[Senate Hearing 105-516]
[From the U.S. Government Publishing Office]


                                                        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.
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    \1\ See Exhibit No. 4 which appears in the Appendix on page 53.
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    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. They are an opportunity to 
discuss ways to be sure that our food is safe while at the same time 
maintaining our agricultural presence in the global economy.

                               __________

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