspberries. Second, we are pleased to have Dr. Jeffery Foran, an environmental scientist who himself became ill in 1996 after eating raspberries from Guatemala. Finally, we will hear from CDC officials. Dr. Stephen Ostroff is an Associate Director at CDC's National Center for Infectious Diseases. Dr. Barbara Herwaldt is a CDC medical epidemiologist who led the Division of Parasitic Diseases team which investigated the 1996 Cyclospora outbreak. The CDC is the Federal agency to which many public health officials turn for scientific expertise when outbreaks of foodborne illnesses occur. Let me also mention that I invited the Guatemalan Ambassador to the United States to submit a written statement describing improvements made to the Guatemalan production and expert process since the 1996 and 1997 Cyclospora outbreaks. This week, we received through the Guatemalan Embassy a written statement from the Guatemalan High Level Commission for Food Safety. This statement will be made a part of today's hearing record.\1\ --------------------------------------------------------------------------- \1\ See Exhibit No. 6 which appears in the Appendix on page 57. --------------------------------------------------------------------------- I want to emphasize that this hearing is not intended to single out Guatemala. As the Guatemalan officials have indicated, considerable improvements have been made in that country's production process, and in fact it was Guatemala which voluntarily suspended the export of raspberries in 1997 after that fruit was identified as the cause of the Cyclospora outbreak. The Subcommittee's purpose is not to indict one country or region of the world but rather to focus on a case study of tainted imported fruit from the farm in a foreign country to the tables of America, in order to understand how we can better protect the American consumer. The safety of food imports is literally a life and death issue for many people, especially our children and our elderly. As the vast majority of our food supply is safe, consumers should not stop eating imported fruit and vegetables. However, this country's food safety net must be improved so that consumers are protected from the risk of unsafe foods, particularly when contamination is not detectable by the average consumer. The difficulty of this task is demonstrated by the fact that just 3 weeks ago, press reports described yet another serious outbreak of Cyclospora, this time in Canada, which may also prove to be caused by raspberries imported from Central America. As we continue this important work, we are looking forward to hearing from our witnesses this morning in order to learn more about foodborne illnesses, how they occur, and how they can be prevented. It is now my pleasure to recognize Senator Levin for any statement he may have. OPENING STATEMENT OF SENATOR LEVIN Senator Levin. Madam Chair, thank you, and thank you for holding this series of hearings. Your leadership is critically important. We all appreciate it, and the Nation is better off because of it. Ensuring the safety of the Nation's food supply, both domestic and imported, should be a top priority for Congress. Americans are eating more and more imported food, especially imported produce. A recent GAO report noted that in 1980, 24 percent of the fruit consumed by Americans was imported and that by 1995, that number had increased by more than a third, to 33 percent. The same report shows that the percentage of vegetables imported had increased from 7 percent to 11 percent. The fundamental importance of ensuring food safety was highlighted once again when an outbreak of hepatitis A in my home State of Michigan occurred last year. Hundreds of Michigan schoolchildren were sickened from eating tainted frozen strawberries imported from Mexico that had improperly and illegally found their way into the school lunch program. Those who are least able to protect themselves, as our Chairman said, including women, children, and people with weakened immune systems, are the most vulnerable to foodborne illnesses. I am happy that we recently passed S. 1150, a bill which included a number of important food safety elements that are similar to elements contained in companion bill which Representative Debbie Stabenow and I had previously introduced, including a provision that requires the Department of Agriculture to form a FEMA-like crisis management team to handle food poisoning outbreaks and other agriculture-related emergencies. These crisis management teams will integrate efforts with Federal, State and local agencies as well as with our colleges and universities and other research organizations and function quickly to limit the harmful effects of contaminated food. As the volume of imported food, especially fruit and vegetables, continues to increase significantly while our Federal Government inspection resources remain the same, it is not surprising that the percentage of imported food shipments actually inspected has decreased. In other words, the FDA cannot keep pace with the increasing volumes of imported foods under its jurisdiction, namely, fruit, vegetables and grains. In 1992, the FDA inspected 8 percent of imported foods. In 1997, it was only able to inspect 2 percent of imported foods. So we are going in the wrong direction. At the first hearing on this subject, we learned that Federal inspection of imported foods is woefully inadequate. Enforcement is understaffed; remedies for violation of the food safety laws are weak. The President, as part of his Food Safety Initiative, has proposed that we provide the FDA with authority to require that imported foods be produced in foreign countries under food safety systems that are equivalent to those in the United States. He has also proposed increasing funding to enhance inspections by FDA personnel. I hope we will act on those measures promptly, hopefully in this Congress. We must also strengthen legal remedies available to Federal inspectors by providing the Department of Agriculture with authority to mandate recalls of food under their jurisdiction and to increase fines that they can levy for food safety related violations. The President has also asked Federal agencies to devise a plan for creating a National Institute for Food Safety Research and has directed the FDA to issue regulations that would require warning labels on fruit juice that has not been pasteurized or otherwise processed to kill bacteria. The case study that the Subcommittee takes up today, like the issue of tainted frozen strawberries from Mexico that sickened children in Michigan, reflects great gaps and weaknesses in our Federal food safety scheme. We should provide the FDA equivalency authority. We should empower regulators to mandate recalls of tainted food. We should strengthen penalties for violating food safety laws, and hopefully, we should act in this Congress before more Americans are stricken by foodborne illnesses that could have been prevented had those fruit and vegetables been grown in the United States. I want to again thank you, Madam Chairman, and thank our witnesses for their appearance today. I have to be at the Armed Services Committee as the senior Democrat there on an important hearing, so I will not be able to be here for this testimony, but I will surely follow it closely. Senator Collins. Thank you, Senator Levin. It is now my pleasure to recognize Senator Cochran, who is the Chairman of the Agriculture Appropriations Subcommittee, for any statement that he might have. OPENING STATEMENT OF SENATOR COCHRAN Senator Cochran. Thank you very much, Madam Chairman. Let me first commend you for this series of hearings you are having and the investigation that is being conducted by this Permanent Subcommittee on Investigations. I am happy to be a Member of this Subcommittee, and I think it can be a very helpful and important contribution to our understanding more fully the problems of food safety in terms of inspection and detection. More complicated, and perhaps more important than any of this, is the question of which options we select to make a part of a reform effort to ensure that we do all that we possibly can to protect the safety and health of the consumers in America. That is the big challenge as I see it, and I hope that as we go through the process of looking at the facts that have been compiled by the Centers for Disease Control and other agencies and researchers, that we keep in mind that at some point, we have to confront the real challenge of coming up with a better system. Obviously, efficiencies have to be introduced into our food safety and inspection system at the Department of Agriculture and at the Food and Drug Administration. Just giving the power to fine, the power to ban, to specific Federal agencies is not enough. We have disagreements now between those agencies as to which would be the more appropriate agency to have what authority, we have to cut through all of this internecine competition within the Federal agencies. We also have to confront the realities of possible retaliation from countries where bans may be imposed unilaterally, without any due process requirement, by a Federal agency. There are all kinds of problems that we have to understand before we make final decisions about how to improve the system that we have. We need to work hard, and I think the conduct of this hearing shows how concerned this Congress is to get something done that makes sense, that is workable, that is affordable, and that serves the overriding interests of the consumers and the public in this country of ours. We have the safest supply of food of any country in the world, and we have an enormous opportunity to import, because of our high standard of living, food from all over the world, and our consumers have a greater range and variety of fresh vegetables and produce and wholesome meat and poultry and seafood of any country in the world, and of this, we are very proud. But we do have some serious problems, and they will be identified, and that is the purpose of this hearing, to find out the extent of the problems that we have now in terms of detecting contaminated food supplies, particularly from imported fruit and vegetables. Ensuring the safety of those foodstuffs comes under the jurisdiction of the Food and Drug Administration. I am very glad to be here today, and I look forward to hearing the testimony and working closely with the other Members of this Committee to try to help come up with the best possible solution for dealing with the problems that we have. Thank you. Senator Collins. Thank you very much, Senator Cochran. Senator Lieberman, it is a pleasure to have you here today as well. OPENING STATEMENT OF SENATOR LIEBERMAN Senator Lieberman. Thank you, Madam Chairman, and thanks for conducting this very important series of hearings examining the safety of the food we eat. Thanks also to your staff for the high level of work that they have done on this. In my first year in the Senate, 1989, I was involved in an investigation that the Environment and Public Works Committee did on pesticides in our foods. One of the things we found was that the FDA was letting into the country products that had been sprayed with pesticides that were illegal here. Another thing we found was that some American growers were using illegal pesticides on crops being grown for export. Both of those practices were outrageous and unacceptable, and in time, Congress and the Executive Branch did something about it. The problem of the safety of the food we eat, particularly the food that is imported, has become much worse since that first series of hearings I participated in in 1989 as it relates to imports, because, as we have indicated, the percentage of food that we eat that is imported has multiplied dramatically. Let me read from a quote given to The New York Times by Dr. Robert Tauxe, Chief of the Foodborne and Diarrheal Disease Branch at the Centers for Disease Control. He said: ``Go to a restaurant and take a look at your supper. How many different continents are on your plate?'' We could say that for a lot of the meals we eat at home as well. ``The food chain that fills those plates has become unimaginably intricate,'' and they cite as an example alfalfa sprouts, which gave salmonella to hundreds of people in 24 States in the last couple of years. The seeds for those sprouts were bought from Uganda and Pakistan, among other nations, they were shipped through the Netherlands, they were flown into New York, and they were trucked around the United States. That is why previously unknown pathogens are being discovered repeatedly and years after they arrive in the United States. It is one of the down sides of the global economy from which we have benefited in so many other ways. So I think this series of hearing is critically important. I remember at the end of that series of hearings in 1989 saying that the party that you register with or the ideology that you hold does not affect the level of your concern about the safety of what you eat. I think that remains true. If there is anything that the public wants us to do, it is to act in areas like this, where they simply cannot act to protect themselves. We are a long way from the days when people used to grow most of the fruit and vegetables they ate right around where they lived. They come from all over the country, and now, from all over the world, and they need us to stand as best we can between them, their stomachs and the rest of the world that puts food on their table. So I think there is a very broad public consensus that we do something about this. I particularly appreciate today, Madam Chair, that you are going to examine a case study, the cyclosporiasis outbreak, because I think it can help us bring into relief those things that the government is doing well along with the private sector and those things were are not doing well and, in some cases, are doing very badly. I was quite impressed in reviewing the materials for this morning's hearing, this instance, by the excellent response of the CDC and our other public health officials to this fast- developing public health crisis. I know we are going to hear today about how they quickly traced seemingly isolated cases of a rare illness to a handful of raspberry farms in Guatemala. It is a modern-day international epidemiological--and I might even add, gastrointestinal--Sherlock Holmes story. There is probably a movie here somewhere. But it is remarkable and quite impressive, and clearly one of the things that we do well to the benefit of all in our country. And in the case of the cyclosporiasis crisis, which affected about 40 people in the State of Connecticut, I want to offer my thanks to the CDC for what they did. But among the things that we do not yet do well, as has been testified to, is to find a way to raise the level of protection of the food that we are importing. As I age, my memory may be somewhat faulty, but I remember a witness, I believe from the FDA--we were talking about how much inspection occurred of imported fruit--and he was referring to a shipment of bananas that had some problems with pesticides, and he referenced ``two'' inspections. So I asked, ``Of boatloads of bananas?'' ``No.'' ``Of two boxes of bananas?'' ``No.'' I asked, ``Two what?'' He said, ``Two bananas.'' Well, I may have the details of the story slightly off, but that is how poor it was then, and it is poorer now. As Senator Levin indicated, only 2 percent of imported foods are inspected by FDA. So we continue to have what I would describe as a desperate need to give more authority to the FDA over imported fruit and vegetables and more people to exercise that authority, and I hope that some support for that emerges from these very important hearings that you are holding, Madam Chair. I thank you for your leadership here, and I look forward to working with you and hearing the witnesses today. Senator Collins. Thank you, Senator. Due to time constraints, the Subcommittee was unable to accommodate everyone who wished to testify today. We will, however, be leaving the hearing record open for 10 days so that anyone who wishes to submit a written statement may do so. In addition, without objection and for the convenience of all the Members, all exhibits, including the photographs and charts previously made available to Subcommittee Members, will be made part of the hearing record. I would now like to ask our panel of witnesses to come forward. Our witnesses this morning will describe for us how outbreaks of foodborne illnesses are investigated and specifically examine the 1996 and 1997 outbreaks of Cyclospora associated with Guatemalan raspberries. The first witness, Dr. Stephanie Smith, is currently an investigator who is on the temporary staff of the Permanent Subcommittee on Investigations. Dr. Smith has a doctorate in food science from Michigan State University and nearly 6 years of food industry experience with two international companies as well as a domestic food distributor. She has been working as an investigator for the Subcommittee since October 1997, and we have been very pleased to have her as part of our team. As part of the Subcommittee's investigation, Dr. Smith traveled to Guatemala to observe first-hand the raspberry production and exportation process. Our second witness, Dr. Jeffery Foran, is an environmental scientist and expert in quantitative risk assessment. Dr. Foran is the Executive Director of the Risk Science Institute in Washington, DC. The Risk Science Institute is a component of the International Life Science Institute, a nonprofit, worldwide foundation established in 1978 to advance the understanding of scientific issues related to nutrition, food safety, toxicology, risk assessment and environment. In addition to being a scientist, Dr. Foran was also a consumer who became ill after consuming Guatemalan raspberries, proving that no matter what your level of expertise, no one is immune to Cyclospora. Finally, we will hear from two officials from the CDC, Dr. Stephen Ostroff and Dr. Barbara Herwaldt, who are both with CDC's National Center for Infectious Diseases. Dr. Ostroff is the Associate Director for Epidemiologic Science, and Dr. Herwaldt is a medical epidemiologist in the Division of Parasitic Diseases. Both have extensive experience in investigating and tracking infectious diseases and were involved in the Cyclospora case that we are examining today. Pursuant to Rule 6, all witnesses who testify before the Subcommittee are required to be sworn in, and you have already stood for me, but please raise your right hands. Do you swear that the testimony you are about to give to the Subcommittee will be the truth, the whole truth, and nothing but the truth, so help you, God? Dr. Ostroff. I do. Dr. Herwaldt. I do. Dr. Smith. I do. Dr. Foran. I do. Senator Collins. Thank you. Please be seated. I am going to ask each of you, in the interest of time, to limit your oral testimony to about 10 minutes each. If you need a little longer, that is fine as well. We will be using a timing system this morning to assist you. Before the red light comes on, you will see the lights change from green to orange, and that will tell you that you have 1 minute left to wrap up your testimony. I want to assure you that your entire prepared testimony will be included in the record in its entirety. Dr. Smith, please proceed, and again, thank you for all your assistance to the Subcommittee. TESTIMONY OF DR. STEPHANIE A. SMITH, INVESTIGATOR, PERMANENT SUBCOMMITTEE ON INVESTIGATIONS, COMMITTEE ON GOVERNMENTAL AFFAIRS, U.S. SENATE Dr. Smith. I would like to thank Senator Collins for the opportunity to testify today before the Permanent Subcommittee on Investigations. I have a doctorate in food science from Michigan State University and nearly 6 years of food industry experience, as the Senator mentioned. I have been working as an investigator on the Permanent Subcommittee on Investigations since October of last year. This morning, I will report to the Subcommittee the results of a case study which is part of the ongoing investigation conducted at the direction of Senator Collins. I will describe the process by which fruit grown abroad reaches American consumers, using raspberry production in Guatemala as an example. Fresh Guatemalan raspberries have received considerable attention because of their association with outbreaks of an infection caused by Cyclospora cayetanensis, which occurred in the United States and Canada during the spring of 1996 and spring of 1997. Cyclospora is a protozoan parasite that causes a gastrointestinal illness called cyclosporiasis. This illness is typically characterized by watery diarrhea and other symptoms such as nausea, abdominal cramps, substantial weight loss and fatigue. If not treated, the illness can be severe and prolonged. Prior to the 1996 outbreak, Cyclospora was relatively unknown in the United States. According to the scientific literature, only sporadic cases, mostly in travelers, and two small clusters of cyclosporiasis were recognized in North America. These clusters were associated with water, not food. I would like to make two points. First, very strong epidemiological evidence implicates the source of cyclosporiasis outbreaks of spring 1996 and spring 1997 as fresh Guatemalan raspberries. However, neither the source of the contamination nor the point at which the contamination occurred is clear. One hypothesis is that raspberries became contaminated through spraying with insecticides and fungicides mixed with contaminated water. Other hypotheses consider soil, animals or humans as sources of the contamination on the farm. Second, our investigation revealed that the Guatemalans, working with the Centers for Disease Control and Prevention and the Food and Drug Administration, have made considerable investments to upgrade their farm facilities and train their employees in proper agricultural, post-harvest handling, sanitation, personal hygiene and recordkeeping practices. In late March of this year, as part of the Subcommittee's comprehensive investigation of the safety of food imports, I, along with the Subcommittee's chief investigator, spent 4 days in Guatemala. The purpose of our trip was threefold: (1) to meet with representatives who were involved in production and exportation of fresh raspberries; (2) to make first-hand observations of raspberry farms and packing facilities; and (3) to document the raspberry production process. Our trip included visits to two analytical laboratories, 10 berry farms, and a produce freezing facility. My comments today will be based on our observations as well as information supplied by the CDC, the FDA, the U.S. Department of Agriculture, the U.S. Customs Service, and officials of the Guatemalan Government. I would now like to walk through the process of raspberry production and distribution from a typical Guatemalan farm to an American table. As I stated, the mode of contamination of the fresh raspberries with Cyclospora remains unknown. However, I will highlight points in the generalized process at which the berries could have become contaminated. Keep in mind, that, in general, anything that comes in direct contact with the fruit, including water, soil and human hands, is potentially a source of contamination. My testimony will follow the flow diagram displayed here.\1\ --------------------------------------------------------------------------- \1\ See Exhibit No. 2 which appears in the Appendix on page 45. --------------------------------------------------------------------------- For seedlings to become flowering plants requires approximately 6 months. Another 6 weeks is required for raspberries to be ready for harvest. This photograph \2\ shows how raspberry plants are grown--typically, in hedgerows, supported by posts and wires. The plants are approximately 4 to 5 feet high and may or may not be tied to the wires individually, as shown here. The location of the fruit on the plant is at least 3 feet off the ground, and therefore, no direct contact occurs between the fruit and the soil. Soil is a possible vehicle of contamination, therefore, it is important that the soil not touch the fruit. --------------------------------------------------------------------------- \2\ Photograph 1 of Exhibit No. 2 appears in the Appendix on page 46. --------------------------------------------------------------------------- The plants are watered using drip irrigation. A drip irrigation system typically consists of a piece of plastic tubing running along the ground as shown in this photograph. The underside of the tubing has small holes so the ground can be wet slowly over a long period of time. Fertilizers, if used, are administered through the drip irrigation system. No direct contact occurs between the fruit and the irrigation water. Pesticides are generally mixed with potable or drinking- quality water and sprayed directly onto the plants or the soil below. This is the only water other than rain that intentionally contacts the berries directly. The berries are harvested dry and not washed at any point prior to sale, because they are very susceptible to mold. Water is also a possible source of contamination. Therefore, the quality of any water that contacts the berries is significant. Raspberries are harvested by hand, primarily by women. The berries must be handled very gently to preserve their quality. Ripe berries can be pulled from the plant very easily. The pickers generally carry plastic trays strapped around their waists to keep their hands free, as shown in this photograph.\1\ The plastic trays hold small plastic baskets into which the berries are placed. Again, let me emphasize that anything that comes in direct contact with the fruit, if contaminated itself, is a possible source of contamination. --------------------------------------------------------------------------- \1\ Photograph 2 of Exhibit No. 2 appears in the Appendix on page 47. --------------------------------------------------------------------------- Once the baskets are full, the tray is taken to a packing shelter such as the one shown in this photograph.\2\ Typically, these structures have poured concrete floors and screened pass- through windows. By passing the trays brought from the fields through a window, tracking dirt from the field into the packing shelter is avoided. Some farms also use foot baths just outside the packing shelter door to clean shoe bottoms before entering. --------------------------------------------------------------------------- \2\ Photograph 3 of Exhibit No. 2 appears in the Appendix on page 48. --------------------------------------------------------------------------- Inside the packing shelter, berries are classified as export grade or domestic grade based on color and degree of ripeness. The berries are generally sorted and classified on large tables with smooth white surfaces, under a covered fluorescent light as shown in this photograph.\3\ --------------------------------------------------------------------------- \3\ Photograph 4 of Exhibit No. 2 appears in the Appendix on page 49. --------------------------------------------------------------------------- The next photograph shows workers actually sorting, classifying and packing raspberries selected for export as fresh product in plastic containers called clamshells.\4\ Containers of this type are commonly used for raspberries and blueberries. The clamshells are packed in cardboard flats, as shown in this photograph.\5\ --------------------------------------------------------------------------- \4\ Photograph 5 of Exhibit No. 2 appears in the Appendix on page 50. \5\ Photograph 6 of Exhibit No. 2 appears in the Appendix on page 51. --------------------------------------------------------------------------- A flat holds 12 clamshells. The packaged fresh berries are stored in refrigerated rooms on individual farms or are transported within hours to exporter warehouses for cold storage prior to export. Possible sources of contamination during sorting and packing include dirty hands and tabletops. For shipping, the cardboard flats are packed in 3'x3'x4' styrofoam-insulated cardboard boxes referred to as E- containers. One E-container holds 10 flats plus gelpacks added to keep the berries cold. The E-containers are transported in refrigerated trucks from exporter warehouses to the airport. Generally, the trucks arrive at the airport between 11 p.m. and midnight. Upon arrival, the berries are held in cold storage in the cargo area. Between 2 a.m. and 4 a.m., the berries are loaded onto either a cargo or passenger plane. All fresh raspberries from Guatemala are shipped by air to the United States. Miami, Florida has been the principal port of entry for fresh Guatemalan raspberries, with the majority of the berries passing through its airport. After arriving in Miami, the berries are unloaded from the planes, as shown in this photograph. \1\ The berries must then be cleared by the USDA's Animal and Plant Health Inspection Service, or APHIS. --------------------------------------------------------------------------- \1\ Photograph 7 of Exhibit No. 2 appears in the Appendix on page 52. --------------------------------------------------------------------------- The inspectors use USDA cargo clearance areas containing examination tables for visual inspection of incoming plants and plant products, including fruit and vegetables. The role of APHIS is to protect U.S. animals and plants from the spread of foreign animal and plant pests and diseases--not to protect U.S. consumers from human disease. For raspberries, the inspectors remove a clamshell from a flat, open it, empty the berries onto the table and visually inspect them. The berries are then returned to the clamshell, replaced in the flat, and returned to the storage location before being collected by the importers. Removing the fruit from its container creates an opportunity for it to become contaminated by contact with human hands or with soil which may remain on the inspection table from previous examinations of plants or flowers. However, while microbial contamination could hypothetically occur in this manner, the sheer number of event locations, shippers, distributors and cargo clearance areas made the possibility of raspberry contamination occurring in the United States highly unlikely. The FDA is also responsible for clearing imported fruit and vegetables as well as all other imported foods, except for meat, poultry and some egg products--which are under the jurisdiction of the USDA's Food Safety and Inspection Service. FDA inspectors may automatically release the fruit based on the product's import history, or the inspectors may conduct a physical examination of the fruit and/or collect a sample for laboratory testing prior to releasing the product into U.S. commerce. Once the raspberries have been cleared at the port of entry, importers ship the berries to distributors either by airplane or by truck. Generally, if they are shipped in a refrigerated truck, the flats are stacked on a pallet without using gelpacks. If they are transported in an airplane or a nonrefrigerated truck, they are repacked into E-containers with gelpacks. Distributors fill and deliver orders for fresh raspberries placed by retail outlets and food service establishments. Surprisingly, our investigation revealed that raspberries harvested one afternoon on a Guatemalan berry farm can be on an American consumer's table the very next day. The entire farm- to-table process can be completed in less than 24 hours, even when the farm is located in Central America. Finally, upon receipt by the retailer or food service establishment, fresh berries are generally stored briefly until displayed for sale or prepared for consumption. Food preparation is always a potential point of contamination, depending largely on how the food is handled. That is why proper handling practices are so important. Proper food preparation practices include washing hands often, separating washed and cooked foods from unwashed and raw foods, as well as animal products from plant products. However, as I stated previously, in these cases, it is most likely the raspberries were already contaminated prior to reaching the retailer or food service establishment. In closing, I would like to quote one of my colleagues from the CDC, Dr. Morris Potter, who I believe accurately summarizes the challenge posed by foodborne illness: ``If one recognizes that ensuring food safety is inherently uncertain, foodborne illnesses become opportunities to learn rather than failures to predict. Foodborne disease will occur, and we must be prepared to react quickly to reduce the risk of new foodborne hazards.'' Further, I would like to emphasize that we live in a Nation that trades food on a global basis. In efforts to ensure the safest U.S. food supply possible from farm to table, it is essential to remember that increasingly, the farm is in another country. In 1996, the United States imported $7.2 billion worth of fruit and vegetables from at least 90 different countries, an increase of 48 percent from 1990. And this trend will continue. The FDA has projected that imports of fruit and vegetables will go up by another 33 percent between now and the year 2002. The United States will continue to import foreign produce to meet the demand of American consumers for a variety of fresh fruit and vegetables year round. Therefore, food safety is an international issue. Thank you again, Madam Chairman, for the opportunity to present this phase of the Subcommittee's food safety investigation. I am, of course, available to answer questions. Senator Collins. Thank you, Dr. Smith. Dr. Foran. TESTIMONY OF DR. JEFFERY A. FORAN,\1\ CYCLOSPORA CASE PATIENT, AND EXECUTIVE DIRECTOR, RISK SCIENCE INSTITUTE, INTERNATIONAL LIFE SCIENCE INSTITUTE Dr. Foran. Thank you, Senator. --------------------------------------------------------------------------- \1\ The prepared statement of Dr. Foran appears in the Appendix on page 161. --------------------------------------------------------------------------- I am Dr. Jeffery Foran. I am Executive Director of the International Life Science Institute (ILSI), Risk Science Institute here in Washington, DC. The ILSI Risk Science Institute is a nonprofit institute established in 1985 to advance and improve the scientific basis for ecological and human health risk assessment. RSI works toward this goal through an international program of research, working groups, conferences, workshops, publications, seminars and training programs. We recognize that public health decisions must be based on the best available science and thus, in all of our activities, we work toward consensus resolution on the scientific issues by facilitating discussion and cooperation among scientists from academia, industry, government, and the public-interest sector. During the spring of 1996, I attended a buffet luncheon at which a variety of fruit and other foods was served. Approximately 10 days to 2 weeks after the luncheon, I developed acute gastroenteritis and diarrhea. Several other individuals who participated in the luncheon developed similar symptoms, which included nausea, fatigue, loss of appetite and weight loss. Upon the discovery of the similarity of our symptoms, and suspecting a similar disease etiology, we contacted the Washington, D.C. Public Health Commission, and subsequently, the Centers for Disease Control and Prevention. We asked them to investigate the potential for food-related causes of these symptoms. During the investigation of the nature of these symptoms, I visited my physician to determine what might be causing my illness. My physician did not at the time suspect a foodborne illness. Rather, he suggested that my fatigue and weight loss might be due to stress and a very hectic schedule. No medication was prescribed during my first visit. After this visit, we began to learn through the news media of a foodborne pathogen, Cyclospora, which elicited symptoms in exposed individuals that were identical to my own, and others who participated in the luncheon. I recontacted my physician upon learning of the symptoms caused by Cyclospora infection and the appropriate treatment. The CDC subsequently confirmed the outbreak of cyclosporiasis in individuals who attended our luncheon. I then received medication and was relatively free of symptoms within 14 days of receiving medication. Subsequently, we learned from the CDC investigation that Cyclospora most likely occurred on the raspberries that were served during the luncheon, and that these raspberries were most likely imported to the United States. For several years, the ILSI Risk Science Institute has been developing a method to assess the human health risks associated with exposure to food- and waterborne pathogens. The disease outbreak in individuals who attended the luncheon has provided valuable, although I admit somewhat uncomfortable, personal lesson of the value of our work. In 1996, RSI published an article entitled ``A Conceptual Framework to Assess the Risks of Human Disease Following Exposure to Pathogens.'' \1\ This framework, which was developed by a group of 30 scientists convened by the ILSI Risk Science Institute, highlights the information that must be gathered to fully understand the health risks posed by exposure to food and waterborne pathogens. Critical to such an assessment is information on the nature of the pathogen itself--for example, where it occurs, its life-cycle, its ability to cause disease; the nature of exposure to the pathogen--how, when and how much we might be exposed to it; information on host susceptibility, the health effects caused by the pathogen, the severity of the disease in the host, the nature of the dose/infectivity/response relationship between the pathogen and the host, and an array of other factors. --------------------------------------------------------------------------- \1\ See Exhibit No. 8, Attachment G which appears in the Appendix on page 142. --------------------------------------------------------------------------- Unfortunately, much of this information is not available for many pathogens that infect humans and cause diseases. For example, with regard to Cyclospora, at the time of our outbreak, most physicians and public health experts did not fully understand the nature of the organism, its occurrence, its infectivity, and many other issues necessary to characterize the human health risks associated with exposure to the organism. And even after significant investigation, scientists have still not resolved several of the critical issues about Cyclospora as well as many other pathogens, such as the nature of the dose/infectivity/response relationship, which is a key issue in conducting a quantitative risk assessment. Stated in a simpler fashion, we did not at the time of our outbreak and still do not know how many contaminated raspberries one must eat to become infected, or what concentration of Cyclospora oocysts must occur on a single raspberry to result in infection. Clearly, the state of the science is poorly-advanced an likely incapable of supporting a comprehensive and conclusive risk assessment for Cyclospora. Similar uncertainties confront the risk assessment community with respect to many other food- and waterborne pathogens. Now, why is risk assessment for pathogens so important? Risk assessment is a process that facilitates the organization of information on health risks posed by exposure to pathogens. Organization of information on health risks is necessary because of the complexity of such information and the likelihood that without such an organizational process, critical pieces of information leading to an understanding of the health risks will be missed. Additionally, the use of risk assessment methods to gather and organize information on health risks facilitates the identification of knowledge and data gaps that must be filled to fully understand and characterize risks. Finally, and I think most important, quantitative risk assessment can provide a probabilistic expression of health risks. This information is critical in assessing the efficacy of control technologies, in comparing the benefits of different control technologies, in the conduct of cost/benefit analyses, and in facilitating the development and selection of policy options to manage health risks. Without a quantitative assessment of health risks, we are left with simple guesses as to which control technologies or policies are most appropriate to reduce health risks associated with exposure to food- and waterborne pathogens. Risk assessment is not a panacea. It will not prevent all human infection and disease. And without reliable data, or used improperly, it can even provide misleading information. However, when used correctly and conducted with reliable data, risk assessment will provide and encourage the development of information that will lead to informed decisionmaking. It can also provide predictions of potential health risks, which can then be managed before disease occurs in human populations. At its best, it could even play a role in preventing the outbreak of cyclosporiasis and other pathogen-related diseases. For this reason, adequate resources must be made available to conduct comprehensive risk assessments for food- and waterborne pathogens and to address the many uncertainties and knowledge gaps that accompany the risk assessment process. I appreciate the opportunity to present these remarks and will be glad to entertain questions. Senator Collins. Thank you very much. Dr. Ostroff, it is my understanding that you are going to be presenting for the CDC today. Dr. Ostroff. That is correct, Senator. Senator Collins. Please proceed. TESTIMONY OF DR. STEPHEN M. OSTROFF,\1\ ASSOCIATE DIRECTOR FOR EPIDEMIOLOGIC SCIENCE, NATIONAL CENTER FOR INFECTIOUS DISEASES, CENTERS FOR DISEASE CONTROL AND PREVENTION, ATLANTA, GEORGIA, ACCOMPANIED BY DR. BARBARA L. HERWALDT, MEDICAL EPIDEMIOLOGIST, DIVISION OF PARASITIC DISEASES Dr. Ostroff. Let me begin by thanking you and other Members of the Subcommittee for holding this hearing and for your ongoing support and interest in food safety. --------------------------------------------------------------------------- \1\ The prepared statement of Dr. Ostroff appears in the Appendix on page 165. --------------------------------------------------------------------------- As mentioned, I am the Associate Director for Epidemiologic Science at the National Center for Infectious Diseases, and thus, I am responsible for all of the outbreak investigations that we do. I am accompanied by Dr. Barbara Herwaldt, from the Division of Parasitic Diseases, who coordinated our investigations of Cyclospora in 1996 and 1997. This is a dynamic period for public health and infectious diseases. Almost every year, we find a new disease-causing microbe or discover the causative agent for a previously-known disease, including ones like HIV, E. coli O157:H7, hepatitis C and hantavirus. Today, there are many challenges in our ability to protect the public's health. These include changing technologies, changes in the environment, global movements of people and products, population growth, and social and behavioral changes. These factors certainly operate in the area of food safety and foodborne diseases, where forces which were hard to imagine at the turn of the century, play a major role today, including a globalized food supply, large-scale food production and distribution networks, and changes in consumer eating habits. Although Americans have one of the safest and most diverse food supplies in the world, foodborne diseases remain a threat to us all. It has been estimated that between 6 and 33 million foodborne illnesses occur each year in this country. As a result of evolving patterns of food supply and production, the spectrum of foodborne disease is also evolving with new agents and patterns of transmission occurring. CDC's mission, put very simply, is to keep our finger on the pulse of the public's health. In the food safety area, we work with a variety of public and private partners to conduct surveillance for foodborne illness, investigate outbreaks, and perform special epidemiologic and laboratory studies. In public health, surveillance means the ongoing collection of information about health events such as cases of salmonellosis or botulism. Traditionally, this has been done using a system set up at the turn of the 20th Century in which physicians, hospitals and other sources reported illnesses to the health department. Today, these systems are simply not adequate by themselves to address 21st Century foodborne disease problems. In 1994, we issued a strategic plan called ``Addressing Emerging Infectious Diseases: A Prevention Strategy for the United States,'' \1\ which emphasized harnessing modern communications, computing and molecular biology to conduct our surveillance, applied research and prevention mission. This has been the platform for all of our activities under the President's National Food Safety Initiative. --------------------------------------------------------------------------- \1\ Exhibit No. 3b is retained in the files of the Permanent Subcommittee on Investigations. --------------------------------------------------------------------------- It seems natural to ask why the estimates of the burden of foodborne disease are so rough. In order to determine the true burden, a series of actions have to occur, as you will see on the poster that is about to be displayed. First, the illness must be serious enough for the victim to seek medical attention. Then, the clinician must consider the cause to be foodborne and request the proper tests. The right specimens have to be collected, and the lab must be able to do the right tests. The results must then be reported to the health department and eventually to CDC. For many cases, not all of these steps occur, and these cases are missed. As an example, we estimate that there are 2 million cases of salmonella infection in the United States annually, but only about one in 40 are ever identified and reported to the health department. CDC and its partners have been working to build better reporting of foodborne illnesses. These steps include building better capacity in State and local health departments for foodborne disease investigation and lab diagnostics, establishing automated reporting systems for foodborne pathogens, and, for better and faster analysis of data, creation of a system known as FoodNet in seven health departments around the country to actively seek out cases of foodborne illness and determine the true burden of diarrheal disease. FoodNet is one of the major tools we must have to demonstrate the impact of actions initiated by our partners at USDA and FDA, such as the 1997 Food Code and HACCP measures, on the ultimate goal of lowering the incidence of human foodborne diseases. Outbreaks are defined as a greater number of cases of illness than expected within a given time frame or geographic area. About 400 to 500 foodborne outbreaks are reported annually to CDC. This, too, is likely to be a gross underestimate as many outbreaks are never recognized, and seemingly sporadic cases of illness are never linked together. To better identify outbreaks, CDC has worked to create the PulseNet system for molecular fingerprinting of foodborne pathogens, much like the local police department fingerprints criminals.\2\ This poster shows the current status of the FoodNet system, which is nationally based, with a centralized computer database at CDC.\3\ Whenever we find two microbes with the same fingerprint pattern, it means they are somehow linked. Our job is to find out how. --------------------------------------------------------------------------- \2\ See Exhibit No. 5a which appears in the Appendix on page 55. \3\ See Exhibit No. 5b which appears in the Appendix on page 56. --------------------------------------------------------------------------- Using resources provided by CDC, routine use of this technology allowed Colorado to recognize the E. coli outbreak linked to beef patties last year, leading to the recall of 25 million pounds of ground beef. This outbreak surely otherwise would have been missed. Molecular viral sequencing allowed us to show that the cases of hepatitis among schoolchildren in your home State of Maine last year were part of the larger frozen strawberry outbreak which was mentioned by Senator Levin in Michigan school children at the same time. CDC's role in outbreak investigations is very well- illustrated by the 1996 and 1997 outbreaks of infection caused by Cyclospora, which the other two presenters have mentioned. Senator Collins. Excuse me, Doctor, I apologize for having to interrupt you. We are in the midst of a vote, and I have only 2 minutes to make it to the floor. It seems to me this is a good breaking point, because I know the next part of your testimony will talk specifically about the 1996-1997 outbreak of Cyclospora which is our cases study today. Dr. Ostroff. That is correct. Senator Collins. So, with apologies to everyone, I am going to call a 15-minute recess, because we unfortunately have two votes. I hope I will make this one, and then we will have a second vote, and I will come back as soon as possible. We will be in recess for 15 minutes. Thank you. [Recess.] The Subcommittee will please return to order. Dr. Ostroff, I will ask you to continue with your excellent testimony. Dr. Ostroff. Thank you, Senator. Getting to the Cyclospora issue, CDC's role in the outbreak investigation is very well-illustrated by the outbreaks of infection caused by Cyclospora in 1996 and 1997. Cyclospora is typically characterized by watery diarrhea and other symptoms such as nausea, abdominal cramps, weight loss and fatigue. If not treated, as was mentioned, the illness can be severe and prolonged. Before 1996, most of the small number of cases of cyclosporiasis in the United States occurred in travelers who had been in developing countries, and only three small U.S. outbreaks had been reported. This pattern changed dramatically in 1996 when health departments noted cases of cyclosporiasis in people who had not traveled overseas. In mid-May of 1996, health departments in Florida and New York informed CDC that sporadic cases of cyclosporiasis had been identified in their States. At the end of May, health departments in Texas and Canada told us that some people who had attended specific events such as a party had become ill with cyclosporiasis. Thus, we were notified of what we refer to as ``clusters'' of cases, which indicated that an outbreak may be occurring. Ultimately, 55 clusters with a total of 725 cases of cyclosporiasis were reported to CDC by 14 States, the District of Columbia and two Canadian provinces. These clusters were associated with events that had occurred between May 3 and June 14, 1996. In addition, 740 sporadic cases that were not associated with identified events or with overseas travel were reported, for an overall total of almost 1,500 cases from 20 States, District of Columbia, and two provinces in Canada. Twenty-two people are known to have been hospitalized, but no deaths are known to have occurred. As mentioned earlier, because many cases are probably not recognized, these numbers are likely to be very gross underestimates. CDC played many roles in the outbreak investigation, including serving as the national reference laboratory for identifying Cyclospora in stool specimens, thus confirming that the parasite caused the outbreak. This role was particularly important because many laboratorians had not had any experience in identifying Cyclospora. We also helped State and local health departments conduct the studies that ultimately implicated raspberries as the food item that had made people sick, focusing on the clusters of cases that were associated with specific events. Health departments interviewed the people who had attended the respective events about what they had consumed and compared the responses of the sick and the well people to see how they differed. CDC assisted in various ways--for example, by helping to design the questionnaires, conduct the data analysis, and identify important issues that needed to be addressed in the investigations. In several instances, we actually fielded teams to assist the State health departments with the investigations. As more and more clusters of cases were identified, CDC's coordinating role at the national level became more important. We sponsored frequent conference calls for all participants who were doing investigations and a meeting in July 1996 to discuss the findings to date and help establish priorities for the investigation and for future research. Whereas the investigators from the individual States and localities were able to focus on their own jurisdictions, our job was to look at the overall national patterns that emerged as data from the individual clusters was compiled and analyzed. Fresh raspberries were found to have been served at virtually all of the clusters of events, and a strong statistical association was found between illness and consumption of raspberries. Studies that compared the exposures of sporadic cases and control subjects were also conducted and also implicated raspberries. Once it was determined that raspberries were the food item responsible for illness, the next step was to determine where they had been grown, a process which required close coordination with FDA, State and local agencies, and industry. The tracebacks entailed determining where the various events took place and where the raspberries that were served had been bought. The raspberries were then tracked from suppliers and distributors back to importers, exporters and farms of origin, looking for common themes at each step. The available traceback data implicated Guatemala as the common source for the raspberries. Investigators next tried to determine how the raspberries became contaminated. We sent investigators to Guatemala and Miami, a major port of entry for imported raspberries, to explore possible modes of contamination. We were able to observe how raspberries were grown, picked, sorted, packed, cooled, transported and inspected. Because no step along the path after the berries left the farm was linked to all events for which we had adequate data about the source of the implicated raspberries, we concluded that some practice or attribute common to multiple farms was the most likely explanation for the outbreak. As was mentioned, one hypothesis was that contaminated water may have been used to mix the insecticides, fungicides and fertilizers that were sprayed on the raspberries. Good laboratory methods for detecting low levels of the parasite on produce such as raspberries, or in water and other environmental samples, are not available. By the time the clusters of cases were detected, leftover raspberries from the events were not available for testing. Although the precise mechanism by which the raspberries became contaminated was unclear, FDA and CDC provided suggestions to the Guatemalan Berry Commission about possible ways to reduce the risk for contamination. The Berry Commission voluntary implemented various prudent measures to improve water quality and sanitary conditions on farms that were going to export to the United States in subsequent export seasons. Despite these control measures, another multi-State outbreak linked to Guatemalan raspberries occurred in North America in the spring of 1997. CDC learned of this outbreak in early May 1997, when several health departments informed us of clusters of cases that were associated with April events. Ultimately, 41 clusters with over 700 cases were reported which were associated with events that occurred April 1 through May 26, 1997, in 13 States, the District of Columbia, and one Canadian province. Counting the sporadic cases, more than 1,000 cases in 17 States, District of Columbia and two provinces were identified. Once again, the investigation which focused on the clusters of cases implicated fresh raspberries and Guatemala was found to be the major source of the implicated berries. The outbreak ended shortly after Guatemala voluntarily suspended exportation of fresh raspberries to the United States at the end of May 1997. Why did the second outbreak occur? One possibility is that the control measures on the farms were never adequately implemented. Another is that the true source of contamination was not found, so that the measures which were taken did not control the problem. The latter is certainly possible since there are so many critical questions about this parasite which we cannot answer. For instance, we do not know where the parasite lives in nature. With no animal models for the disease, it cannot be easily studied in the laboratory setting. Infected human stool is the only source we have for this parasite, so a ready supply of the organism is not very easy to obtain. We have no test to tell us whether the parasite is alive or dead, other than when it causes human illness, and no subtyping methods like we do for some of our other pathogens. Most importantly, we do not have a good test for it in fruit or in water. Although this parasite can be cured with antibiotics, as our mothers told us, an ounce of prevention is worth a pound of cure. Lacking these answers, the only preventive measure available to FDA was to restrict the import of Guatemalan raspberries into the United States between March 15 and August 15 of this year. So far, this step seems to have worked, since we have seen no Cyclospora outbreaks linked to raspberries in the United States this year. The Cyclospora story is a model for emerging foodborne diseases in many ways. This includes a newly-recognized pathogen, many unanswered scientific questions, an unusual food vehicle for disease, a high-profile disease outbreak involving thousands of people over multiple States and countries, and economic and diplomatic overtones. As we move into the next century, we are likely to see more stories like Cyclospora that involve a newly-recognized microbe and many unanswered questions. We must have the tools at hand to rapidly recognize and respond to these new foodborne threats. As we work toward this goal, the number of reported cases and outbreaks will probably first go up rather than down. This should be viewed as good, as it means we will be seeing the problems that we now surely miss. We can only devise appropriate preventive measures and assure ourselves that our risk reduction strategies work if we know what the problem are that are out there. We owe this to you and to the American consumer as we move into the next century. Thank you for your time, and both Dr. Herwaldt and I would be happy to answer any of your questions. Senator Collins. Thank you very much, Dr. Ostroff. Dr. Ostroff, let me start by asking you a question about the recent outbreak of Cyclospora in Canada. You mentioned just now that the United States took steps to ban the export of Guatemalan raspberries, which seems to have prevented the spring outbreak in the United States that occurred during 1996 and 1997. In Canada, however, we have had a spring outbreak of Cyclospora just this year. Can you tell us anything about the Canadian outbreak? Is CDC involved at all in assisting the Canadian public health authorities in trying to do the traceback process? Dr. Ostroff. Yes. Let me answer very briefly and then I will ask Dr. Herwaldt if she has anything to add. We have been assisting the Canadians in looking into the outbreaks, the clusters, which have been recognized so far in 1998. Our understanding is that there have been 14 separate clusters that have been recognized involving about 200 individuals. Certainly the preliminary data--and those numbers will probably change; they are very preliminary--suggests that these outbreaks are once again linked to raspberries. The preliminary information in terms of the tracebacks suggest that the source was Guatemala. Again, we have been assisting the Canadians in terms of conducting the investigations as well as the tracebacks. Barbara, do you have anything to add? Dr. Herwaldt. No. I would just like to reiterate what Dr. Ostroff said. The investigation is ongoing. All the numbers are preliminary. Both clusters and sporadic cases have been identified, and as he pointed out, both the epidemiologic and traceback investigations to date are leading us and the Canadians to the conclusion that again, Guatemalan raspberries have caused this outbreak. Senator Collins. Dr. Herwaldt, I would like to examine with you in more detail the traceback process. Senator Lieberman aptly described it as being akin to a medical detective story, and I think it is, in many ways. I know that the CDC is not responsible for every part of the investigation, but I would like you to respond based on your knowledge of how other entities cooperate with the CDC and give us a fuller picture of the traceback process going from a patient like Dr. Foran, who became ill from eating the contaminated raspberries, back to the farms in Guatemala. First of all, I assume that you start with reports from State health departments that identify an incidence of cyclosporiasis and that they were greater than normal. But it must have been difficult for public health authorities, given what Dr. Ostroff has told us about the lack of information and the lack of tests, to deal with this rather exotic microbe that we are dealing with in Cyclospora. Could you tell us how the reports came to the CDC and walk us through the process? Dr. Herwaldt. Yes. Thank you for the question. These sorts of investigations are very complex, as you alluded to, and difficult to conduct. It requires the collaborative work of many persons from many agencies. As you said, we initially hear about cases of ill persons from State health departments, local health departments, sometimes from the physician and sometimes from the patient himself or herself. Cyclospora is one of the many emerging pathogens that we are dealing with, and many people in State and local health departments know that we are interested in organisms such as Cyclospora and do let us know when they hear of cases. As has been previously mentioned, there are some severe constraints we are operating under because many sick people may not go to see their doctors, and many doctors may not do the appropriate tests. They may not realize that you have to specifically request testing for Cyclospora to have the testing done. Many laboratories, at least before the 1996 outbreak, did not yet have the necessary experience and expertise to identify the organism even if they did the appropriate test. So there were many links along the chain for us to even hear that a case was caused by Cyclospora. Sorry, did you have a question? Senator Collins. Once you do get that report, is there an interview process where you try to figure out who ate what, at what event? Dr. Herwaldt. Exactly. Senator Collins. I mean, to try to identify the food involved must be a difficult task and involve some sort of interview process; is that correct? Dr. Herwaldt. Yes. Senator Collins. Tell us about that part of the process. Dr. Herwaldt. OK. We have two types of cases, and I will emphasize what happened with the clusters of cases. These were associated with events, or parties. To investigate them, the health department would use a structured questionnaire and interview both sick people and well people, asking them not only about their symptoms, but about everything they ate and drank at the event. Then they would compare the exposures of the sick people and the well people to see how they differed. Then, statistical tests would be used to determine what could differentiate the exposures and determine what caused the illness. We had both the blessing and the curse of having multiple clusters. We did not have just one little one; we had multiple ones. It was both a blessing and a curse. It was a curse because, obviously, it required much more work, but it was a real blessing because it strengthened our conclusions and made them all the more compelling because we had the same conclusions being reached by multiple investigators scattered all across the country and also in Canada. Senator Collins. When did it become evident that the raspberries were the culprit? Dr. Herwaldt. Well, there are a couple of different kinds of evidence. First and foremost, the mere fact that raspberries overwhelmingly were the common theme was an important observation. Of course, that was not clear at the very beginning because we just knew of a few clusters at that time. But as we heard of more and more clusters and more and more events and learned about the menus, it became quite obvious that raspberries were the common theme. Then, we moved one step beyond that. We did not rely on that alone. We also wanted strong statistical evidence that could compellingly say with real confidence that it was the raspberries. Senator Collins. Once you identified raspberries as the source, how did you then go about determining where the raspberries came from? Dr. Herwaldt. In all aspects of the investigation, we looked for common themes. That was true for the epidemiologic aspects, and it was true as well for the traceback aspects. We looked for common themes at every step along the way. To trace the source of the raspberries, we had to, as Dr. Smith pointed out, look at every step. We were going in reverse; it was to trace back from the table back to the farm. For example, if there was a party, we needed to find out where the raspberries were bought, where they came from--was it a restaurant, was it a supermarket--where that supermarket or restaurant got its raspberries. We had to go back to the distributors, and from the distributors back to the importers, and from the importers back to the exporters, and from the exporters back to the farms. So every step along the way had to be investigated in detail, and again, the overwhelming common theme was Guatemala, so that we could confidently conclude that not only were raspberries the vehicle but that Guatemala was the source of the raspberries. Senator Collins. Did the CDC actually visit farms in Guatemala to try to pinpoint the source of the contamination? Dr. Herwaldt. Yes. CDC in fact fortuitously has a field station in Guatemala which has facilitated our investigation, but on multiple occasions, officials from CDC here in the States, as well as from FDA and other agencies, have gone to Guatemala. Unfortunately, we have not been able to identify with confidence the mode of contamination. As has been previously mentioned, we have various hypotheses, but we do not yet know with certainty what caused the problem. Senator Collins. The CDC was able to trace the source back to specific farms. As I understand it, there were 10 farms that were visited, and your statistical analysis suggests that five farms could have been the source of some 85 percent of the contamination. Is that accurate? Dr. Herwaldt. That is actually a little bit complex, because the problem is you do not always know with certainty which shipment of raspberries was used to supply a supermarket or a restaurant or whatever. Then, in addition, usually, multiple farms contribute raspberries to a shipment of raspberries. So what we needed to do was say for an individual event, this was the list of possible farms that could have contributed the raspberries, and then we again looked for common themes. We were able to say the minimum number of farms that could have been responsible, but we did not know for sure necessarily that it was Farm X, Farm Y, Farm Z, in all cases. But we can say that no one farm could have accounted for the whole outbreak, nor could any one exporter have accounted for the whole outbreak, and that is true for the 1996 outbreak and the 1997 outbreak. Senator Collins. Is the CDC's best hypothesis at this point that it is a case of contaminated water used by the farms? Dr. Herwaldt. I would say that that is one of our major hypotheses, and it is an attractive hypothesis for several reasons. First and foremost, we know that this organism can be transmitted by the waterborne route. Also, another reason the hypothesis is attractive is we need a hypothesis that can account for the fact that both outbreaks were rather long, and no one farm could account for the entire outbreak. So we needed a mechanism for contamination of relatively large numbers of raspberries. But given that it is an emerging pathogen, so many unanswered questions, and we do not have definitive evidence of how the contamination occurred, we do not want to be too strong in what we say about how it might have occurred. Senator Collins. Thank you. Dr. Smith, I would like to turn to you to learn more about the Subcommittee's investigation and specifically, your visit to the 10 berry farms in Guatemala. First, are raspberries native to Guatemala? Dr. Smith. They are not. Senator Collins. Could you tell us how raspberries came to be grown in Guatemala and the role that the United States may have played in that effort? Dr. Smith. Actually, it was the United States Agency for International Development that, through contractors, got the Guatemalans and other Central American countries into nontraditional agricultural crops for export. In the 1980's, the contractors introduced blackberries, and then the decision was made, because of the demand being higher in the United States for raspberries, that raspberries be considered, and in fact, in the early 1990's raspberries were introduced. Senator Collins. Could you tell us a bit more about your observations on the farms that you visited? Did they vary as far as the conditions you found on the farms, or were they all approximately the same? Tell us more about your personal observations as a food scientist when you were in Guatemala. Dr. Smith. Actually, at the time we were there, which was the end of March, beginning of April of this year--and some things have changed since then as far as measures put in place--but at the time, they were categorizing based on a set of criteria, and they had inspectors give scores. The criteria included water source, the packing shelter, materials that were used to make the structure itself, recordkeeping, personal hygiene of employees. These kind of things were considered, a numerical value was given, and then, based on that numerical value, the farms were categorized high, medium or low risk. Since then, the high-risk farms have gone out of business, and I believe even since then, some of the medium-risk---- Senator Collins. Excuse me. Since your visit, some of the high-risk farms where you observed conditions that caused you concern are now no longer in production; is that correct? Dr. Smith. Actually, we did not even go to a high-risk farm. We saw a medium-risk farm, and medium-risk farms are now out of business, too. So when AID first went down, there were about 12 farms that they worked with, and that grew to about 150 farms, and the most recent information I have is that they are back to about 26 farms. So that only the farms doing the best job with the best infrastructure are still remaining and being considered for potentially exporting to the United States next spring. Senator Collins. Understanding that the farms that you observed may no longer be producing, could you describe some of the conditions that caused you concern and that could be a possible source of cyclosporic contamination? Dr. Smith. Yes, and I will refer to notes that I took while in that country. We did see one medium-risk farm, and one concern that I had was dirty toilet facilities. Actually, when I went to wash my hands after using the facility, I could not get water out of it; but I was shown to a sink inside which the employees were using, and there was water with soap and paper towels. Again, that was a medium-risk farm and is no longer in existence. Senator Collins. Dr. Foran, one of the most fascinating aspects of your testimony was that when you became ill, you went to your physician, and your physician was not able to diagnose you originally as having a foodborne illness. It sounds to me like you more or less put the evidence together yourself when you heard of your friends who were at the same luncheon, who also had similar symptoms. In addition, I believe that you read about press reports of Cyclospora. Is that accurate? Dr. Foran. Yes. The group of us that participated in the luncheon all developed the same symptoms, identical symptoms, at the same time. As a scientist, but even as an individual, that was well beyond any expectations of coincidence. That led to the first suspicion, although we did not know the disease or what was causing the symptoms. But shortly after that, we saw an article in The New York Times that described an outbreak of cyclosporiasis, I believe it was in New York, and it described the symptoms associated with that outbreak, and they were identical to our own. At that point, simply putting two and two together was very easy. Senator Collins. Dr. Ostroff, that suggests that public disclosure of foodborne illnesses is very important, because in this case, it enabled Dr. Foran to get treatment that he might not otherwise have gotten. And while it is my understanding that people do not die of cyclosporiasis, there are other foodborne pathogens that can cause death. How does the CDC decide when it has enough evidence of a foodborne illness to make that information public and thus to alert unsuspecting clinicians or patients that they may in fact be suffering from a foodborne illness? Dr. Ostroff. Senator Collins, that is an excellent question, and it is an issue that we constantly struggle with as we conduct investigations with our partners at the State and local levels of foodborne disease outbreaks. A similar example in the last couple of months has been the salmonella outbreak in the Midwestern States which turned out to be associated with the toasted oats cereal. Part of the difficulty is that if you make an announcement before you have all the data you need to assure yourself with scientific certainty that you are correct, you could potentially implicate the wrong product, that would put a smear on a product and an industry that you will have difficulty dealing with. In addition, it will not be preventing any illness. Alternatively, if you wait too long, you decrease the likelihood that you are going to be able to prevent additional cases of disease. In addition, certainly at the Federal level and at the State level and at the local level, there are very different priorities in terms of being able to get information out to the public about a perceived risk. It requires an enormous amount of coordination to be able to successfully know the precisely correct moment to inform the public about these problems. One thing that we have done at CDC is to work very collaboratively with our partners at the State level and the Council of State and Territorial Epidemiologists to set up a group that can get together 24 hours around-the-clock to discuss all of the epidemiologic information that has been collected up to a certain point. This allows us to make a unified determination about whether we have enough to go public with the information. This is one of the things we have set up in the last year or two to specifically deal with the problem that you have identified. Once we feel that we do have that information, we make the full court press to the degree that we can to get this information out, both in terms of presenting the information to the media, putting reports in our weekly report, which is the Morbidity and Mortality Weekly Report. With the increased scrutiny and attention that foodborne outbreaks are getting, the level of media interest has increased astronomically, so there is much more attention and much more likelihood that people will hear about these problems, but it is a very delicate issue. Senator Collins. Thank you. Senator Lieberman. Senator Lieberman. Thank you, Madam Chair. I regret that I have been in and out today, because this hearing is of real interest to me, but I did get a chance to read the testimony that was submitted beforehand, and I appreciate very much your presence here today. Dr. Smith, I want to start with you, and again, thank you for your excellent work for the Subcommittee. In your testimony, you mention that pesticides in the Guatemalan farms are often mixed with what is described as drinking-quality water. I noticed a memo which was an attachment to the Permanent Subcommittee on Investigations' excellent report, from a Dr. Marta Ackers of CDC, which described water that does not sound very appealing, which is to say that several of the implicated farms drew from open reservoirs, shallow wells or rivers which were subject to contamination. It continues, ``On at least one farm, the river from which the farm obtained its water supply was noted to have people bathing in it upstream, in addition to garbage floating in it.'' And the article in The New England Journal of Medicine describing this outbreak refers to wells maintained near deep- pit latrines or seepage pits. My question is is it fair to assume that the drinking water quality in Guatemala falls far below the health standards that we would apply to that term here in the United States--or, am I being unfair in taking that term ``drinking-quality water''---- Dr. Smith. I think I know what you are getting at, Senator. Certainly, even in Guatemala, I do not think they would consider that ``drinking-quality'' water. And what is important to keep in mind is that that report referred to the outbreak which occurred in 1996, and since that time, there have been continual efforts, and in cooperation with FDA and CDC, the Guatemalans have tried to put in place practices that are closer to what the United States does to the point now where I would say that they are very comparable. And the most recent proposal submitted by the Guatemalan Government in order to be allowed to export to the United States next spring would be that their three best farms, which FDA is requiring have filters, where the mesh is actually small enough that it would not allow the Cyclospora organism to get through, to be used prior to the water being used in any way associated with the plant. Senator Lieberman. So the conditions described in Dr. Acker's memo from CDC and in The New England Journal of Medicine article, which are certainly unappetizing and unsanitary---- Dr. Smith. And unacceptable. Senator Lieberman [continuing]. Unacceptable--to the best of your knowledge of the circumstance now, those are being changed, or being improved. Dr. Smith. Correct, and that has been with assistance from the U.S. Government agencies. CDC and FDA have been providing assistance. The Guatemalans have also hired U.S. scientists as consultants to help them get proper procedures in place and improve their infrastructure. Senator Lieberman. OK. Just to show how complicated this can be, but you will help me understand it--let us assume they install the kind of very modern, elaborate filtration system for the water. How do we assure ourselves that they are guarding against surface water runoff which may bring with it contaminants--or is that less of a real concern? Dr. Smith. The primary concern would be water that is intentionally put on the plant. Certainly, runoff is also a concern. Part of the problem here is that we do not really understand what the source of the contamination is, and if we had a better understanding of how it was getting introduced onto the product, we could take preventive measures accordingly. So that has been the challenge. This organism--and Dr. Herwaldt can comment more about the organism's unique characteristics--but it seems to be highly seasonal and has been associated with the rainy season. So the more we learn about this particular organism, the more it is going to help with taking the proper preventive measures and interventions necessary. Senator Lieberman. That leads me to the next question. I was very interested in the chart and the way you tracked the raspberries from the farm in Guatemala to the stores and in a sense to the tables here in the United States. I want to go back to the port of entry when the raspberries entered. Am I correct that the U.S. Department of Agriculture does inspect the raspberries at that point? Dr. Smith. That is correct, APHIS. Senator Lieberman. And what is the nature of that inspection? Dr. Smith. That is merely a visual inspection. The inspectors actually put the fruit or vegetable out on a table and look for insects--live insects would be actionable--or signs of disease. Senator Lieberman. In the fruit itself? Dr. Smith. Yes, or maybe there would be a soft, brown spot. Senator Lieberman. Which again would be visibly observable? Dr. Smith. Correct. Senator Lieberman. And the goal there is--certainly, with the inspections, I presume the goal is to stop insects from coming in that could affect---- Dr. Smith. U.S. crops. Senator Lieberman [continuing]. U.S. crops. And the visual inspection is for what we might call just bad fruit which would affect people who would eat it, or---- Dr. Smith. That is the distinction I need to make, that the mission of APHIS---- Senator Lieberman. Why don't you spell it out for us? Dr. Smith. I am sorry. It is the Animal and Plant Health Inspection Service, and that is under the Department of Agriculture. Their mission is to protect the United States plant and animal resources. So they are not looking at food for human disease, and it is incidental in some ways that plant materials are actually food. So they are looking at it as plants rather than as food. Senator Lieberman. And at the port of entry, does the FDA play any inspection role? Dr. Smith. The FDA does. They have to clear each entry. That may just involve looking at the paperwork that comes with the entry. It could also involve, however, visual inspection, going and looking at the product, and in addition they may decide to sample the product and have laboratory testing done. Senator Lieberman. Do you have any idea what the nature of the inspection of this particular run of Guatemalan raspberries was when it came in? Dr. Smith. I do not know. Senator Lieberman. But is it fair to conclude that at this point, just to make the point, our law and its implementation really does more to protect plants and animals in the United States than it does to protect people who eat the fruit or vegetables coming in? Dr. Smith. Certainly, APHIS looks after plant and animal health. I would not say that FDA does not look after human health, though. I think the issue here is that Cyclospora cannot be detected visually, and there is not even a laboratory test for it. Senator Lieberman. I want to get to that. I guess the point I want to make is that from what I understand--and it is unsettling, but it is something that I hope we will deal with-- on the average, fruit and vegetables coming into the United States are much more likely, because there is a larger apparatus there to be researched, to be inspected by APHIS of the Department of Agriculture for possible damage to plants and animals in the United States, than to be inspected by FDA for possible damage to people, because FDA does not have the same resources to do it. You can almost always be sure that there was some kind of visual inspection of the fruit by the Department of Agriculture, and clearly not so by the Food and Drug Administration. Dr. Smith. I was told by an APHIS inspector that their target is 2 percent per shipment. Senator Lieberman. Two percent of every shipment is inspected. Dr. Smith. Correct. Senator Lieberman. Then, the second point that you made is an important one, and this goes to the question of how do we come up with a remedy that not only looks good, but really does something, which is that when we are talking about organisms like the one involved in cyclosporiasis, a visual inspection would not do anything; right? Dr. Smith. That is correct. Senator Lieberman. Let me ask the CDC, is it conceivable that we might get to a point--is there technology being developed where we might get to a point where fruit and vegetables coming into the United States could be subjected to some kind of inspection that would reveal pathogens like this one, or all the others that have caused illnesses? Dr. Ostroff. I guess, Senator, the easy answer to that is that at some point in the future, we may reach that point, but ultimately, the better thing would be to not have to worry about having to do the test in the first place. Certainly, especially for fruit and vegetables, if you look at the raspberry issue, raspberries are very highly perishable. That is why, in terms of the process that Dr. Smith was describing, you have to very rapidly get them from farm to table, or they have perished. To potentially have to hold them up to conduct this type of testing and receiving the results, would decrease the relevance. Senator Lieberman. So the science here is a ways away. Dr. Ostroff. Yes, that is correct. Senator Lieberman. And as we think about remedies for this problem to protect people from diseases carried by food imported into the United States, it may be--the discussion that Dr. Smith and I had indicated that FDA does not really have much in the way of inspection at the port of entry--that the real point here is the other one we are talking about and that you have worked on here, which is to try to establish standards in the country of origin, of growth, to raise the level to guarantee that we are going to eliminate the possibility for these diseases which really cannot be seen in an easy way. We are not even sure now exactly what caused this outbreak, are we? Dr. Ostroff. No. That is correct, Senator. Senator Lieberman. Madam Chair, I have a few more questions, and I can yield back to you or follow your judgment as to whether you want to do another round. Senator Collins. Why don't we do one more round. I only have a few more myself. Senator Lieberman. Fine. Thank you. Senator Collins. Dr. Herwaldt, I was reading one of the CDC reports which contained the intriguing information that the Guatemalan population experiences during the rainy season what I guess is called ``mal de Mayo,'' which is a gastrointestinal disease that seems to come in the spring. Similarly, it appears that the Guatemalan raspberries that are tainted with Cyclospora are also seasonal. There does not seem to be a problem in the fall, the winter or the summer, but just in the spring. Do you think there is a connection? Does that suggest that Cyclospora is the cause of the illness that the Guatemalans are suffering through in the spring and also could be--I am just asking. I was intrigued as I was reading through the report. Dr. Herwaldt. We wish we could answer that question, and actually, it is probably a series of questions. It is a very intriguing thought, and it is one that we have been wrestling with since these outbreaks occurred. The first point is an important one, which is that this does appear to be a seasonal disease, not only in Guatemala, but in some other countries where it has been studied. In Guatemala, human infection does peak during the spring months. But as we have pointed out before, we still do not know how the raspberries became contaminated, and therefore, do not know whether humans played a role in that contamination either directly or indirectly. Certainly, ``mal de Mayo'' is caused by a number of different microbes, so it is not just Cyclospora. Cyclospora is part of ``mal de Mayo,'' but it is not all of ``mal de Mayo.'' We need to have a better understanding not only of ``mal de Mayo'' but of the seasonality and what accounts for it. We can say that the 1997 outbreak actually began before the rains began in earnest, and therefore, although moisture may play a role, it is probably not as simple as saying that when the rains begin, then Cyclospora begins. We do not have all the answers. Senator Collins. Let me ask you a question, Dr. Ostroff--I was not trying to play medical detective there, but it does strike me as an interesting coincidence that suggested a possible link. Another question that has been raised is why raspberries and why not blackberries, which are also grown in Guatemala. We have two electron photomicrographs of a raspberry and a blackberry, and as they are shown here,\1\ you can see that the surfaces of the two berries appear to be very different. --------------------------------------------------------------------------- \1\ See Exhibit No. 4 which appears in the Appendix on page 53. --------------------------------------------------------------------------- Could the differences in the berries' surfaces account for why Cyclospora has been associated with Guatemalan raspberries but not Guatemalan blackberries? Is that something that has been looked at? Dr. Ostroff. I think it is certainly one hypothesis that may indeed play a role. If you look at these pictures, it is obvious that the surface of raspberries, especially when you look at them under a microscope, is quite convoluted. There are lots of crevices and lots of nooks and crannies on the raspberries. We know that some of those nooks and crannies are the exact size that makes a very nice place for an organism like Cyclospora, which is 8 to 10 microns in size, to hide out. That is certainly one possibility. What we do know is that the overwhelming preponderance of the data that was collected in 1996 and 1997 certainly suggested that raspberries were the major culprit. It does not mean that we could totally exonerate blackberries, because certainly in many of these clusters, at many of these events, at many of these parties and weddings, we know that what was actually served was a fruit cup, or some item which had multiple different berries including, in some instances, blackberries. We cannot say with absolute certainty that there has not been any illness associated with blackberries. What we can say is that the overwhelming amount of the evidence certainly suggests that raspberries were the major culprit here. Senator Collins. Thank you. Dr. Foran, could you elaborate more on the role that you think risk assessment could play in helping us get a handle on this problem of foodborne pathogens? Dr. Foran. I was intrigued by Senator Lieberman's question or statement at the end of his observations, which I thought were excellent, about the level of guarantee I think he suggested, and should we be able to implement a particular technology, say, in Guatemala to deal with Cyclospora. I would phrase that question just a little differently, that is, rather than suggest that we want to know something about the level of guarantee, we want to know something about the level of risk reduction, and that is where risk assessment comes in. Suppose we implement technology--a filter of some sort to remove the pathogen. Well, it is unlikely that there is anything we can do that completely removes the pathogen from a process. So the consequence will be that we will have some pathogen leftover. I think the question we have to ask is how much pathogen is left over, and how much risk does that pose when it is left over, assuming that some of those raspberries will have a small amount of pathogen left on them when they come into the country. Again, that is where risk assessment can play a very important role. One, it can predict the risk associated with eating the raspberries when there is a small amount of pathogen left on them, so it can help us understand the efficacy of the technology that we use to reduce pathogen. Two--and what is more likely with regard to Cyclospora--it is going to tell us that we do not know what the answer is, and we do not know what the answer is because there is a whole array of uncertainties--we do not understand the dose/ infectivity/response relationship; we do not even understand how to detect the organism. I argue that risk assessment is a very effective tool in organizing and identifying the uncertainty and the scientific questions that we have to address through research so we can ultimately go back and make that prediction and make that estimate of the level of guarantee that we have got a safe product. Senator Collins. Thank you. Dr. Ostroff, it occurs to me that the increase in food imports, particularly of imported produce in this country, has allowed us to try exotic new fruit and vegetables that we would not otherwise have access to. It has also improved our ability to have year-around access to fruit and vegetables. But it seems to me that a down side is that it has exposed Americans to pathogens that we do not have any natural resistance to; that perhaps these pathogens are less of a problem in their native lands because they are indigenous, and the population over time has built up some sort of resistance. How do we deal with this issue? Americans want these imported fruit and vegetables. They have given us variety in our diets, and they are supposedly healthy for us. But we are being exposed to emerging pathogens that we cannot even test; we do not even have the lab tests available for them. What do we do? Dr. Ostroff. That is another excellent question, and I think that is the challenge that an agency like CDC has, because it is our job to be able to monitor for these types of diseases as they occur. Many of these changes in dietary habits are quite good for our cardiovascular systems, but they wreak havoc on our gastrointestinal systems in some instances. We know that certainly the spectrum of pathogens, or microbes, that cause gastrointestinal disease in tropical locations are quite different than they are in many temperate zones, like the United States. We are being exposed, and we are seeing outbreaks such as the one of Cyclospora. I think another example of one that we probably would not have seen is the recent one in Chicago, where thousands and thousands of people became ill from an organism called enterotoxigenic E. coli--not the E. coli O157:H7 that seems to get all the attention--that was related to potato salad coming from a particular deli. We are seeing these new challenges. I am not sure I can state with absolute certainty that there is immunity built up in populations in tropical countries keeping them from getting the same types of illnesses from these pathogens that we do in the United States. I think that the systems for surveillance and monitoring and for diagnosis are not quite in place to the same degree that they are in places like the United States and other developed countries. Certainly if you look at Cyclospora, this is an organism that was only first recognized in the 1970's, and it was recognized in, of all places, Papua New Guinea. It is only because somebody was looking that they even identified these cases, and have probably gone on for some period of time. The only answer I can give you in terms of this particular challenge is that we need to have monitoring systems in place in this country so we can recognize these diseases and investigate them. I think, as importantly, that there are systems in place in the areas where these diseases naturally occur in the developing parts of the world so that we can identify, as was mentioned by Dr. Foran, what some of these risks potentially are even before they get here. Senator Collins. Thank you. Senator Lieberman. Senator Lieberman. Thank you, Senator Collins. Let me pick up briefly on the last, very interesting line of questioning from the Chair. I gather that before 1996, cyclosporiasis was very rare in this country and was generally associated with people who traveled internationally; and now, it essentially rode in on the back of the raspberries. I am about to ask you the kind of questions that Senators ask, and I want to give you the opportunity not to answer it, but a question I have is are we reaching the limits of the possible number of new pathogens coming in here because of the globalization of our food supply that has already occurred, or is this going to go on without limit? Dr. Ostroff. Senator, that is a question that many people other than Senators also ask. Senator Lieberman. That is reassuring. Dr. Ostroff. It is an excellent question. In this whole area of emerging infectious diseases, if you look at the array of different diseases and microbes that we have discovered over the last 20 years, it is a very impressive group of pathogens. Even in diarrheal diseases, if you just look at the diarrheal disease arena, if you were to take a large number of individuals who presented with diarrheal illness, and you sent specimens off to a clinical laboratory to look for the cause of their illness, in the large proportion of these people, the test would not show anything. We actually test for a relatively limited number of microbes when these specimens are sent off to the laboratory. Even in the research setting, if we were to apply the very best technology, all the razzle-dazzle diagnostics that we currently have available to us, in well over half of these individuals, we still cannot quite figure out what the cause of their diarrheal illness is. That does not mean that all of it is due to an infection. Some of it may be due to other kinds of causes. What it tells us is that there are still many bugs out there just waiting to be found, and in the same way that if we had done a study just like that in 1980, we would not have looked for E. coli O157:H7 because we did not know it existed until 1981 or 1982, we certainly would not have looked for Cyclospora because we did not know it was there. There are still lots of them out there, waiting to be found, so, by no stretch of the imagination, have we reached the outer limits in terms of the things that we are going to see in the coming years. Senator Lieberman. So there is more to worry about and work on. Also, as some of you indicated in your testimony, the number of reported cases is probably lower than the actual number of cases related to these pathogens that are brought in on food because of the difficulty of diagnosing. I did want to ask Dr. Foran--I was quite interested in your own experience, and just very personally, people watching this may wonder what was the difference in the treatment you received, based on your own connection with the newspaper article about this outbreak, once you told your doctor that you thought you had a foodborne illness? In other words, was it a significantly different treatment from the original response? Dr. Foran. It was not just communication that it was a foodborne illness. We were able to be much more specific than that, because events moved so quickly. We suspected there was a foodborne illness, and shortly after we saw the article in The New York Times which identified Cyclospora and the symptoms associated with cyclosporiasis, at that point, it was absolutely clear what we had and what was causing our symptoms. And I think that around the same time--and it has been 2\1/2\ years now--that the CDC began to become involved in the investigation, and I believe there was enough information about the appropriate antibiotic--and I have been trying to remember what it was, and I cannot--but putting all that together, I was able to go back to my physician and say we have a confirmed outbreak of Cyclospora, here is the appropriate antibiotic, give it to me. In essence, he did, and the rest is history. Senator Lieberman. You are a great patient to have. Dr. Foran. Some might argue. [Laughter.] Senator Lieberman. In other words, there was a particular antibiotic that you needed to take that dealt with this rather immediately, much different from the general treatment that a doctor--a good doctor--would give a patient who came in with some of these symptoms. Dr. Foran. Well, I would guess that a physician, if he or she suspected a foodborne illness, would use a standard antibiotic if the level of suspicion were high enough. In this case, there was a specific antibiotic that was effective for Cyclospora, and it was a 5-day course, and once that is taken, it is resolved. Senator Lieberman. I do not want to make too much of this-- but the difficulty in diagnosing is a problem because it affects the success of the treatment. Dr. Foran. No question, and the symptoms for cyclosporiasis were different than symptoms associated with most of the food- or waterborne pathogens that my physician and I assume most physicians were familiar with at the time--Cryptosporidium, E. coli, Salmonella, and so on. Senator Lieberman. Thank you. Very briefly, I have questions for the two witnesses from CDC. First, a simple question--are you satisfied with the cooperation that our government has received from the Guatemalan Berry Commission? Dr. Herwaldt. We have striven to work collaboratively with the Guatemalans. Again, we fortuitously had a field station and still have a field station in Guatemala which has facilitated this whole process. You can imagine it has not been an easy process because of the nature of what we had to work on together. We are having to work on trying to solve a problem related to outbreaks that have affected many people in the United States. Both sides have worked very, very hard to come together repeatedly and discuss what the issues are, to discuss how best to address them and to discuss where we should go from here. We have scientific constraints that we are dealing with, and we are working hard with the Guatemalans so they will understand why we do not have all the answers that they would like us to have. It certainly has not been an easy process, but we are happy that the Guatemalans have been eager to talk with us and to continue the collaboration despite the fact that there are these difficult issues to deal with. Senator Lieberman. And am I correct that they are under no obligation to talk with the U.S. Government, any legal obligation, that they are doing this voluntarily, I presume, with an economic motivation, which is that if they do not give some reassurance, the Guatemalan berries are not going to sell very well in the United States. But let me come back to my first question. Am I right that these are discussions and cooperative efforts that are going on voluntarily between our government and the Guatemalan Berry Commission? Dr. Ostroff. That is correct. Senator Lieberman. And I ask the question just to draw attention to the point that there is no existing statutory authority as I understand it for the U.S. Government to apply standards, safety standards, sanitary standards, for the production of produce, fruit and vegetables, and I guess grains, too, in foreign countries, as compared to the authority that I believe the U.S. Department of Agriculture has with regard to meat and poultry. Is my understanding correct? Dr. Ostroff. Senator, it would be best to have that answer from the Food and Drug Administration because this is in their sphere. My understanding--and again, I will emphasize, my understanding--is that your presumption is correct. Senator Lieberman. Maybe I should turn to our staff witness, Dr. Smith. That is correct, isn't it, that at the current time--and this is why we have the calls for the so- called equivalent authority---- Dr. Smith. Equivalency, correct. Senator Lieberman [continuing]. To give, presumably, FDA, or maybe some part of the United States Department of Agriculture the same authority that they have with regard to meat and poultry to certify the production standards in foreign countries, to give them that same authority with regard to fruit and vegetables. Dr. Smith. It is important to understand that under the GATT agreements, we already have the authority to--that we have the sovereign right is the way it is stated--to inspect food that we import into this country to meet our level of protection, however that is defined. The challenge comes in how we define that level of protection. Senator Lieberman. And how do we enforce it. Dr. Smith. And how do we enforce that so that it is met domestically before we can impose it internationally. In this situation, the Guatemalans have voluntarily allowed our U.S. Government agencies to go into their country and work with them, so we have not had an issue there, but that might not be the case with other countries. Senator Lieberman. You made a good point, that the standard with regard to meat and poultry is that the country of origin has to have sanitary and safety standards comparable to ours. Is that right? Dr. Smith. That is correct. Senator Lieberman. Now, I am interested in what you said about GATT. Theoretically, if we were concerned that fruit and vegetables were coming in from a country that had deficient standards, we could initiate an action at the World Trade Organization? Dr. Smith. We need to establish, though, that we do it domestically, and currently, as far as agricultural practices, the FDA is developing guidance on that, but there are no formal standards or regulations in place. Senator Lieberman. And I gather, incidentally, as a matter of note, that only 37 countries, interestingly, have passed the USDA test with regard to meat and poultry, so a standard has been applied that not everybody has met. This is one constructive way that we in Congress can go forward, which is to give more detail and substance to what is implicit in the GATT agreement by adopting legislation that gives us equivalency authority to hold producing nations to standards comparable to their own if we are going to allow their fruit and vegetables to come in, understanding that the more we go into this, the more complicated it gets. It is not easy, but we can raise the standard so there is a higher probability that the farms that they are grown on the places where they are handled will be at higher sanitary levels, and therefore, it is less likely that they will be bringing in foodborne illness. I think that may end up being the challenge for us. Now, how we implement that and whether we have to put inspectors in foreign countries and have their agreement to that is a topic for another day. You have all been excellent witnesses, and I thank you very much for your contributions. Thank you, Madam Chair. Senator Collins. Thank you, Senator Lieberman. I have just a couple quick questions before I yield to Senator Durbin. Although the United States does not currently have an equivalency system for fruit and vegetables that parallels the Department of Agriculture system, does the FDA currently have authority to ban foods imported from other countries that they believe are unsafe, and has that happened in the case with the Guatemalan raspberries? Dr. Ostroff. Dr. Ostroff. As I mentioned in my testimony, Senator Collins, and I think you mentioned this earlier, my understanding--and again, it would be up to the FDA to provide more detailed information--is that they cannot ban the export, but they can restrict the import. This is what they actually did, and they indicated that they would not permit raspberries out of the ports between certain dates, March 15 and August 15. That was based on the epidemiologic information that was accumulated in 1996 and 1997 about when the risk period was for the outbreaks in the previous years. Senator Collins. That is my understanding as well, that initially, the Guatemalan Government on its own suspended shipments, but that subsequently, the FDA said that it would not allow imported raspberries from Guatemala to enter the American marketplace until its concerns were resolved; is that accurate? Dr. Ostroff. Right, and that letter was sent out in November of last year. Senator Collins. Thank you for clarifying that point. Senator Durbin. Senator Durbin. Thank you, Madam Chair. I appreciate the testimony here today, and I read through it, but I am sorry I could not be here for the oral presentation in its entirety. Let me first address what I consider to be an overarching issue here, and I would like to have the comments of those who are involved in this. I think that one of the major problems we face in terms of food safety in this country is proliferation of Federal agencies with jurisdiction. There are some 12 different Federal agencies and 35 different laws that govern food safety and inspection. As a case in point, this raspberry investigation that we have showcased today involved at least four different Federal agencies, each with specific jurisdiction over some part of the investigation. I have introduced legislation in S. 1465 to try to replace this fragmented food safety system with a single, consolidated, independent agency with responsibility for Federal food safety activities. I would like to note that in the last hearing before this Subcommittee on food safety, we learned that some of the computer systems that are used in U.S. ports of entry were not compatible. CDC, FDA, and USDA have developed a cooperative food surveillance project called FoodNet for foodborne disease. I would like to ask the panel, are the computer systems integrated such that each of the agencies has access to the latest information on outbreak investigation? Dr. Ostroff. Senator, not being aware of all the computer system, I think the best answer I can give to that that exist currently, through some of the activities that have gone on as part of the President's National Food Safety Initiative, the interagency food safety initiative, we have a much closer level of cooperation. For instance, any information that the USDA has concerning contamination of meat products, they immediately send us either by computer or by fax, telling us of any potential recalls. We also inform them of any investigations that we are conducting. We tend to give them this information even before we know whether they are foodborne or not. We know with many of the foodborne pathogens, even with salmonella, that sometimes we will conduct investigations, and we will find out that the source is not necessarily a foodborne source. Witness the recent experience that we had with the swimming pool outbreak of E. coli O157:H7 in Atlanta. There is a much greater degree of cooperation among the agencies in terms of information-sharing than there used to be. In many ways, it is actually more useful to pick up the telephone or to send specific information than to have to wait to massage data through a computer system. Senator Durbin. I think we have made some progress. I think we have a long way to go. I hope that by consolidating this into one agency that this communication will take place. Let me give you an illustration. As I understand the Food and Drug Administration process on fresh fruit and vegetables brought into the country, samples are taken at border ports and then sent to FDA laboratories for investigation. I have gone through this process, and once having arrived, for example, in Nogales, Arizona, the sample is sent off to the Los Angeles lab. The Los Angeles lab receives it a day or two later. When the shipment is on its way to some store, the lab is usually in the process of investigating it. As we have established here, the lab is not going to detect the Cyclospora problem that we have discussed. As I understand the testimony, there is no known means of detection. The lab takes a look at these samples for suspected problems, and they have to start with a suspicion, because the universe of possibilities is almost unlimited. So they start with a suspicion that it might have an insecticide, a herbicide, a pesticide, something on it that it should not have, and therefore might be problematic. And again, let me confess that, being a liberal arts major, I get lost here in a hurry, but they set up their calibrated equipment to look in certain spectrums of chemicals to find their presence on the fruit and vegetables--and this is leading to a question--if they find it, they have noticed that some shipper and some producer have a problem. And once that is established, that shipper and producer are treated a little differently in the future. They start looking more closely, holding shipments for further inspection before they are released at the border, and in the worst case scenario, actually requiring proof that the shipments are clean before they can go forward from the border. In this situation, when we are dealing with a foodborne illness like the Cyclospora problem, since it cannot be detected at the outset, about the only thing of value is to try, as we have in the Guatemalan raspberry situation, to trace back and find out whether there is a problem area in some part of the world that requires some type of effort by the United States to reduce risk. Dr. Smith, one of the problems as I see it in this situation is that raspberries are usually pooled before they are shipped, and that makes it more difficult to identify the source farm where there was an outbreak. Do you believe that pooling harvested fruit before shipment adversely impacts traceback efforts? Dr. Smith. Well, it certainly complicates the efforts. I really do not see how we could get around pooling. We do that here, too. That is just how you fill orders--although I believe the Guatemalans are implementing a tracking system where they will actually be able to tell on any shipment which farms the berries came from. So there are some systems we could put in place to facilitate tracebacks. Senator Durbin. That was my next question. I wonder if you believe that bar-coding the shipment, for example, as to the farm sources, so that when the shipment is received, if in fact we find a problem 2 weeks or a month later that could not have been detected by any type of reasonable inspection, we at least then know the source farms to go back to, and we can try to retrace the steps and find out what the problem might be and work with the country of origin to reduce it. It is an investigative tool which I think might be helpful. You say they are in the process of doing it in Guatemala. Are other countries moving in this direction? Dr. Smith. I really do not know about other countries. I would suspect, though, that once one country does it, it is going to be something that other countries will consider. Senator Durbin. Having said that, going back to our discussion about trade standards, I have probably just invited the same standard to be applied to the United States exports, and there may be some people who say it is inevitable, and others who ask why did you bring it up--now we have to go through the same kind of thing. But in the scheme of things, when we are talking about so much fresh produce being exported from country to country it strikes me that this is inevitable, that since we cannot detect it in the clamshell baskets, once having discerned the problem, we can at least get back to the source. I wonder--you made a reference earlier in response to Senator Lieberman's question--do you think that establishing this kind of standard would be consistent with the trade agreements and the phytosanitary sections of those agreements? Dr. Smith. Establishing---- Senator Durbin. The bar codes on source farms. Dr. Smith. I think the way that it works is that it is negotiable bilaterally with a particular country, but I know that transparency is important, and if you are openly discussing what measures you think are important, I believe that would fall under GATT agreements. Senator Durbin. Let me ask you about the whole HACCP revolution that is taking place in terms of food inspection, which is relatively new on the Federal scene. Is the implementation of a HACCP-based approach to reduce the risk of foodborne illness an effective approach with respect to the Guatemalan raspberries and imported foods in general? That question is for anyone. Dr. Foran. I will be glad to start. HACCP is an approach that implements technologies at particularly sensitive points along the process, for example. It is called the Hazard Analysis Critical Control Point approach. I believe it is a useful approach for reducing hazard- associated with foodborne pathogens, but I argue very strongly that it is ineffective without a risk-based component to it. If we implement a technology at a particular control point and assume we are being effective in reducing hazards, we are just guessing at that point. We need a risk-based component so that we can quantitatively estimate how effective that technology is at the particular control point and then determine have we been effective enough, or do we need to implement technologies at other control points, or do we have to ban import of the product. But without a quantitative risk assessment or an estimate of the quantitative estimate of reduction in risk, I think HACCP in and of itself will not be effective. Senator Durbin. Tell me what you mean when you use the term ``quantitative risk assessment.'' Dr. Foran. It means an estimate, a probabilistic-based number of how many people will become infected or what the risk of an individual is when they eat a raspberry that may have Cyclospora on it. It is a predictive estimate of the risk that someone faces when they eat a product. Senator Durbin. So the suggestion is that before a public health initiative, we measure what the cost would be absent the initiative. Dr. Foran. Cost is another issue, and risk assessment can help us understand cost and enlighten the issue of cost, but risk assessment does not provide estimates of cost. It simply provides estimates of disease probability. The cost issue, then, can come in around the issue of suppose the technology that we are going to implement under HACCP costs ``x'' dollars; if we have a risk assessment to go along with that, we can make a determination of whether we want to spend that amount of money to get the requisite amount of risk that we predicted with the risk assessment process. Senator Durbin. We debate this term ``risk assessment'' on this Subcommittee, and there is a lot of difference of opinion here about what it means, and I for one worry about cost as an element in risk assessment and what it means. Your experience with foodborne illness was obviously troubling and discomforting, but not disabling, and I take it you have made a full recovery; but a person who is more vulnerable--a child, an elderly person, or someone with a compromised immune system--could have gone through a much more difficult experience. Dr. Foran. I think that is likely, and I will turn to Dr. Ostroff, but I am not aware that we know enough at this point about variability in human susceptibility associated with the severity of disease, cyclosporiasis. That is a big unknown right now, and it is a critical data gap that I think we have got to fill if we are going to do a better job of understanding the risk posed by Cyclospora and other foodborne pathogens. Senator Durbin. That, of course, is part of the debate here that will continue as to how do we quantify these risks. If we want to really get down to the bottom line, as we call it, and say how many dollars are at stake here, how many trips to the doctor are acceptable before we can impose a new standard by law, how many deaths are acceptable before we impose a new standard by law, how much cost to society and how much cost in terms of public health before we impose a new standard, a new law, I think that is very troublesome, and as a Member of the U.S. Senate, I think this is too close to the ``God squad'' assignment as far as I am concerned. I think that we have historically decided to err on the side of caution when it comes to public health and safety, and we are now calling in the accountants to help us make the decision. I think there are times when we may make the wrong decision and later find that we have an unfortunate occurrence. Dr. Foran. Senator, I would simply suggest that in my mind, there is a big difference between cost-benefit analysis and risk assessment. I think risk assessment is a critically important tool to help us understand the hazards or the probabilistic expression of risk to help us understand the issues that are associated with being infected and having a disease caused by exposure to a pathogen. Cost-benefit analysis, technology issues--those are all separate. There is a linkage there. They help each other, I think. They can work in concert. But if we are not conducting risk assessment, if we are not gathering the information that we need to conduct risk assessment, we are doing ourselves a disservice because we are simply guessing about all the other issues, about whether it is an effective technology, whether we can rationalize the cost, whether we even have acceptable or unacceptable risk. These are all guesses unless we have a good, strong, quantitative, scientifically defensible approach to understanding risk. Senator Durbin. And you get down to the bottom line--and someone on the panel made reference to it earlier--we now have a choice between cardiovascular health and gastrointestinal health, and the question that may come from this hearing for anyone who is following it closely is, all right, let us get to the bottom line here--is it better that I eat the fresh produce even though I cannot be certain of its safety--is that better for me in terms of my health, or is the risk too high in terms of possibility of foodborne illness that I should steer away from it and not eat the fresh produce. Dr. Foran. There is an analogy, which I am sure you are familiar with, with regard to contaminated fish. The argument has been that we should not eat some fish because they carry high body burdens of chemicals. Of course, we are not getting the benefits of fish if we do not eat fish. How do you deal with that? I would argue that we should not stop at that level of the argument. Why not take steps to make sure that the chemical burden in fish is low enough in all fish so that they are all safe to eat, and we do not have to worry about this? And I would suggest that the same argument applies here. Why not take steps as best we can to reduce the pathogen burden on the product so that we do not have to worry about tradeoffs like cardiovascular health and other kinds of health issues. Senator Durbin. Thank you very much. Thank you, Madam Chair. Senator Collins. Thank you, Senator Durbin. I want to thank all of our witnesses for their very valuable assistance today. Today's hearing has focused on a specific case study of tainted imported fruit. The intention was to highlight the challenge we face in our effort to improve the safety of imported food. I believe the hearing today has underscored the fact that the safety of imported food is a growing problem, especially with respect to emerging foodborne pathogens, and that finding an effective solution is very difficult when we are dealing with pathogens that cannot be visually detected by consumers, removed by washing the fruit involved, or in some cases, such as Cyclospora, even detected through laboratory tests on the fruit in question. I mentioned in my opening statement that this hearing is the second in a series of hearings the Subcommittee will be holding on the safety of imported food. The Subcommittee will hold two more hearings; the next one will focus on fraud and deception in the import process, and our final hearing will focus on remedies and solutions. We will give Members of Congress, the Executive Branch, and consumer and industry groups the opportunity to provide recommendations for improving our Nation's food import system. Our intent is a careful and thorough examination that will provide the foundation for effective reforms to improve the safety of imported foods. As I mentioned, the difficulty of our task is underscored by the fact that we have had two outbreaks of Cyclospora associated with imported raspberries in the United States, and right now, our neighboring country, Canada, is dealing with a very similar outbreak. I appreciate the contributions made by all of our witnesses. We would also welcome any suggestions that you might have on specific legislative recommendations; that would be very helpful to our records as well. The hearing record will remain open for 10 days. Again, thank you all for your contributions to our effort. I would also like to thank the staff of the Permanent Subcommittee on Investigations, including Tim Shea, Dr. Stephanie A. Smith, who has done an outstanding job for us, Don Mullinax, Lindsey Ledwin, Mary Robertson, and the entire staff, for their assistance. Thank you very much. This hearing is adjourned. [Whereupon, at 12:10 p.m., the Subcommittee was adjourned.] A P P E N D I X ---------- PREPARED STATEMENT OF MAX CLELAND, A U.S. SENATOR FROM THE STATE OF GEORGIA The safety of our families' food is critical to each of us. America's farmers have long supplied the country with nutritious, disease-free produce. In the United States, we have come to take for granted that the food we eat is clean and safe. In almost every instance, it is. We in Congress need to take prudent precautions to be sure that it stays safe. Increasingly, fresh produce is available throughout the year from growers in other countries, some of which do not impose the high public sanitation standards in force in the United States. It is important, therefore, we ensure that the food we serve to our children, from whatever country of origin, will not make them sick. There are, however, other factors to be considered in our attempts to control the produce growing conditions of other nations. If we act impetuously, we may inadvertently jeopardize relations with our trading partners. Just as the United States imports food to satisfy demand, other countries import U.S. agricultural products. These exports are an important market for U.S. farmers. We must also seek to maintain the best possible diplomatic relations with our neighbors in the Western Hemisphere. As we work with these countries to reduce the production of illegal drugs which find their way into our country, one of the solutions is to introduce other crops as profitable alternatives for the growers. It is important to keep diplomatic channels open and work together to solve problems in imports. I thank the Guatemalan High Level Commission for Food Safety for their cooperation with the Center for Disease Control in finding the cause of the cyclospora outbreaks and for their written statement for this hearing. Guatemala and the United States have been able to work together to pursue solutions to both the health and economic problems presented by the outbreak. This cooperation benefits both countries. We must be careful, however, that in our attempts to regulate food safety we do not provoke retaliatory actions by our trading partners. We must also be sure that we do not impose expensive, unnecessary restrictions on U.S. farmers in our food safety efforts. I thank the Chairman for these hearings. 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