[House Hearing, 107 Congress]
[From the U.S. Government Printing Office]




                               before the


                                 of the

                              COMMITTEE ON
                           GOVERNMENT REFORM

                        HOUSE OF REPRESENTATIVES

                      ONE HUNDRED SEVENTH CONGRESS

                             SECOND SESSION


                            OCTOBER 3, 2002


                           Serial No. 107-233


       Printed for the use of the Committee on Government Reform

  Available via the World Wide Web: http://www.gpo.gov/congress/house


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                     DAN BURTON, Indiana, Chairman
BENJAMIN A. GILMAN, New York         HENRY A. WAXMAN, California
CONSTANCE A. MORELLA, Maryland       TOM LANTOS, California
CHRISTOPHER SHAYS, Connecticut       MAJOR R. OWENS, New York
JOHN M. McHUGH, New York             PAUL E. KANJORSKI, Pennsylvania
STEPHEN HORN, California             CAROLYN B. MALONEY, New York
JOHN L. MICA, Florida                ELEANOR HOLMES NORTON, Washington, 
THOMAS M. DAVIS, Virginia                DC
MARK E. SOUDER, Indiana              ELIJAH E. CUMMINGS, Maryland
BOB BARR, Georgia                    ROD R. BLAGOJEVICH, Illinois
DAN MILLER, Florida                  DANNY K. DAVIS, Illinois
DOUG OSE, California                 JOHN F. TIERNEY, Massachusetts
RON LEWIS, Kentucky                  JIM TURNER, Texas
JO ANN DAVIS, Virginia               THOMAS H. ALLEN, Maine
DAVE WELDON, Florida                 WM. LACY CLAY, Missouri
CHRIS CANNON, Utah                   DIANE E. WATSON, California
ADAM H. PUTNAM, Florida              STEPHEN F. LYNCH, Massachusetts
C.L. ``BUTCH'' OTTER, Idaho          ------ ------
EDWARD L. SCHROCK, Virginia                      ------
JOHN J. DUNCAN, Jr., Tennessee       BERNARD SANDERS, Vermont 
JOHN SULLIVAN, Oklahoma                  (Independent)

                      Kevin Binger, Staff Director
                 Daniel R. Moll, Deputy Staff Director
                     James C. Wilson, Chief Counsel
                     Robert A. Briggs, Chief Clerk
                 Phil Schiliro, Minority Staff Director

   Subcommittee on Criminal Justice, Drug Policy and Human Resources

                   MARK E. SOUDER, Indiana, Chairman
JOHN L. MICA, Florida,               BERNARD SANDERS, Vermont
BOB BARR, Georgia                    DANNY K. DAVIS, Illinois
DAN MILLER, Florida                  JIM TURNER, Texas
DOUG OSE, California                 THOMAS H. ALLEN, Maine
JO ANN DAVIS, Virginia               JANICE D. SCHAKOWKY, Illinois

                               Ex Officio

DAN BURTON, Indiana                  HENRY A. WAXMAN, California
                   Christopher Donesa, Staff Director
                Roland Foster, Professional Staff Member
                         Nicole Garrett, Clerk
                     Tony Haywood, Minority Counsel

                            C O N T E N T S

Hearing held on October 3, 2002..................................     1
Statement of:
    Hughes, Dr. James, Director, National Center for Infectious 
      Diseases, Centers for Disease Control and Prevention; and 
      Dr. Jesse L. Goodman, M.D., M.P.H., Deputy Director, Center 
      for Biologics Evaluation and Research, Food and Drug 
      Administration.............................................    10
    Lumpkin, Dr. John R., M.D., M.P.H., Director, Illinois 
      Department of Public Health; Deborah McMahan, Commissioner, 
      Allen County Health Department, Fort Wayne, IN; George 
      Wichterman, chairman, legislative and regulatory committee, 
      American Mosquito Control Association; and Mohammad Akhter, 
      executive director, American Public Health Association.....    58
Letters, statements, etc., submitted for the record by:
    Akhter, Mohammad, executive director, American Public Health 
      Association, prepared statement of.........................    93
    Goodman, Dr. Jesse L., M.D., M.P.H., Deputy Director, Center 
      for Biologics Evaluation and Research, Food and Drug 
      Administration, prepared statement of......................    28
    Hughes, Dr. James, Director, National Center for Infectious 
      Diseases, Centers for Disease Control and Prevention, 
      prepared statement of......................................    13
    Lumpkin, Dr. John R., M.D., M.P.H., Director, Illinois 
      Department of Public Health, prepared statement of.........    60
    McMahan, Deborah, Commissioner, Allen County Health 
      Department, Fort Wayne, IN, prepared statement of..........    69
    Souder, Hon. Mark E., a Representative in Congress from the 
      State of Indiana:
        Letter dated October 3, 2002.............................     3
        Prepared statement of....................................     6
    Wichterman, George, chairman, legislative and regulatory 
      committee, American Mosquito Control Association, prepared 
      statement of...............................................    77



                       THURSDAY, OCTOBER 3, 2002

                  House of Representatives,
 Subcommittee on Criminal Justice, Drug Policy and 
                                   Human Resources,
                            Committee on Government Reform,
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 2:25 p.m., in 
room 2167, Rayburn House Office Building, Hon. Mark E. Souder 
(chairman of the subcommittee) presiding.
    Present: Representatives Souder, Cummings and Schakowsky.
    Staff present: Christopher Donesa, staff director and chief 
counsel; Roland Foster, professional staff member; Nicole 
Garrett, clerk; Tony Haywood, minority counsel; and Earley 
Green, minority assistant clerk.
    Mr. Souder. The subcommittee will come to order, and I 
would like to recognize myself for an opening statement.
    Good afternoon, and thank you all for being here today. 
Today's hearing will examine the public health implications of 
the West Nile virus and the Federal response to the growing 
epidemic. We will hear from both Federal agencies and local 
officials who are responding in different ways to protect the 
public from the West Nile virus.
    While West Nile virus has been recognized as a health 
threat for over 60 years in other parts of the world, the 
disease only appeared in the United States in 1999. For the 
past 3 years, the virus has spread quickly across most of the 
United States and is now believed to be permanently established 
in the western hemisphere. My State of Indiana, and 
particularly Allen County, is one of the most heavily impacted 
areas in the Nation.
    Much is known about West Nile virus, but mysteries and 
questions still remain. In fact, only recently was it learned 
that the virus could be contracted from organ and possibly 
blood donations. Likewise the West Nile virus is also being 
blamed for a previously unseen polio-like paralysis in some of 
those infected. Just this past week scientists announced that 
genetic material from the virus has been detected in breast 
milk, raising the possibility that the microbe could be 
transmitted through nursing.
    The virus is primarily spread by the bite of an infected 
mosquito and can infect people, horses, birds and other 
animals. And while West Nile virus is believed to make about 20 
percent of those infected sick, most of whom experience very 
mild flu-like symptoms such as headache and fever which last 
only a few days, the virus can cause a severe inflammation of 
the brain. Only recently have scientists linked West Nile virus 
to a polio-like partial paralysis. And West Nile virus 
infection can result in severe and sometimes fatal illnesses. 
This year alone the deaths of over 110 Americans have been 
attributed to the West Nile virus. Those most at risk for the 
severe effects of the disease are the elderly and those with 
weakened immune systems, although young are people are 
affected, too.
    And I personally want to add I have not seen an issue that 
has so rattled so many people in an area as it has in my 
hometown of Fort Wayne. It has changed band practices, football 
games. You get sprayed when you go into a football game. It is 
a constant conversation every night at my house at the dinner 
table as to whether my son should go out and rollerblade, 
whether he should go out at all. I just had one of our major 
executives in Fort Wayne say his kids aren't allowed out in the 
evenings right now. It has caused disturbances in school board 
fights all over my district. There are few things that have 
caused as much controversy.
    I've had many people ask to include things to be inserted 
into the record, and over the next few days I'll be doing that, 
but in particular we could not accommodate my friend Indiana 
State senator and former county councilman, leader in Allen 
County, Tom Wyss to be one of the witnesses today, but he asked 
that I include his full statement. I wanted to put a couple of 
statements in here, because he's been very outspoken in our 
    [The information referred to follows:]
    [GRAPHIC] [TIFF OMITTED] T8611.001
    Mr. Souder. There comes a time when public officials need 
to depend upon the advice of experts when you have a situation 
like the spread of West Nile virus. When the Indiana/Allen 
County boards of health agreed that spraying was needed to help 
reduce risk of the West Nile virus spreading, it should have 
not been delayed by some public officials. We need to work 
together, local, State, and Federal, to fight the public enemy 
of West Nile virus like we are working together to fight 
    As I say, this has been a very difficult issue, multiple 
deaths, still more notices pouring in on the infection. Part of 
the problem has been that there has been no clear test, and 
people can't get the results for 3 weeks. Some of them are now 
down to 10 days. No specific medication exists to treat it, and 
no vaccine is available to prevent it, which means it's as 
scary a phenomenon as you can have as a parent and family 
    Food and Drug Administration has predicted the test may be 
available by next summer, and the National Institutes of Health 
forecasts a vaccine will not be ready for at least 3 to 5 
years. Doctor Jesse L. Goodman of the FDA is here today to 
provide us with an update on the progress that is being made in 
developing these necessities. Until tests, treatments, and 
vaccines are available, prevention remains the only defense we 
have against West Nile virus.
    Earlier this week the House of Representatives passed a 
bill authorizing $100 million in grants for communities to 
develop mosquito control programs. Dr. James Hughes, the 
Director of the National Center for Infectious Diseases at the 
Center for Disease Control and Prevention will tell us today 
what actions his agency is taking to protect the public's 
health as well as what individuals can do to protect 
    We will also hear testimony from several State and local 
officials who are on the front lines of our Nation's effort to 
control the West Nile virus. We will hear from my own Allen 
County health commissioner, Dr. Deborah McMahan. In Allen 
County, by the way, we have one-third of the cases in the 
entire State of Indiana.
    We're also going to hear from Dr. John Lumpkin, Director of 
the Illinois Department of Public Health, which has more cases 
than anywhere in the United States; Dr. Mohammad Akhter, 
Executive Director of the American Public Health Association; 
and Mr. George Wichterman of the Lee County, Florida, mosquito 
control district.
    It is my hope that from this hearing we in Congress can get 
a better understanding of what we can do to assist the efforts 
of the Federal and local health authorities in controlling West 
Nile virus. Likewise, I hope that the representatives of the 
Federal agency will listen to the testimony of our other 
witnesses so they can gain a greater appreciation of those 
needs and the viewpoints of those in the front lines in our 
efforts to control West Nile virus.
    We had originally hoped that the administration panel could 
go second to respond to those issues by State and local, but 
they have requested they testify first, and that is the long-
standing protocol of our committee, and we can do followup 
questions if we need.
    I thank you again for--all of you for being here, and I 
look forward to hearing your testimony and insights. And I'd 
now like to yield to the distinguished ranking member, Mr. 
Cummings, of Maryland.
    [The prepared statement of Hon. Mark E. Souder follows:]
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    Mr. Cummings. Thank you very much, Mr. Chairman. Let me, 
first of all, thank all of our witnesses for appearing before 
us today to discuss their efforts, the challenges they face and 
the lessons they are learning as front-line combatants against 
the West Nile virus epidemic.
    West Nile virus is new to the United States, but it is not 
a new disease. First diagnosed in Uganda in 1937, West Nile 
virus has since spread to other areas in Africa, the Middle 
East and parts of Europe. Three years ago it arrived in the 
United States, and it's rapid spread from New York City where 
the initial outbreak occurred to other parts of the country 
confirms that the virus is now firmly established in the 
Western Hemisphere.
    Today's hearing, Mr. Chairman, is especially timely. Just 
this morning the tragic impact of the West Nile virus hit home 
for my constituents as Maryland public health officials 
reported that a kidney transplant patient at Johns Hopkins 
Medical Center, which is located in my district, died after 
testing positive for the West Nile virus. Although there had 
been six previously reported cases of West Nile virus infection 
in Maryland, none had resulted in the life-threatening illness, 
and this is the State's first West Nile fatality.
    As is the case in a number of the 116 West Nile deaths that 
have occurred across the country, the source of the infection 
in the Maryland death is unclear for the time being. According 
to the Maryland Department of Health and Mental Hygiene, 
initial tests for the virus on the organ donor were negative. 
And the department, the American Red Cross and the Centers for 
Disease Control and Prevention are investigating the 
possibility of transmission through blood transfusions or from 
outside exposure.
    The West Nile virus epidemic is frightening to Americans 
because we have limited testing capability, no vaccine, as the 
chairman said, and no specific therapies for treating the West 
Nile encephalitis and meningitis that develop in a small 
percentage of persons infected with the virus. It is the rare 
individual who does not receive a mosquito bite during the 
course of a summer season.
    The rapid spread of the virus suggests that within a short 
period of time, virtually all Americans could be at risk of 
West Nile virus infection if they are not already. There's 
still much we do not know. Indeed the possibilities of 
contracting the virus from organ transplantation and blood 
transfusions was confirmed only within the last month or so. 
Fifteen people this year have been diagnosed with the West Nile 
virus within a month after receiving blood transfusions. 
Another recent case raised questions about the safety of 
nursing by mothers who may be infected with the virus. Just 
over 2 hours ago the Centers for Disease Control and Prevention 
confirmed that the infant in that case did, in fact, get the 
virus from breast milk. The suspected source of the mother's 
infection is a blood transfusion, and blood from the same donor 
is also believed to be the source of another West Nile 
    Numerous investigations into individual cases as well as 
efforts to map the spread of the virus nationwide are ongoing. 
To date, 42 States have reported cases of West Nile infection 
in humans, mosquitoes, birds or other animals. Thirty-two 
States have reported cases of human infection. Inexplicably, 
for the first--for the time being Illinois has been the hardest 
hit with 32 human deaths having occurred this year alone and 
massive impact on bird populations. As you know, Mr. Chairman, 
three members of this panel are from Illinois, so I'm glad that 
Dr. John Lumpkin, the Director of the Illinois Public Health 
Department, is able to appear today at the minority's request. 
We can only hope that the terrible experience Illinois is 
having will yield knowledge that will be instructive to other 
States across the country.
    By all accounts, the Centers for Disease Control and 
Prevention, the Food and Drug Administration and other Federal 
agencies that make up our Federal public health infrastructure 
ought to be commended for their efforts to respond to this 
epidemic. Even as we recognize the aggressive efforts of our 
public health agencies to respond to this new threat, it is the 
duty of this oversight subcommittee to ascertain what gaps may 
exist in our public health system and what more might be done 
by our government to ensure the health and safety of the 
American public from West Nile virus and similar future 
threats. This hearing is a constructive step in that process. 
And I commend you, Mr. Chairman for calling this hearing and 
giving us the opportunity to hear from all of our invited 
witnesses. I yield back.
    Mr. Souder. Thank you.
    Before proceeding I would like to take care of a couple of 
procedural matters. First I'd ask unanimous consent that all 
Members have 5 legislative days to submit written statements 
and questions for the hearing record. And any questions, and 
any answers to written questions provided will also be included 
in the record. Without objection, it is so ordered.
    Second, I ask unanimous consent that all exhibits, 
documents and other materials referred to by Members and the 
witnesses may be included in the hearing record, and that all 
Members be permitted to revise and extend their remarks. 
Without objection, it is so ordered.
    Would the witnesses on the first panel please rise. Raise 
your right hands. I'll administer the oath. As an oversight 
committee it is our long-standing tradition to swear in all 
    [Witnesses sworn]
    Mr. Souder. Let the record show that the witnesses have 
each answered in the affirmative.
    I think we're going to go ahead with the testimony on the 
first panel. I know Congresswoman Schakowsky from Illinois 
wants to give a statement, and we'll get at least your 
statements in the record. I just ran into her in the hall a few 
minutes ago. She's trying to cover two things simultaneously, 
so she'll be over. But we'll start with Dr. Hughes.

                    AND DRUG ADMINISTRATION

    Dr. Hughes. Thank you very much, Mr. Chairman, Mr. 
Cummings. It is a pleasure to be here with my good friend and 
colleague Dr. Goodman from FDA. Thank you for your invitation 
to testify on West Nile virus-related illnesses and CDC's 
public health response.
    Although Americans have not regarded mosquito-borne 
diseases as a major health risk for some time, the introduction 
and rapid spread of West Nile virus in the country has changed 
this. In 1998, CDC issued Preventing Emerging Infectious 
Diseases: A Strategy for the 21st Century, which described 
CDC's plan for combatting today's emerging diseases and 
preventing those of tomorrow. The plan emphasizes the need to 
be prepared for the unexpected. The West Nile virus is a 
dramatic example of an unexpected emerging infection.
    West Nile virus was first recognized in the West Nile 
district of Uganda in 1937, as we've heard. Since then it has 
been seen in Europe, the Middle East, Africa and as far east as 
India. The West Nile virus was first recognized in Northeastern 
United States in 1999, and as you can see on the map, it has 
subsequently spread across much of the country. The virus has 
been found in 42 States and Washington, DC.
    This year, through yesterday, there have been 2,530 
reported human cases of West Nile virus infection; 125 of these 
patients have died tragically. While most people who become 
infected with West Nile virus develop a mild illness or do not 
become sick at all, a small fraction, less than 1 percent, 
develop neurological disease. Approximately 10 percent of these 
severely ill patients die. Some patients with West Nile virus 
infection experience a polio-like paralysis. It is not known 
how long the paralysis will last, and we are planning long-term 
followup of these patients.
    CDC, FDA, HRSA and State and local partners are 
investigating some cases of West Nile virus infection with 
onset of illness following blood transfusion and organ 
transplantation. To better assess these risks, we are actively 
engaged in identifying and following up on additional possible 
cases. Dr. Goodman will address the transfusion issue in more 
detail in his statement.
    In addition, breast milk from a woman with West Nile 
encephalitis has been found to contain West Nile virus RNA. The 
infant, who remains well, has IGM antibody to West Nile virus.
    CDC is the lead Federal agency for response to the West 
Nile virus outbreak in humans. Building on lessons learned from 
last fall's anthrax attacks, we have activated our emergency 
operation center to coordinate our response, deploying field 
epidemiologists, vector-borne disease experts and 
communications specialists to assist State and local health 
departments in the affected States in conducting surveillance, 
investigating cases and implementing prevention and control 
    With the U.S. Geological Survey, the Department of 
Agriculture and other partners, we are monitoring the spread of 
West Nile virus in humans, birds, and animals. Maps such as 
these aid in developing and implementing prevention and control 
strategies regionally and locally. You can see perhaps in that 
graphic the reported human cases on top, this year the 
geographic distribution in the middle, the avian cases, and on 
the bottom the veterinary cases, which are predominantly in 
    We have provided education to health care workers, 
disseminated information to clinicians and public health 
officials, and held frequent press telebriefings, all critical 
activities both for this disease outbreak and for strengthening 
our future capabilities.
    Since fiscal year 2000, the Department of Health and Human 
Services and CDC have provided more than $58 million to State 
and local health departments to develop or enhance 
epidemiologic and laboratory capacity for control of West Nile 
virus and other mosquito-borne diseases.
    In conclusion, addressing the threat of emerging infectious 
diseases such as West Nile virus depends on a revitalized 
public health system and sustained and coordinated efforts by 
many agencies and organizations. We have made substantial 
progress to date in enhancing the Nation's capability to detect 
and respond to this infectious disease outbreak. However, the 
emergence of West Nile virus in the United States has reminded 
us yet again that we must not become complacent. As our new 
Director Dr. Julie Gerberding says, ``complacency is the enemy 
of preparedness.''
    Priorities include strengthened public health laboratory 
capacity, increased surveillance and outbreak investigation 
capacity, education and training for clinical and public health 
professionals at the Federal, State, and local levels, and 
communication of health information and prevention strategies 
to the public. A strong and flexible public health system is 
the best defense against any disease outbreak.
    Thank you again for the opportunity to testify. I will be 
happy to answer any questions you may have.
    Mr. Souder. Thank you.
    [The prepared statement of Dr. Hughes follows:]
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    Mr. Souder. Dr. Goodman.
    Dr. Goodman. Good afternoon, Mr. Chairman, Mr. Cummings. 
I'm Dr. Jesse Goodman. I'm an infectious disease physician and 
scientist and Deputy Director of the Center for Biologics 
Evaluation and Research at FDA. I would like to thank you for 
providing FDA with the opportunity to talk with you about West 
Nile virus today.
    There are and always will be newly emerging infectious 
diseases which pose a threat to human health. Unfortunately, 
some of these will likely also threaten the safety of the blood 
supply, and West Nile virus is the newest such challenge.
    In this testimony I'd like to try to do three things. First 
I'll provide a chronology of recent events from the perspective 
of the safety of the blood supply; second I'll tell you about 
what our response has been to date; and finally, I'll tell you 
about plans to further address the problem. I think you'll see 
we've come a very long way in just 4 short weeks.
    I'd also like to take this opportunity to mention what I 
feel has been extraordinary cooperation between CDC and FDA and 
an impressive pace with which the case investigations of 
concern here have been and are being conducted. I also want to 
thank the involved States and the blood organizations whose 
response has been exemplary under very difficult and 
challenging circumstances.
    Until a month ago the potential threat of West Nile virus 
to the blood supply was thought to be very low. Because of the 
dramatic increase in the spread of West Nile this year, on 
August 17, FDA, in consultation with CDC and NIH, issued an 
alert. This alert to blood banks emphasized the importance of 
careful attention to screening procedures for blood donors, 
especially the exclusion of donors with even mild flu-like 
symptoms which could be early signs of West Nile infection. And 
I should say we did this with no--in a setting of no previous 
reported cases of transmission of West Nile in this manner.
    Then about 4 weeks ago, as you know, the initial results of 
the investigation of a cluster of cases of West Nile among 
organ transplant recipients from a single donor led to the 
strong suspicion that the virus could be transmitted by organ 
transplantation, and we now believe it's almost certain that 
the organs from a single donor carried the infection to four 
recipients. The source of that donor's infection, as you have 
heard mentioned, may have been from a mosquito or from 
    During our current state of heightened alert, additional 
cases in which West Nile virus disease developed in the days to 
weeks following transfusion both in and out of the setting of 
transplantation have been reported to date and are under 
investigation; for example, the case--the unfortunate case 
mentioned by Mr. Cummings. In each case studied so far, the 
patients were from areas of known mosquito transmission. 
However, special studies of blood donated to a single patient 
in Mississippi who later developed West Nile disease suggested 
that three blood donors may have unknowingly and coincidentally 
had the West Nile virus in their blood at the time of their 
donations. So far one of these donor's infections has been 
confirmed, including detection of live virus in frozen plasma 
from the same patient.
    In addition, just last week, we learned that two different 
individuals who developed West Nile virus infection had both 
previously received transfusions; in one case platelets, and in 
the other red cells from a single donor whose retained blood 
samples from that donation have tested positive for West Nile 
    Based on these ongoing investigations and particularly the 
cases I mentioned, we have identified a risk to blood safety. 
We do not yet know how big or small that risk might be. 
Critical studies are being implemented in different donor 
populations to better assess the risk to blood and organ 
recipients. Meanwhile, we have taken several important steps.
    First, we're continuing to encourage reporting of cases of 
West Nile that follow recent transfusion or transplantation, 
and if a case is reported in a recent donor, any blood products 
which might still be available are being withdrawn to protect 
others, even before any infection in the donor has been 
    Second, FDA is working with blood banks and will soon 
provide guidance to improve the reporting of postdonation 
illnesses and the appropriate actions to be taken. I should 
mention in one of these cases an individual who had been well 
at the time of donation shortly thereafterwards developed 
symptoms of infection. And these steps again include withdrawal 
of products where needed to help protect others.
    Third, because of the potential--and this is what we're 
quite concerned about--for West Nile virus transmission from 
donors who never develop any symptoms of infection, FDA 
believes it is important to be ready and able to move rapidly 
toward testing donor blood. No validated test is currently 
available for screening of donor blood, and such screening of 
large numbers of samples cannot be implemented overnight.
    To jump start that process of getting a reliable and 
practical blood screening test, we recently took the step of 
proactively meeting with the American Association of Blood 
Banks, AdvaMed, which is a medical device manufacturer 
association, and other partners in the blood banking and 
diagnostic testing laboratories, along with Federal and State 
laboratories whose tests could be readily adapted to this need. 
We have signaled our view of the high importance of making 
testing available and our willingness to provide maximum 
flexibility in moving this forward. CBER will also continue 
and, where necessary, seek to expand its related work relevant 
to the development and review of potential West Nile virus 
diagnostic tests, vaccines and treatments.
    I'm pleased to be able to continue to report that the 
medical diagnostic and blood banking communities are highly 
engaged and motivated by the public health importance of this 
problem. While the success of these efforts depends largely on 
their overcoming some scientific and technical obstacles that 
may be significant, our hope and intent is that a West Nile 
virus screening test for blood could be made widely available 
at least for study use under an investigational new drawing 
exemption for the next transmission season and perhaps sooner, 
if possible in more limited settings.
    In addition, based on our evolving knowledge, my 
expectation is that if the epidemic continues, FDA will 
recommend the use of blood donor screening tests for the 
presence of West Nile virus once approved. At the same time, 
we're continuing to explore a relatively new strategy for 
treating blood to kill microbes called pathogen inactivation, 
and we are working with the developers of these technologies to 
help carefully assess their safety and to determine whether 
they will work for West Nile virus.
    In conclusion, we do believe there is sufficient evidence 
to say that there is a risk to the blood supply from West Nile 
virus, and we are taking this risk extremely seriously, and we 
are acting upon it. At the same time, we want to communicate 
this risk in perspective. There are approximately 4\1/2\ 
million people in the United States who receive blood products 
each year. Both blood transfusion and organ transplantation are 
often life-saving or life-enhancing. While it is currently 
believed that the risk from West Nile virus is likely to be low 
overall, our knowledge is very recent and is limited and 
changing rapidly, and, in fact, as Jim mentioned, through 
frequent telebriefings, public meetings, etc., we are trying to 
continuously communicate new knowledge as it becomes available, 
including to you Members of Congress.
    Patients should be aware that this risk exists and can 
discuss their concerns and their medical treatment and possible 
options with their physicians. FDA, CDA, HRSA, all our partners 
are continuously monitoring this situation. We can expect 
continued reports of West Nile virus both naturally occurring 
and potentially transfusion-related to occur even as the peak 
period of West Nile virus transmission passes for this year. We 
will continue to work together to better understand and deal 
with this risk as quickly and effectively as possible.
    Meanwhile, I'd also like to take the opportunity to remind 
everyone that voluntary blood donation is a key to maintaining 
an adequate blood supply, and regardless of the findings here, 
blood donation remains safe. Blood has been in short supply 
very recently, and we encourage and we thank all of America's 
blood donors for making a commitment to donate blood 
periodically. We've come a long way in a few short weeks. I'm 
optimistic that we can and will respond to this new challenge 
quickly and effectively. Ultimately, though, success and 
controlling the mosquito-borne epidemic itself will be critical 
in determining the risk of infection to the blood supply and 
the need for routine blood donor screening.
    Again, I thank you very much for the opportunity to be here 
today and would be very happy to answer your questions.
    [The prepared statement of Dr. Goodman follows:]
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    Mr. Souder. I want to thank you both for your testimony.
    Before we move to questions, Congresswoman Schakowsky is 
recognized for an opening statement.
    Ms. Schakowsky. I want to thank you, Mr. Chairman and 
Congressman Cummings, for convening today's hearing to explore 
the public health implications of West Nile virus and the 
Federal response. This is a particularly important hearing for 
my State of Illinois and for my district. Although the 
statistics are changing daily, the most recent numbers that 
Illinois--show is that Illinois has suffered the highest 
numbers of human cases of West Nile virus in the country: 614 
cases. Is that right, Dr. Lumpkin? Something like that. Thirty-
five people have died as a result, including 15 in suburban 
Cook County. In my own district there have been 42 confirmed 
cases of West Nile virus in the village of Skokie, almost 50 in 
Evanston, and 10 in Morton Grove and Lincolnwood. The mayor of 
Morton Grove is now recovering from a bout with West Nile.
    These numbers reflect the uncommonly high outbreak ratio in 
the Chicago metropolitan area, which accounts for 86 percent of 
all cases throughout the State. I'm pleased to say that the 
contact the municipalities in my district have had with Federal 
authorities, specifically the CDC, have been quite useful in 
providing critical expertise and assistance.
    On behalf of my constituents and their local elected 
officials, I want to thank our CDC witness for the work the 
centers have done; however, I am concerned that Illinois, one 
of the most affected States in the Nation, has not received its 
fair share of Federal resources in combatting this epidemic. 
While Illinois received $300,000 at the beginning of the year 
and additional emergency funding in August and on September 30, 
the funding received by Illinois and the city of Chicago lags 
far behind those of other States. In fact, the totals for 
Illinois and the city of Chicago come out to $1.6 million for 
the fiscal year out of a total of roughly $35 million handed 
out to State and local health departments. That is 4.5 percent.
    I commend Senator Durbin in his fight to bring more funding 
to our State, funding that is needed to allow us to win the 
battle against this horrible virus. I'm not arguing that other 
States should not receive the funds that they need to respond 
to West Nile. I'm not arguing that the Federal officials have 
not been as responsive as they can. I'm arguing that we need to 
provide all the funding necessary so that Illinois can receive 
the resources necessary to protect against the West Nile 
outbreak and other public health threats. We must invest 
necessary resources in providing States, and in turn localities 
and individuals, with information, funds and training.
    As a Chicagoan I never thought I would find myself praying 
for an early and a cold winter, but I am. Winter will give us 
some relief, but it should not lull us into inaction. We need 
to use the coming months to aggressively plan for when the warm 
weather and mosquito season return next spring and summer. We 
must be not only prepared to respond for the next season of 
West Nile, but need to take preventative measures to try and 
avert an even worse outbreak next year. Part of that means 
adequate funding for States and local abatement authorities.
    As Dr. Lumpkin, our Illinois health department director, 
will suggest, we may need to expedite training and 
certification protocols so that more hands will be available to 
participate in the prevention process and so that other key 
personnel will not be diverted from ongoing public health care 
needs. We need to do much more to educate the public. We need 
to do more multilingual outreach. We need to do more to alert 
the elderly to this problem who are particularly vulnerable and 
the steps that they can take to protect themselves. We need to 
reach special populations through a multimedia campaign and by 
direct outreach. We need a major new investment in our public 
health care system to prepare not just for the future West Nile 
outbreaks, but all possible health threats, the expected as 
well as the unexpected. I'm particularly interested in the 
recommendations of Dr. Akhter of the American Public Health 
Association in this regard.
    I want to welcome our witnesses. I want to extend a special 
welcome to our public health director from Illinois, Dr. John 
Lumpkin. I appreciate each of you taking time to be with us, 
and I look forward to your testimony and to working closely 
with you on protecting and improving our Nation's public 
    Thank you, Mr. Chairman.
    Mr. Souder. Thank you.
    One of the things that's apparent is that we have a 
particularly huge shift into the midwest, with Illinois, with 
600 cases Michigan I believe is second. I represent the 
northeast corner of Indiana. If you extrapolated our one county 
to the State of Illinois, you'd have 1,250 cases in Illinois. 
That suggests that we have a corridor, if they're concentrated 
in Chicago, rather than downstate and southern Michigan and 
northern Indiana.
    Something has happened, and I wanted to kind of--we were 
looking at the April 2001 CDC Set of Revised Guidelines for 
Surveillance, Prevention, and Control of West Nile, and it 
recommended enhanced surveillance for many States, including 
active bird and mosquito surveillance as well as enhanced 
surveillance of animals and humans. And the guidelines note an 
appropriate timely response to surveillance is the key to 
preventing human and animal disease associated with West Nile 
and other arboviruses. The guidelines recommended this type of 
approach for the northeast in spring and fall, and also active 
ecological surveillance and enhanced pest surveillance in the 
southern United States; but it is not recommended for the 
midwest and Western States, only that there would be efforts to 
increase awareness in the medical community, dead bird 
surveillance and enhanced passive human surveillance during the 
    That last graphic was described elsewhere in the report as 
a backup system that I'm interested in the process of. 
Obviously you have difficult tradeoffs. Obviously there are 
funding questions. How do you--how did you determine that the 
midwest in particular, which has been hard hit in this season, 
would not have a more active? When did you start to do more 
active in the midwest? You alluded to now going in and 
providing local assistance, and could you explain the process a 
little bit so we can understand that here in Congress?
    Dr. Hughes. Yes. Thank you, Mr. Chairman.
    Let me try to respond to that. As all of us have 
acknowledged this is an emerging infectious disease. An 
excellent example, the disease first appeared in New York City 
in 1999 and, as the other map showed, has moved to the South 
initially over the last couple of years, and to the West, and 
then this year back up into the midwest. The cases occurred 
earlier this year than in previous years, and they occurred 
initially in Louisiana, Mississippi and Texas. That outbreak 
has appeared now to have waned. As the summer went on, as we 
all know, the disease has emerged in a major way in the upper 
    We anticipated that this virus would move through the 
country. It's the reason that over the recent years we've 
provided support to all of the 48 continental State health 
departments to enhance their capacity to deal with this 
problem. We have developed diagnostic laboratory tests that are 
now in place in all the State public health laboratories, and 
we've trained people to use them properly. This is an excellent 
example of why people should care very much about the capacity 
of their State public health laboratory as well as their State 
public health--or the State public health department in general 
and also the capacity of their local health departments.
    Each of the previous 3 years following the transmission 
season we have held meetings with State and local partners 
initially to develop the initial set of those guidelines that 
you allude to, and then during the past 2 years to update and 
refine those. The pattern of movement up until this year had 
been to the south and then westward in the southerly States. So 
we're not surprised that it has appeared in the upper midwest, 
but it points out the need to have surveillance in place so 
that this virus can be tracked.
    Mr. Souder. Since there was some occurrence moving toward 
2001, what's--already--what's in the midwest, part of the 
question would be why--how do you determine when to do as a 
predictive agency as opposed to a rec--in other words, did you 
have no evidence, either from FDA or bird death research or 
suggestions of mosquito patterns, that when you had the first 
signs that this could all of a sudden became a major wave--
because this isn't like a--the signs were coming, and all of a 
sudden it's overwhelming, I mean, the numbers.
    Dr. Hughes. Right. Well, Dr. Lumpkin and I have talked 
about this, and as I'm sure he will tell you in his testimony, 
the disease in the Illinois area is behaving very much like St. 
Louis encephalitis, caused by a virus that's a cousin of West 
Nile, behaved back in 1975 when it caused a very large epidemic 
there. So in that sense, I mean, there's ample evidence 
historically that this is, for reasons that we don't fully 
understand, an area that is prone to mosquito-borne diseases. 
So, as I said, we had made investments in strengthening the 
public health capacity in those areas, and happily so.
    In terms of prediction versus reaction, I've learned over 
the years that these microbes are pesky critters, and they're 
extremely difficult to predict exactly what they're going to 
do, particularly when they are either newly recognized or 
emerging in a new area. At CDC we feel that the public health 
action starts with active aggressive surveillance that requires 
the clinical community and the public health community be tied 
closely together. This is true whether we're dealing with 
antibiotic-resistant and vector-borne disease or the threat of 
bioterrorism. It's very important, and we put a lot of 
resources into that. It doesn't stop there because all of these 
emerging diseases raise a lot of research questions, and they 
stretch our capacity to deal with them.
    In terms of research issues, one of them relates to 
prediction and modeling, and that work is very, very important, 
but as always, it is a tradeoff with limited resources in terms 
of how to most effectively utilize them.
    Mr. Souder. Does the prediction usually lose out in the 
budget debate?
    Dr. Hughes. Well, I can't comment on that. I think we go 
with the things that we think are most critical, and right 
now--because, you know, predictive modeling would not have told 
us that hanta virus was going to emerge in the Southwest in 
1993, nor would it have told us that a terrorist was going to 
use the U.S. postal system to disseminate anthrax. So we have 
to be, both on the clinical side and on the public health side, 
on high alert.
    Having said that, we need to think about diseases in other 
parts of the world to which we are vulnerable, and there are a 
number of examples. If we were talking 5 years ago, we might 
have had West Nile encephalitis on our list. I can tell you we 
should have another related virus, Japanese encephalitis virus, 
which causes very severe disease in much of Asia. That should 
be on our list. That would be, could be introduced. Recent 
experience in Virginia reminds us that malaria can appear in 
this country. We have vectors that are capable of transmitting 
malaria here.
    So there's a long list. There's the recent experience with 
nepa virus encephalitis, Malaysia and Singapore, a devastating 
biodisease that affects pigs and spreads from pigs to people, 
that would be a major problem if that were to be introduced 
into the United States. So we have to pay attention to problems 
in other parts of the world. We have to make determinations 
about diseases that could be introduced in ways in which we 
might be vulnerable to them. So it's a very important part of a 
great big puzzle.
    Mr. Souder. Dr. Goodman, do you have any comments?
    Dr. Goodman. No. I really am very supportive of everything 
that Jim said. The way we try to interact with this is by 
taking the kind of surveillance data and predictions that our 
colleagues at CDC are so helpful with,and working with CDC and 
NIH periodically--and here I'm talking with respect to blood 
safety--periodically looking at the potential agents that are 
out there, getting a feeling for what the risk may be from 
them, again in the best way we can with respect to prediction 
and the disease incidence that's going on, and to try to be as 
prepared as possible.
    Again, do we need to learn new lessons from what has 
currently occurred? Well, we certainly should try to learn as 
much as we can from that. Can we effectively use additional 
resources to move these--to increase preparedness at all times? 
That's something we want to look at very carefully, too.
    Mr. Souder. Thank you.
    Mr. Cummings.
    Mr. Cummings. Thank you very much, Mr. Chairman.
    Gentlemen, what--I mean, this is not a new disease, and I 
was just wondering, why is it, do you think, that we have not 
been able to--our counterparts in foreign lands have not been 
able to develop a vaccine for this?
    Dr. Hughes. I think in large part it has not been viewed as 
a priority in other parts of the world where this disease 
occurs, recognizing, as I am sure you do, that in Africa where 
the disease first appeared, of course, the continent's 
devastated by HIV infection, by TB and by malaria. So you could 
see how on their radar screen, you know--West Nile virus would 
be pretty far down the list. With the introductions in Eastern 
Europe and in France and in the Middle East, it's been 
introduced. I don't think it's had, I mean, like the dramatic 
impact that it has here, and it's been a problem that has kind 
of died down after a year or 2, and so it hasn't gotten in 
those countries high on the priority list either.
    Mr. Cummings. Do we have a--do we--do you anticipate we'll 
have a vaccine for this any time soon?
    Dr. Hughes. Well, Dr. Fauci and his colleagues at NIH are 
supporting a lot of research around vaccine development, and 
the results of some of the candidate--of the work with some of 
the candidate vaccines are quite promising. But it does take 
time to bring these vaccines through appropriate testing to 
production and marketing. It's--I know it is a very high 
priority for them, and we see it, as I'm sure Dr. Goodman does 
as well, as a high priority.
    Mr. Cummings. I've noticed that when we had problems in 
Baltimore, the--with the mosquitoes, they did the spraying. And 
I guess that's what they usually do. They spray?
    Dr. Hughes. Well, there are a number--what we try to 
promote is what we call integrated pest management, and that 
has a lot of components to it. It has--it starts with control 
and reduction of sources, and that's where people, individual 
members of the public, have an important role to play in terms 
of taking steps in their living environments to reduce settings 
in which these mosquitoes can breed.
    Surveillance of mosquito populations is very important. 
Larval control is important. That can begin much earlier in the 
year. Spraying is somewhat of a last resort which is done when 
the mosquito populations proliferate where there is 
transmission to humans, and it comes at kind of the end of the 
intervention spectrum, if you will.
    Mr. Cummings. And is that--have you found that the spraying 
is effective as far as preventing cases; in other words, in 
places where they spray?
    Dr. Hughes. Well, you're widely raising the need to 
rigorously evaluate interventions that are done.
    Mr. Cummings. And I understand you want to do stuff before 
you get to spraying. I understand that. It's just that, I mean, 
I just see all the effort that goes into it, and I think that's 
basically what the public sees. I mean, you get--you know, you 
hear on the radio, on the radio and television, don't let water 
sit still and all that kind of stuff. I know that. But I'm just 
trying to figure out--you know, I'm always interested in 
measuring what we do so that we can determine whether or not 
we're being effective. And so when I see in the city, for 
example, these trucks going through all-night spraying all over 
the place, I'm just wondering, as a result of that, are we 
seeing a--I mean, do we--are we--can we tell whether we are 
preventing or not?
    Dr. Hughes. Well, again, it is an excellent question, and I 
wish I could answer that concisely, but what we have seen now 
down in Louisiana and Mississippi is the epidemic has peaked, 
and it has fallen off. They have taken very aggressive control 
measures there, but those include public education campaigns in 
Louisiana. They have the Fight the Bite program that they think 
has been very effective. But at the same time it is a 
multifactorial set of interventions, so it is a bit difficult 
to tease out in terms of whether the reduction of transmission 
is more because of public education and the public response 
vis-a-vis, you know, use of insect repellent versus staying 
indoors at dawn and dusk versus a continued larviciding versus 
introduction of adulticiding.
    Mr. Cummings. Let me just ask you this: In the death of the 
kidney transplant patient I mentioned a little bit earlier in 
Baltimore, it was reported that the organ donor tested negative 
for the West Nile, but it appeared that the blood the patient 
received may not have been tested. What, if any, 
recommendations is the FDA making to blood collection centers 
and hospitals regarding the testing of donated blood?
    Mr. Goodman. OK. Well, you have asked an important 
question, which is how with can we deal effectively with the 
potential threat through the blood supply. I would say that in 
the investigation of that case, donor samples that exist are 
being retrieved to be studied to see if any of those donors may 
have been infected and may have been involved in spreading this 
to this individual who developed West Nile disease. So that is 
being investigated. But as a more general question, what we 
have been doing is taking the steps that we now have available 
to us to reduce that risk, and those steps, such as they are, 
we are taking aggressively, but they are not perfect and 
complete at this time.
    I mention that, for instance, to try to remove from the 
pool of potential blood donors those who might even have a mild 
illness that could be West Nile virus, we think that is 
helpful, and that was something we worked on a couple of months 
ago with the blood community and our alert, providing guidance 
about those groups of individuals who soon after blood donation 
may become sick so that they can be tested and their product 
    But as I had mentioned, and as I think you are focusing on, 
that does not deal with the issue of those individuals who may 
have no symptoms at all, but unbeknownst to them have--after 
mosquito bites for what we believe a short period of time have 
virus presence in the blood and potentially could transmit this 
to somebody, causing serious disease. And for that, what we 
really need to do is to be able to screen donor blood in real-
time, ahead of time, to reduce the risk of transmission to 
others, and since this problem became apparent, we have been 
working very hard and closely to bring that quickly toward 
    The positives on doing that are that over the last years, 
as this has become West Nile virus, in general a public health 
problem in this country, there has been investment and work in 
diagnostic technology, some of which is very relevant and 
promising for blood screening.
    The other--you know, what I should mention here is this 
isn't like the simple--what we would need to do isn't like the 
simple blood test that one would go to one's doctor and get, 
which might measure your body's response to a virus. OK, that 
is what you have, that is your diagnosis. That is the 
diagnostic test that Jim mentioned that the State health 
departments perform. That's relatively straightforward. To 
detect it in the blood, we need to detect it before the body 
has even responded to it, so we need to detect the presence of 
the virus itself, and that involves much more sophisticated, 
demanding tests to detect tiny amounts of the genes of the 
virus, amplify them to a level that we can detect them.
    As I said, the good news is that those technologies exist. 
They have been developed to a certain point. And another very 
good piece is that FDA and the blood industry and the medical 
diagnostics industry have taken exactly that approach over the 
last several years, and now all blood in the United States is 
tested with those kinds--same kinds of tests for HIV and 
hepatitis C, which has reduced the risk from those diseases in 
transfusion down to 1 in a million to 1 in 2 million.
    Mr. Cummings. I've got to ask you this, and then this is my 
last question.
    Dr. Goodman. Sure.
    Mr. Cummings. And try to put this in lay terms, if you can. 
You know, like some people, if they eat certain types of food, 
shellfish or whatever, it is like they get allergic to it while 
everybody else is eating it, and there is no problem. Or MSG. I 
have seen people just, I mean, swell up. Is this something 
like--you know, when I think about all the people who get 
mosquito bites and are not affected, is there something--you 
may have already answered this. Is there something special in 
these people that you have noticed that is common? Are you 
following what I'm saying? And is that----
    Dr. Hughes. Yeah. Yes. Let us both respond to that. Again, 
another excellent question. You are doing very well in defining 
a research agenda for addressing these infections.
    We don't know why the elderly are the ones at greatest risk 
for development of severe manifestations of the disease. We 
don't--it is not surprising that immunosuppressed people such 
as organ transplant recipients would be at risk for development 
of severe disease. We see that with a broad range of agents. 
But not every elderly person who gets infected with the virus 
develops severe disease.
    So, as you say, why do some and not others? There are 
clearly other factors that play, whether it is behavioral 
factors or genetic factors or other drugs that a person might 
be taking or--you know, it is very important that we try and 
determine that, but we most definitely don't have all the 
    Mr. Cummings. Thank you.
    Mr. Souder. Congresswoman, Ms. Schakowsky.
    Ms. Schakowsky. Thank you, Mr. Chairman.
    In the 1980's, the CDC provided Iraq with a number of 
biological samples, including West Nile virus. I have two 
questions. One is, has the CDC--does it commonly get requests 
from countries around the world? And is there any possibility 
of any connection between that virus that was provided to Iraq 
earlier and what's the epidemic in the United States right now?
    Dr. Hughes. Thank you actually for asking that, and let me 
respond. I will take your second question first, if you don't 
mind, and that is, given that West Nile virus strain was 
supplied to Iraq back in the 1980's, does that have anything to 
do with the current outbreak? And the answer is no. The strain 
that was provided is not closely related to the strain that is 
causing the current outbreak, which is one that was recognized 
in the Middle East back in 1998, and it is the one that is 
uniformly present, so far as we know, with the studies that 
have been done to characterize the genetic structure of the 
virus; that all the virus in the country currently, as far as 
we know, is related to that strain that appears to have had an 
origin in Israel using molecular techniques.
    Now, the other part of your question is excellent.
    Ms. Schakowsky. Yeah. But did you just say that it does 
seem to be--we are finding it in Israel, the strain related to 
that which was provided to Iraq in the 1980's?
    Dr. Hughes. No. The strain in the United States is 
virtually identical to a strain that was first recognized in 
Israel in 1998.
    Ms. Schakowsky. I see.
    Dr. Hughes. It is not closely--neither of those is closely 
related to the strain that was sent to Iraq.
    Ms. Schakowsky. Thank you.
    Dr. Hughes. So that is a very, very important point.
    Now, the question about is this important to work with 
colleagues in other countries, it absolutely is, and the West 
Nile experience illustrates that. Fortunately, CDC colleagues 
were involved in investigating a West Nile outbreak that 
occurred in Romania back in 1996, and from that we learned some 
lessons that have been helpful in responding to the 
introduction here.
    Another story that might be of interest to you is with 
hanta virus pulmonary syndrome, again that disease that was 
recognized in the Navajo reservation in 1993. We were able to 
recognize that only because we had the benefit of reagents 
developed by DOD, Department of Defense, supported researchers 
who focused on the problem of another severe hanta virus 
infection that occurred in Korea and infected a number of U.S. 
soldiers during the Korean War. Because of that work, which is 
research in another part of the world, we actually have 
reagents that could be used that cross-reacted with the virus 
that occurred here, and it was through that happy coincidence 
that we were involved in the cross-reaction that unusual 
outbreak was recognized and the agent identified within 7 or 8 
days of notification of the first cases.
    We at CDC are involved in a global network that is 
sponsored by the World Health Organization that consists of 
collaborating centers that are focused on a broad range of 
diseases, starting with influenza. And data from that network, 
which we support through provision of reagents and in training 
of scientists around the world, generates the data that we use 
every year and in collaboration with our colleagues at FDA to 
formulate the recommendations for the composition of the annual 
influenza vaccine.
    So this idea of collaborating and working with scientists 
in other parts of the world is very, very important. Having 
said that, we all recognize in the current world in which we 
live, this has to be done with great care and in compliance 
with the existing regulation. So we take this very seriously.
    Ms. Schakowsky. Well, I would hope that there would be a 
renewed look. I am reading from a news report that says that 
invoices from the 1980's included in the documents read like 
shopping lists for biological weapons programs. And I guess 
some of the material was delivered directly to--the companies 
sent the bacteria to the University of Baghdad, which U.N. 
inspectors concluded had been used as a front to acquire 
samples for Iraq's biological weapons programs. The CDC, 
meanwhile, sent shipments of germs to the Iraqi Atomic Energy 
Commission and other agencies involved in Iraq's weapons of 
mass destruction programs.
    So I am assuming that we are reviewing wherever we are 
sending anything right now?
    Dr. Hughes. Well, we absolutely are, and we are making sure 
that we are in compliance with the current regulations. And we 
work closely with the Department of Commerce, which issues 
export permits, and there is a list of countries to which we 
don't send anything. But things are different today than they 
were in the mid to late 1980's.
    Ms. Schakowsky. I understand. But we don't want it to quite 
literally come back and bite us.
    Dr. Hughes. We agree.
    Ms. Schakowsky. Mr. Chairman, can I ask one other question? 
Are we going to do another round? OK.
    Regarding Illinois, you know, though we are pleased that 
there, on September 30th, was more money freed up, if we look 
at other places where they have less of a problem with West 
Nile, I just--maybe you said this already and I missed it--a 
formula for how you would distribute funds particularly for 
this. And I understand that the September 30th had to do with 
reserve revenues, and now that money was distributed on the 
30th, are there more--are we out of reserve revenues to do 
    Dr. Hughes. We have a little more money left that can be 
used through the rest of this transmission season. It is not a 
lot. We are trying to be responsive to specific requests from 
States who continue to have a problem, and, in fact, Dr. 
Lumpkin and I were talking about that before the session began.
    Ms. Schakowsky. Great. Thank you very much.
    Mr. Souder. Do you have some additional time that we can do 
a second round with you?
    I have a couple of different type of questions. One is do 
you agree that the rate of spread--when you looked at the cases 
of this around the world, that the rate of the spread in the 
United States is occurring faster that in previous cases in 
other countries?
    Dr. Hughes. Well, I can't see the original map, but you may 
recall from the colors that the impacted geographic area each 
year has more than doubled. There--thank you. There you can see 
it. Again, blue were the four States in 1999. And you can see 
what happened in 2000 in green, 2001 in red, and 2002 in 
yellow. The virus in Romania, as far as we know, the outbreak 
that I mentioned in the mid-1990's, did not spread beyond the 
country of Romania. So, obviously, this is a much more dramatic 
    See, the virus, though, had been present in Central Europe 
from time to time in the past. It is brand-new to the Western 
Hemisphere. So, not only do people not have any immunity to it, 
our bird populations don't have any immunity to it. They may be 
developing it along the eastern seaboard now after several 
years of experience. But certainly, the bird populations in 
Indiana would have had absolutely no experience with this virus 
and would have no immunity at all. So I think in part that 
contributes to the spread as well as the bird migration 
    Mr. Souder. Could the strain that we sold or gave or 
whatever to Iraq have been genetically altered?
    Ms. Hughes. It would be very difficult for me to imagine 
how that strain could have been converted into this particular 
    Mr. Souder. We may have some followup questions. It is a 
very potent question being asked in a lot of places, given the 
spread and the rapidity of the spread.
    Let me ask another line of questions, and once again, 
looking at the international cases and even our United States, 
basically, it seems to be within the last few weeks we are 
really looking at the blood supply in the organ donors. Did 
that not happen anywhere else in the world? Did it not happen 
in other years? Why is this all of a sudden an intense focus?
    Dr. Goodman. Well, it is an excellent question that we have 
talked a lot about at all hours of the day and night. We do 
not--there were no previous case reports from any country or 
from the United States that showed transmission of West Nile 
virus by either organ transplantation or transfusion. So that 
is part of the background and kind of the background that led 
to, although this was on our radar screen, it seemed to be a 
low risk. So that is a good question.
    In terms of what is different, I think there are 
potentially a number of factors. I think that, as Jim just 
alluded to, this virus is spreading rapidly in populations with 
no previous immunity, human, bird, and others, and the sort of 
crescendo and just sheer number of cases and burden of disease 
is quite high at this time.
    So, certainly increased numbers of people are at risk of 
being infected, and even though those--the number of people 
with disease and symptoms is small--or not small. I mean, it is 
remarkably larger this year than previous years. But we do know 
there is a much higher ratio of people who never have any 
symptoms and get infected.
    So I think part of this is the sheer burden of disease, but 
another part of it may reflect things about our population and 
medical progress, the degree to which we use health care and 
attendant blood transfusions, the degree to which organ 
transplantation has become a common and lifesaving event in 
this country, and the fact that, at least in those cases under 
investigation now, the majority of them are individuals--not 
all, but the majority who would be expected to have immune 
systems that are not functioning well.
    But it could be that in other countries some transmission 
in this route occurred, but may not have attracted attention 
because it wasn't being looked for in the same way, or may not 
have caused a severe disease, because if it were in healthy 
people, it may be that even when you get it by the blood, a 
healthy person many times will not develop symptoms.
    But these are good questions, and we are working with CDC 
and the blood community to rapidly mobilize studies to help 
answer these questions.
    Mr. Souder. And I want to make sure I reinforce on the 
record that even with the epidemic outbreaks in certain parts 
of the country, more people die from--and potentially die from 
not having blood transfusions than the risk at this point. And 
this could be--we don't want to have a panic about people 
giving blood or taking blood, because that is a daily 
dependency in our hospital and medical system in the United 
States, but we want to try to make sure that it doesn't explode 
and get out of control.
    I have two other brief things I want to address, sir, that 
are important to us in Indiana that can be extrapolated. The 
season is generally considered mosquito season, late summer, 
but we have some sign that we could see the first cases in the 
early spring season. Do you see that in other parts of the 
midwest, other parts of the country? And what do you--when you 
earlier referred to season, how do you define that? And are 
there preventative things you can do before the early spring 
season so we don't see--right now in my area it is concentrated 
in one county, but so that it doesn't explode to the rest of 
the counties around it?
    Dr. Hughes. Yes. The early case this year occurred in the 
southern part of the country, which I guess wouldn't be 
surprising given the temperatures.
    I think, in terms of thinking about next year, you know, we 
definitely all--you know, this--dealing with this, as I think 
has been apparent from the discussion, requires a real 
partnership between people in clinical medicine and in public 
health; and within public health, among many partners at the 
Federal level, the State level, and the local level.
    We are going to continue to learn. We have to look at areas 
that have been particular hot spots this year, as in the case 
in two parts of Cook County and in the area that you referred 
to in Indiana, and anticipate that next year they may again be 
at high risk for transmission.
    And so mosquito control efforts that ought to begin early 
in the season--again, it is this integrated pest management 
early in the year, source reduction, use of larvicides when 
appropriate to try to keep mosquito populations down is very 
appropriate and should be particularly intense, I would submit, 
in these areas where transmission have been highest this year. 
So we will need to be sure that resources are provided in 
advance so that work can begin early in the year.
    Mr. Souder. One last, and I will yield to the other Members 
for additional questions.
    I have been trying not to be offended by the senior 
designation, because when you turn 50, you get the AARP thing; 
and I am wondering whether that is the definition of senior you 
are working off of, because I believe several of our deaths in 
Allen County were in the 1950's, not in the 1960's; 1953 I 
think was--'56; and that I also know some who are very sick who 
are between 25 and 35. They weren't either very young or very 
old, and they were in very good physical shape.
    That I understand, the potentially weaker immune systems of 
the elderly or the very young. Clearly there has been a lot of 
focus on teens. But this--going back to Congressman Cummings' 
question--seems on the surface to be a little more generic. 
Could it be, well, blood sugar? Are you looking at other things 
in the system? Because it doesn't seem to quite have this 
pattern in my area.
    Dr. Hughes. Yes. Thank you.
    Let me give you just a little bit of data and say that in 
public health we often think of populations. So if you look at 
the median age of people who have died this year, it is 
actually 79 years of age. Now, what the median is, it is just 
right in the middle. That means that 50 percent of the people 
are older and 50 percent of the people are younger. The 
youngest person that we know of that has died of West Nile this 
year is 27 years of age. I can't tell you offhand where that 
tragic death occurred. But, you know, on average we can say 
that it is the elderly people that are at greatest risk for 
severe disease and death, but that risk is not limited to 
people above a certain age.
    Mr. Souder. Thank you.
    Mr. Cummings.
    Mr. Cummings. Is this easy to diagnose?
    Dr. Hughes. It is easier to diagnose today than it was 4 
years ago. Four years ago, it was extremely difficult to 
diagnose. And you may, in fact, recall that when the initial 
cases were recognized by an alert clinician in Queens, reported 
to the New York City Health Department, investigation was done, 
specimens were collected and analyzed, the initial results 
suggested that this was St. Louis encephalitis virus in a new 
part of the country, in New York City. We were misled initially 
by the cross-reactivity because of the genetic relatedness of 
these two viruses. So we had to go back and develop tests 
specifically for the diagnosis of West Nile infection, and 
develop those tests, develop the reagents that are required to 
run them, get them to the State public health laboratories, and 
get people trained in how to do the tests, and at the same time 
maintain confirmatory laboratory capacity at our CDC laboratory 
in Fort Collins.
    So, it is easier today. The public health laboratories have 
the capacity. There are companies working on developing tests. 
We need licensed tests that are more widely available that 
could be used in clinical laboratory settings. So we are not 
totally there.
    Mr. Cummings. Is there any such thing that if I got to a 
doctor early, does that make a different at all?
    Dr. Hughes. There is no effective specific treatment today 
for West Nile encephalitis, so it would make a difference to 
that proportion of people who were going to go on to develop 
severe illness, because obviously the earlier someone is 
recognized to have a severe illness, the sooner proper 
supportive care can be provided. So in some people it--
certainly, the earlier you are diagnosed, the better off you 
    Mr. Cummings. The money that the CDC funds, what--I notice 
in fiscal year 2000, $10 million, to fiscal year 2001, $25 
million. And then it says 2002--2002, $46 million. What is that 
money used for?
    Dr. Hughes. Well, of the $46 million, $35 million has gone 
to the State and local public health jurisdictions, and there 
it is used for a number of things. It is used to strengthen 
surveillance programs, it is used to support the delivery of 
these diagnostic laboratory tests that we have been talking 
about, it is used for prevention and control programs and 
outreach to the public. In some cases--although we don't 
encourage this, in some cases some of that money has been used 
by local jurisdictions for spraying.
    Mr. Cummings. How do you all prioritize, I mean, 
particularly with the spread? And is there something 
comparable--has something comparable happened in the world to 
what's happening now in the United States, in other words, this 
extent, and seems to be growing quite rapidly?
    Dr. Hughes. OK. In terms of the budgeting, you know, there 
is no precise formula that's used to determine the allocation 
of funds, and as has been pointed out, the funding to the State 
and local jurisdictions this year occurred initially, and then 
there have been three supplements following the initial 
allocation. Those supplements have really been targeted toward 
the--or been determined really by the behavior of the epidemic 
and the movement of the virus. So, in fact, I am actually glad 
we did it that way, because if we had used all available 
resources back early in the year and put it into the South 
where the problem had been last year, we would have had 
precious little left over to deal with the progression of the 
    We listen very carefully to what the States tell us about 
what their priority needs are, and we try to be as responsive 
to those as we can be.
    In terms of your question about the geographic movement 
over large areas, I think we are going to have to stay tuned 
for that. The virus has spread to Canada. It has been 
identified in the Cayman Islands. The Caribbean is certainly at 
risk. Mexico is certainly at risk. This virus may be with us in 
the Western Hemisphere, but time will tell. It is another 
reason why working with colleagues in other countries is 
important to do, and we have tried to do some of that to 
strengthen diagnostic capacity in the hemisphere, working with 
the Pan American Health Organization and others.
    Mr. Cummings. Has that been very helpful?
    Dr. Hughes. I think we have made progress in terms of 
increasing capacity, at least in some countries, to diagnose 
this. More work needs to be done, clearly.
    Mr. Cummings. Just the last thing. When you have folks in, 
say, small towns, and people come in with West Nile, how do 
you--what are they--I assume that folks come and seek 
information from the CDC, doctors, whoever, and trying to 
figure out, well, what do we do? The panic that the chairman--
the concerns that the chairman mentioned about sending your 
kids out to the baseball game and stuff like that. I mean, what 
is the CDC saying to folks like that?
    Dr. Hughes. Well, again, thank you for bringing that up. 
This is this communication issue that is so critically 
important. You know, we certainly have this emphasized to us in 
the response to the anthrax attacks last year. It did not go 
well. Because clinicians are so important in the initial 
recognition of these new syndromes, as we have talked about--
and in fact, Dr. Gerberding, our Director, likes to talk about 
the golden triangle of close relationships between people in 
clinical medicine, people in the health care delivery system, 
and people in public health. Those cultures are somewhat 
different, and we must bridge the gulf between those different 
groups, and it is something that both she and I are very 
passionate about. And hopefully you are seeing some evidence of 
us becoming much more proactive on the professional educational 
    Then equally important is the public educational needs. 
People really need to understand. I mean, we have their 
attention now, so we need to take advantage of that to deliver 
to them practical advice that can help demystify some of this a 
little bit, and also give them constructive guidance about 
measures that they can take to reduce their risk. And we are 
trying to do that in a number of different ways.
    Mr. Cummings. Thank you.
    Mr. Souder. Congresswoman Schakowsky.
    Ms. Schakowsky. I just have one quick question. Is there 
any reason you think that Illinois would have more cases than 
other States?
    Dr. Hughes. I would ask that you ask Dr. Lumpkin for his 
thoughts on that when he comes, but I think, for whatever 
reason, as I had mentioned earlier, some of the areas of 
highest incidence this year in Illinois are the same areas 
where the incidence of St. Louis encephalitis was quite high in 
1975. And so to me it must have something to do with the nature 
of the environment there and its interaction with the bird and 
the mosquito populations.
    Mr. Souder. I want to thank each of you. I would encourage 
you to, and let us know, what we need to do on the budget side, 
because the initial funding request is flat level whereas we 
had a big supplemental this year, and yet potentially this is 
explosive. If 80 percent of the cases in Illinois are in Cook 
County, it suggests that while Cook County is a big county, 
that is only a small percentage of the State. In my 
congressional district, Allen County is the biggest county, but 
it is less than 40 percent of the district, and it is only a 
small percentage of the State; yet, nearly 50 percent of the 
cases are in one county, which suggests that it is not just 
going to stay localized as we work with this. So we'd 
appreciate working with you in addressing the midwest.
    Thank you for your work. We will probably have a few 
written questions. And, with that, thanks for coming.
    Would the second panel then come forth. Dr. Lumpkin, Dr. 
McMahan, Mr. Wichterman, and Dr. Akhter. If the second panel 
could remain standing, we will do the oath at this time. If you 
can remain standing, we will do the oath.
    For those of you who were not here earlier, it is a 
standard practice as an oversight committee that all our 
witnesses are sworn. If you could raise your right hand.
    [Witnesses sworn.]
    Mr. Souder. Let the record show that the witnesses have 
each answered in the affirmative.
    We will first start with Dr. Lumpkin, the director of the 
Illinois Department of Public Health.


    Dr. Lumpkin. Thank you, Mr. Chairman, and members of the 
committee. Thank you for the opportunity to present before you. 
This year the Illinois Department of Public Health is 
celebrating its 125th anniversary as a State agency. 
Interestingly enough, our agency got its start in 1877, in 
response to an outbreak of yellow fever, which is a mosquito-
borne illness, and as such, just as we started, now at our 
125th anniversary we are facing a major outbreak.
    Today we have the results of our testing. We now have 623 
cases in Illinois and 35 deaths. West Nile virus has been found 
in every single county in the State of Illinois, all 102 
counties, in birds, mosquitoes, and, in most of those counties, 
also in people. We are past the peak. Our numbers of cases and 
the date of onset have peaked somewhere in the beginning of 
September, yet we are continuing to see cases, and we expect we 
will be seeing cases because of the delay in diagnosis and 
reporting for some weeks to come.
    And what we have seen is very much what we saw in 1975, 
when there was a major national outbreak of St. Louis 
encephalitis. And during the outbreak, the majority of the 
cases--a large number of those cases occurred in Illinois, more 
than any other State, where we had almost 600 cases.
    As we began to look at this in perspective, something that 
was said by Joshua Lederberg, who is a Nobel laureate, that 
``nature is not benign; the survival of the human species is a 
not preordained evolutionary program;'' and that our public 
health system has to be strong and be able to respond. And the 
challenges of West Nile, in fact, demonstrate why we need to be 
    In 2001, West Nile had a national total of somewhere in the 
neighborhood of 157 cases and 15 deaths. There have been as 
many cases in Representative Schakowsky's district as there 
were in the entire United States prior to this year, and that 
includes 1999, 2000, and 2001. So obviously, what we are facing 
this year is dramatically, dramatically different.
    We as a State began to get prepared based upon--with 
resources provided us by Center for Disease Control, and last 
year we prepared our first West Nile plan prior to having any 
cases in birds or in mosquitoes, and that plan was distributed 
throughout local health departments. We began funding them to 
develop their own West Nile plans and began to respond.
    We developed a task force of State agencies that began 
meeting last fall after we had our first positive bird and 
began to put in plans. Recognizing the experience in 1975, we 
built upon a strong foundation of surveillance that have been 
in place since 1976 where over 5,000 birds a year were trapped 
and sampled, looking for St. Louis encephalitis, western equine 
encephalitis, eastern equine encephalitis, and this year for 
West Nile virus. That system began to indicate that in July we 
were having quite a significant problem.
    Thirty-five of the most involved counties and local 
jurisdictions have spent over $5 million this year on mosquito 
abatement. An additional $3.5 million was made available by 
Governor George Ryan to be able to address this issue. Once 
again, it has been a system that has indicated that our public 
health system has been able to respond and responds quite well.
    But what we have done is we have borrowed from Peter to pay 
Paul. These funds that were made available--because there are 
no emergency public health funds in our State, and generally 
not in the Nation--were taken from an account that is used to 
fund local health departments to do food inspections and do 
infectious disease outbreaks, and what we did is we took the 
money from the fourth quarter. So come April we are going to be 
in very short supply of funds to support our public health 
programs at the local level.
    We have to look at the lessons from this year as we begin 
to look toward next year. Obviously, we need to look at ways 
that we can support our public health infrastructure. Through 
the support of Congress and the administration, a significant 
amount of funds were made available to the States. 
Unfortunately, it was really too late to be able to shore up 
our public health system. In our laboratory--for instance, the 
reports on West Nile began coming in later and later. We 
started to check into it. It was because the person who was 
running it, Rosie, in the laboratory was doing it on a hand 
calculator, our inability to implement that. Now, with the 
funding that has been made available, we are going to start 
automating that, but it takes time, and it takes persistence, 
and it takes consistency. Trying to buildup for decades of 
neglecting our public health system cannot occur overnight and 
cannot be done with one single shot.
    We need to look at how to support that public health 
system. We also have to recognize that public education is the 
key. In Representative Schakowsky's district, when we went 
there with the Centers for Disease Control to look at where the 
mosquitoes were coming from, the first two homes we went to had 
mosquito larva growing in containers that were in the yards of 
individuals. No mosquito abatement district can address those 
particular problems. It has to be a partnership between 
government and individual citizens, and that means we need to 
expend the resources to do the kind of research--I mean, the 
kind of outreach and public information that will help people 
realize how important they are in preventing the spread of this 
    Research is also key. Public health, I believe, has once 
again responded, but will need assistance to respond again, and 
I think having hearings such as these are very important to 
highlight the problems and begin to address the needs for next 
year. Thank you.
    Mr. Souder. Thank you for your testimony.
    [The prepared statement of Dr. Lumpkin follows:]
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    Mr. Souder. Dr. McMahan is next. I want to thank you for 
your aggressive leadership in Allen County on this issue. And 
basically anybody who doesn't understand right now in Fort 
Wayne, my hometown, that they need to empty out every container 
and sweep off if there is any puddle in their driveway, you 
have done an excellent job of working to get that information 
out, and I am looking forward to your testimony.
    Dr. McMahan. Thank you.
    Good afternoon, Mr. Chairman and members of the committee. 
The national impact of West Nile virus has generated intense 
media interest this summer. The evolving numbers of human cases 
and deaths can be found on a regular basis on the front pages 
of local and national newspapers as well as crawlers on 
national news programs. However, the local impact of the West 
Nile virus is not often explored or attended to, and we thank 
Chairman Souder and this subcommittee for inviting 
representatives from the front lines on the war against the 
West Nile virus to testify as to the impact this infection has 
caused in our community.
    In Fort Wayne, Indiana, a community of approximately 
330,000, we have identified 51 human cases of West Nile virus 
as of September 30th. This gives our area an attack rate of 
15.4 cases per 100,000 population. It is important to note that 
West Nile virus has not been a benign illness for most of the 
people infected in our community. One of our residents who has 
been severely affected with West Nile virus had this to say 
about the virus: If I could say one thing to someone about West 
Nile virus, it would be that people should not take this 
lightly. I just wish I knew how long it is going to last.
    Over 40 percent of the people identified with West Nile 
virus were hospitalized, and two patients required further 
treatment in a rehab facility after discharge from the 
    There has also been a significant economic impact locally 
due to the lost productivity by the 65 percent of those 
identified with West Nile virus who were unable to work while 
they were ill. In addition, considerable medical costs were 
incurred by all of the patients identified with West Nile 
virus, in addition to the 40 percent who were hospitalized for 
supportive care. But most importantly, there is no way to 
measure the grief caused by the three probable deaths due to 
the West Nile virus in Allen County; 37 spouses, children, 
grandchildren, and great-grandchildren have been left behind to 
try to understand how a simple mosquito bite could have killed 
their loved one.
    From a resource perspective, our local health department 
has spent over $285,000 fighting the West Nile virus this 
summer. We have had to divert human resources from ongoing 
public health functions to keep up with the bird and mosquito 
surveillance and treatment, and the human case investigations. 
Although expensive, we do believe it has been effective at 
limiting the number of additional human cases of West Nile 
virus in our community. However, it is important to note that 
childhood vaccinations, restaurant inspections, septic system 
failures, disaster preparedness, and other public health 
responsibilities continue during this outbreak.
    Infectious disease outbreaks serve as an important 
opportunity to understand the strengths and weaknesses of a 
community's and a nation's ability to provide an integrated 
response to identify and contain the offending agent. What we 
have learned thus far in our community is that while we are 
rich in talent and communication, we are significantly lacking 
in the human and economic resources locally to implement the 
necessary interventions.
    Our department, too, began planning last year for the first 
occurrence of West Nile virus in our community. West Nile virus 
requires a collaborative response from both environmental and 
medical specialists. We worked at length to develop a science-
based comprehensive plan for the surveillance and treatment of 
West Nile virus in our community. Our Vector Control Division 
has worked extensively to identify and treat environmental 
sources of mosquito breeding. They have also worked in 
collaboration with the laboratory of both our department and 
the Indiana State Department of Health to perform timely bird 
and mosquito surveillance to identify areas of increased risk 
of human transmission.
    Our medical community, whom we began educating last year 
about the West Nile virus, has done an exemplary job of 
identifying patients infected with the West Nile virus. This in 
turn has allowed our public health nurses and environmental 
investigators to quickly identify and treat high-risk areas 
surrounding the human cases, thereby preventing even more of 
our residents from becoming infected with the virus. Our public 
information officer and speakers bureau has provided timely 
epidemiological information and educational materials to both 
the media and the public. And finally, our board and public 
officials have been prompt and responsive in allocating the 
funding necessary to contain this disease, despite the 
significant economic hardship it has placed on the county.
    West Nile virus has served to highlight one of the most 
important aspects of any infectious disease outbreak, the 
unpredictability of bacteria and viruses. We have seen 
significant changes in the West Nile virus this year, including 
a striking increase in the number of people and animals 
infected, the potential for transmission through organ 
transplants and blood transfusions, and an increase in the 
number of young people seriously affected by the virus.
    Because bacteria and viruses have the ability to mutate, 
the potential for large-scale outbreaks will always exist. 
Therefore, humans will always be vulnerable to the potential 
health consequences of infectious disease agents and the 
extraordinary efforts needed to manage and contain the 
outbreak. This vulnerability requires an infrastructure that is 
sufficient in terms of human and economic resources so as to 
provide the necessary flexibility to rapidly identify, treat, 
and contain the infectious agent at every level.
    Previous studies have indicated that our public health work 
force is woefully inadequate to effectively manage routine 
public health issues, let alone large-scale outbreaks. This is 
particularly true in Indiana where our local and State public 
health staffing rates are significantly less than the national 
standard. Indiana has 46 public health workers per 100,000 
population compared to the national average of 138 per 100,000. 
Because the need is so great throughout the entire public 
health system, Federal dollars are often not realized at the 
local level. And it is important to remember that all outbreaks 
begin locally. Federal and State funds are needed to develop 
the public health work force such that we will not be in this 
position when another perhaps even more deadly outbreak occurs.
    In conclusion, public health serves as the interface 
between environmental conditions in the field and the medical 
consequences for patients seen in hospitals and doctors' 
offices. The solvency of the public health infrastructure 
reflects the values of the Federal, State, and local public 
officials that allocate financial resources. Let us use the 
West Nile virus outbreak and all the devastation it has caused 
for the thousands of people infected throughout the country, 
including the 51 people and their families identified at Fort 
Wayne, Indiana, as an opportunity to establish mechanisms by 
which we can develop and support our local, State and Federal 
public health system.
    Thank you again for the opportunity to present the local 
    Mr. Souder. Thank you very much for your testimony.
    [The prepared statement of Dr. McMahan follows:]
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    Mr. Souder. Next we will here from Mr. George Wichterman, 
who is chairman of the legislative and regulatory committee of 
the American Mosquito Control Association and is from Lee 
County. This is also going to be very interesting for my 
district, because I, like many others, I go to Sanibel Island, 
but at Fort Myers area, Sanibel, Captiva, and the areas just 
north and just south basically have almost as many Indiana 
license plates as Florida license plates in the spring. So I am 
interested in hearing that from a local as well as your 
national perspective.
    Mr. Wichterman. Thank you, Mr. Chairman and members of the 
    Mr. Chairman, I would like to ask you, if at all possible, 
would you please include my written statement into the record 
as well what I am about to present.
    Mr. Souder. Yes. We will have all your written statements. 
And if you have other information you would like to submit 
after you hear the full hearing, we will submit that also.
    Mr. Wichterman. OK. Thank you, sir.
    I am George Wichterman, chairman of the legislative and 
regulatory committee for the American Mosquito Control 
Association, and senior entomologist with the Lee County 
Mosquito Control District in Fort Myers, Florida.
    I would like to thank Chairman Souder for his leadership in 
holding this important hearing regarding the Federal response 
to West Nile virus and the challenges in addressing its spread 
and impact on the Nation's public health. The American Mosquito 
Control Association is a nonprofit international association 
involved in supporting mosquito and other vector control. Our 
mission is to provide leadership, information, and education 
leading to the enhancement of health and quality of life 
through the suppression of mosquitoes and other vector-
transmitted diseases.
    The AMCA commends this subcommittee inquiry into the West 
Nile virus. This disease represents a clear and present danger 
to the public's health. Given the nationwide potential spread 
of this disease, it is incumbent upon the Federal Government to 
determine what must be done to prevent its spread and 
ultimately eradicate it from our country.
    The AMCA would request that as Congress studies the West 
Nile virus situation, it consider several issues which 
potentially affect the ability of our members to address not 
only the virus, but other diseases as well. The first issue 
concerns the shrinking supply of effective control agents to 
address the pests which carry this disease.
    As you may be aware, the vector control industry has a very 
limited number of pesticide products available to treat 
dangerous pests such as mosquitoes. Our use is not considered a 
major use by the pesticide industry. Consequently, there is not 
a lot of ongoing research development of new pesticides that we 
can use. This volume of product we use is not remotely similar 
to the amount of corn, wheat, cotton, soy bean acreage which 
may be used in treatment for herbicides--as with herbicides.
    For economic reasons, pesticide manufacturers tend to focus 
on these other markets in developing new products. As a result, 
maintaining the limited number of existing tools that we have 
to combat vectors such as mosquitoes is of vital interest to 
our members. These products are going through the 
reregistration process before the U.S. Environmental Protection 
Agency. In conducting those reviews, often vector control use 
is immediately in jeopardy because it is such a minor use, and 
registrants would rather focus their energies on other larger, 
more economically valuable uses. Sometimes the registrant 
simply cannot afford to address EPA's data needs for a vector 
control product because the cost of the data outweigh the 
return on sales of the product. EPA has one such pesticide 
under reregistration that may be lost due to this economic 
consideration, resulting in its cancellation.
    Technically there was a section included in the Food 
Quality Protection Act of 1996 which was intended to address 
this situation. The public health provisions of FQPA 
established the Public Health Pesticide Data Collection Program 
administered by the Department of Health and Human Services to 
develop data to support the continued registration of these 
critical vector control products. Unfortunately, while this 
potentially valuable program was authorized, no funds have ever 
been appropriated for this program. DHHS has never even 
requested funding for this program. Our repeated attempts to 
try and meet with the DHHS Secretary's office on this important 
issue have been rebuffed. It appears that the Secretary simply 
is not interested in trying to tackle this issue. We have heard 
that this is considered an unfunded mandate by the DHHS, and no 
one in these economic times wants to consider unfunded 
    AMCA submits that such an approach is wrong. The West Nile 
virus and other vector-borne diseases are a clear threat to our 
Nation's citizens. If we, the persons charged with dealing with 
these disease outbreaks within each State, do not have the 
requisite tools to do our jobs, the conclusion is self-evident: 
More people will become exposed to these diseases, and 
potentially more people will die from such exposure. We need 
the leadership and assistance now of the Secretary of the DHHS 
to work with Congress to secure the necessary funding for this 
program. We need our limited supplies of pest controls tools 
    The second issue represents a legislative initiative which 
was passed this week in the U.S. House of Representatives 
entitled the Mosquito Abatement for Safety and Health Act, H.R. 
4793, which would authorize grants through the Centers for 
Disease Control and Prevention for mosquito control programs to 
prevent mosquito-borne diseases. This bill would enable 
political subdivisions of States to establish and operate 
mosquito control programs where none currently exist.
    As of today, mosquito and other vector control programs 
throughout our Nation represent only 28 percent of the Nation's 
counties. Many of these mosquito control programs are situated 
in coastal areas of the United States, thereby leaving a 
greater number of counties and municipalities unprepared for 
this more ubiquitous task of controlling West Nile virus 
epidemics. By providing appropriate funding to these entities, 
entomological surveys or assessments may be conducted to 
determine potential mosquito breeding areas, thereby providing 
for the development of a plan for carrying out such a mosquito 
control program. Technical assistance with respect to planning, 
development, and operation of control programs would be made 
available by the Secretary of DHHS, acting through the Director 
of the CDC, for program coordination. The American Mosquito 
Control Association supports this landmark legislation, and 
strongly encourages your colleagues in the U.S. Senate to 
support its passage through Congress.
    As an organization of over 2,000 public health 
professionals across the Nation, the American Mosquito Control 
Association is dedicated to preserving and protecting the 
Nation's public health. We respectfully urge DHHS and the Bush 
administration to collectively work together to implement the 
Public Health Pesticide Data Collection Program by providing 
the appropriate funding which is necessary to preserve these 
important public health products. And with your colleagues in 
the U.S. Senate supporting passage of H.R. 4793, public health 
professionals will be able to function in an effective manner 
in order that they may protect our people and Nation, 
especially the most vulnerable segments of our population, our 
children and senior citizens.
    Again, AMCA appreciates the opportunity to provide their 
views. If the subcommittee has any additional questions, we 
would be pleased to address them. Thank you so much.
    Mr. Souder. Thank you very much.
    [The prepared statement of Mr. Wichterman follows:]
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    Mr. Souder. And for cleanup is Dr. Akhter from the American 
Public Health Association. We appreciate your coming today and 
look forward to your testimony.
    Dr. Akhter. Thank you, Mr. Chairman, members of the 
committee. My name is Mohammad Akhter. I am the Executive 
Director of the American Public Health Association. We are a 
membership organization of 55,000 professionals that work at 
the State, Federal, county level to provide services to the 
American people to make sure that their health is protected. I 
am delighted to have this opportunity to be able to speak to 
    You have heard all about West Nile virus, but now we are 
going to talk a little bit about West Nile virus, but more 
importantly talk about the future, the way we look at this 
emerging and reemerging infection, and what kind of actions we 
can all take to protect ourselves.
    The world around us is changing. The ecosystem is changing, 
populations are shifting, globalization has taken over, and so 
the diseases have become global. Our last century's model of 
treating disease is no longer relevant. For this century we 
must substitute, we must add additional things to it to make it 
effective to protect the health of the American people, and our 
agencies are the very best. CDC, wonderful. FDA, excellent. 
NIH, no other country has such an agency. And they work very, 
very hard, they have done a superb job, and we are very 
grateful we have such agencies.
    But despite all their efforts, their actions started after 
disease hit our shores, not before. We didn't do anything 
preemptive. We were just sitting and waiting for disease to 
come. And think about this: it is 3 years since the disease hit 
our shores. How many scientists, how many people does it take 
to really think proactively, that if HIV virus is transmitted 
through blood transfusion, if Hepatitis C gets transmitted 
through blood transfusion, is there a possibility that West 
Nile virus may be transmitted through blood transfusion, so we 
could start working and develop a test? Because we are not used 
to being proactive. We just want to sit and wait for the case 
to take place and then act.
    And, Mr. Chairman and members of the committee, that is too 
late. That is now no longer acceptable. And despite our best 
efforts, we are unable to contain the outbreak. It has now 
gotten to the heartland of America. It is going to be with us 
for a long time to come and around our Nation. So we need to 
really look at it a little bit differently, and I suggest that 
we take four very distinct steps to deal with this situation 
for the future.
    First, we need to have good medical intelligence around the 
world that we should collect ourselves. We can't rely on other 
countries. They don't have good infrastructures. They don't 
have good people to really do that. We need to know how disease 
is moving around, where it is coming, so that we are warned 
ahead of time so we could start taking actions. Developing 
vaccines takes 3, 4, 5 years. Developing tests take a long 
time. The sooner we are informed, the better we are in a 
position to help other countries as well as help ourselves.
    Second, we should be looking at the diseases that are 
emerging and reemerging so that we should be doing research on 
them. We should be doing some work on them. Private industry is 
not going to do this work, because there is no benefit in them. 
This is the work that needs to be done by the government, and 
that should go on all the time so that we could look at how the 
viruses are changing, what kind of conditions are changing, how 
the virus might spread, what might happen in the future.
    But the first thing we need, Mr. Chairman and members of 
the committee, is a long-term, sustained thinking, not by the 
people who are doing the work. They are too involved. FDA, CDC, 
NIH, they are working too hard taking care of us all. We need 
people who are retired, people who have the expertise, people 
who come together to work on it as a think tank, who think, 
scan the horizon all around us to see what are the potential 
threats and what are the potential situations around the world, 
and then come up and give us the information, give you the 
information, Members of Congress, provide the administration 
with the potential threats, make different modelings so we are 
not caught by surprise that disease is spreading too fast, that 
it has gone South, then it has gone West, when we should know 
by modeling what kind of resources will be needed.
    You shouldn't be asking professional people how much money, 
and they say, we don't know, we just will see what happens. 
Somebody should be calculating what kind of manpower will be 
necessary to deal with the disease if it spreads around, and 
that capacity we don't have in our country.
    We are changing environments, Mr. Chairman. This is the 
most important and pressing need, that there be a think tank 
that looks for the future.
    And finally, in concluding, we need to have, Mr. Chairman, 
continuous capacity-building at the State and local level. My 
good friends here have said and the Congress has provided the 
resources last year. We need to continue to maintain that 
capacity so that our people are able to take prompt action when 
disease outbreak does take place to make sure that our people 
are safe.
    I greatly appreciate this opportunity, Mr. Chairman, to 
come before you and members of the committee, and look forward 
to answering any questions that you all might have for me and 
my colleagues. Thank you.
    [The prepared statement of Dr. Akhter follows:]
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    Mr. Souder. Well, I thank you all. It has been very 
informative for each of us.
    Let me ask a couple of kind of basic questions first.
    Mr. Wichterman, I presume you have a mosquito control 
district in Lee County.
    Mr. Wichterman. Yes, that's correct.
    Mr. Souder. Have you had any West Nile in Lee County?
    Mr. Wichterman. Yes. Mr. Chairman, I am from a mosquito-
controll district, and we cover roughly 1,000 square miles in 
southwest Florida and Fort Myers, and we do have West Nile 
virus indicated in our surveillance program, both in the avian 
population as well as our sentinel flocks that we use for 
surveillence for determining whether we have encephalitis, 
whether it be St. Louis encephalitis or Eastern equine 
encephalitis. But to date we have not had any human cases in 
southwest Florida.
    Mr. Souder. Why do you think you don't have any human 
    Mr. Wichterman. My best guess----
    Mr. Souder. In other words, one of the things that somebody 
from Indiana would immediately look at is basically Florida is 
out of a swamp; you have huge migratory bird populations there, 
with Ding Darling and all sorts of wildlife refuges. You have 
more seniors. Why wouldn't you have any human cases?
    Mr. Wichterman. That is an excellent question. My best 
answer would be in the State of Florida there are currently 54 
organized State-certified mosquito control programs out of the 
67 counties in the State of Florida, and because each of these 
mosquito-controlled districts maintain a surveillance program 
like what you have been hearing earlier from Dr. Hughes, and 
surveillance is key to finding out whether you are going to 
have a problem or not, and surveillance helps to preclude any 
human cases that you may have on the horizon.
    Currently in the State of Florida, as of this past day we 
have nine human cases of West Nile virus, but the cases are in 
southeast Florida around Miami, up in west central Florida, out 
in the western Panhandle of Florida, and up in north central 
Florida, where some of these mosquito control districts are not 
    Mr. Souder. Let me move to Dr. McMahan next.
    Could you for the record give a few pattern insights into 
what you have seen in Allen County? I'm going to ask the same 
question in Illinois. Do you see equally divided between the--
Allen County is unusual because, for those people who aren't 
there, we have rural, suburban, and urban, an urban center of 
200,000, and about 130,000 in the county, but we also have 
large Amish populations. So it is rural and urban. What 
percentage roughly is in the urban versus the rural? Have you 
been able to--could you give some kind of just rough 
breakdown--not precise--of when you have gone out to 
investigate, does it seem to be things that are in the 
immediate surroundings of the home or broader? Just a little 
bit of an insight into the mix of what you are finding at the 
grassroots level.
    Dr. McMahan. Well, what we have found in Allen County is 
that this is predominantly an urban problem. When a human case 
is identified, that triggers an environmental investigation, 
and halfway through our outbreak, we had evaluated 23 human 
cases. Sixty-five percent of those properties in those 1-mile 
target areas surrounding the human case we were able to find 
multiple mosquito breeding sites, things like old tires, 
aquariums, containers, all sorts of containers that were 
breeding Culex mosquitoes.
    So I think that really points to why it is so important for 
our medical community to do the surveillance, because it does 
assist us in identifying other areas for which other humans 
would be at risk surrounding those human cases that have been 
    Mr. Souder. Have you seen similar patterns with the bird 
    Dr. McMahan. The birds, I think, have been identified 
throughout Allen County. I think, unfortunately, we stopped our 
bird surveillance fairly early in the season once it was 
established that the West Nile virus was entrenched in Allen 
County, and our mosquito population surveillance was also 
turning positive. But we continue to hear from the farmers that 
they are just finding tremendous amounts of dead birds on their 
    It has also been a problem for our horses. We have had 45 
horse deaths in Allen County due to the West Nile virus. 
Although, as you mentioned, a significant portion of our 
farmers are Amish, and unfortunately they didn't take advantage 
of the vaccine that was available. But there have been 350 
horse deaths in the State of Indiana.
    So it has been a significant problem. The virus is well 
established and entrenched in Indiana.
    Mr. Souder. Well, is there--I discussed this earlier. But 
if you find a dead bird on your yard, it doesn't necessarily 
mean you are extra vulnerable? Or does it mean you are extra 
vulnerable? We talked earlier. If it is an owl or a red-tail 
hawk, that might be more unusual. Does that--do you see a 
direct correlation at all in the imminence of the immediate 
    Dr. McMahan. Well, I think the Cornell model that is used 
to identify risk predicts that if you find 1.5 birds with West 
Nile virus within a square mile, that area has a high risk for 
human transmission. And that was the model that we have used 
for our--one of the criteria that we have used for our 
adulticiding program.
    But I think it is important to note that the reason that 
the larger birds are always selected by at least our State 
department of health for identification is that they have more 
brain tissue. But sparrows, chickens, all sorts of birds have 
been identified with West Nile virus. So I think if you find a 
dead bird on your property, I think it is important to make 
sure that you dispose of it properly and with care so as to 
minimize your own risk.
    Mr. Souder. Are you suggesting it can be transferred by 
handling a dead bird?
    Dr. McMahan. I think we need to be very careful, and I 
think this year, with over 2,500 cases thus far, we are going 
to have--at the end of the year when we evaluate this 
epidemiological data, I think we are going to have such a much 
better understanding of this virus and all the potential rounds 
of transmission, more so than we had based on the 161 cases in 
the previous 3 years. So I would urge people to take all 
precautions that they can.
    Mr. Souder. Not because there is any particular evidence, 
but just to be cautious.
    Dr. Lumpkin, would you comment on some of the responses in 
Illinois, what some of the patterns you have seen, particularly 
in Cook County? We have huge cases, but I assume if you are in 
every county, you have got rural cases and urban cases.
    Mr. Lumpkin. We do. We are seeing cases in--human cases 
throughout the State. There are 35 counties; out of 102 that 
have had human cases. And we have seen deaths throughout the 
State. The largest concentration, though, of cases are in Cook 
County, and of those cases the largest concentration are in two 
areas, one in essentially Representative Schakowsky's district 
and the other in the southwest side of the suburbs in the area 
directly adjacent to the city. These are again two areas that 
we saw high concentrations of St. Louis encephalitis in 1975.
    The pattern of human cases exactly follows the pattern of 
bird cases that we saw earlier on in the summer, where you can 
just see an explosive progression beginning in July, starting 
in the Chicago metropolitan area and then fanning out across 
the State, so it really has been quite an extensive experience.
    But one of the key questions we are asking is why those two 
areas? And we have asked the CDC and we are looking to do 
studies over the winter to see if there are any things that 
place those communities particularly at risk. At first blush, 
there is no evidence. There is no evidence of increased amounts 
of vegetation. The two areas do have a higher rate of people 
who are over the age of 50, but why that would necessarily mean 
that there would be more transmission from mosquitoes we are 
not really certain at this time.
    Mr. Souder. Do you know why there wouldn't have been a 
focus, given the correlation of St. Louis, if that would have 
been an immediate focus of the Federal Government to look at?
    Mr. Lumpkin. I am not sure how many people in the Federal 
Government are still in their positions who were around in 
1975. We were obviously very aware of that in Illinois because 
of our continued ongoing commitment to do surveillance of 
mosquitoes and birds. So I think--that would be my only 
    Mr. Souder. Could--Mr. Cummings, let me finish up this line 
of questioning.
    Did we have--I should know, but I don't. Did we have any 
St. Louis encephalitis in Allen County in any extraordinary 
    Dr. McMahan. In 1975, probably at the same time that you 
had your outbreak, we had an extensive outbreak in Indiana. We 
had 27 cases of St. Louis encephalitis in Allen County at that 
time. That was actually when we started our vector control 
division, after that outbreak. That was when the vector control 
division actually was initiated.
    Mr. Souder. Was that a complete shock?
    Dr. McMahan. Pardon me?
    Mr. Souder. It is not a complete shock of the patterns of 
places, given the previous patterns. It is interesting--it 
would be interesting if the Federal Government's taken--have we 
had much Federal Government money come into Allen County? We 
have a huge supplemental boost nearly of 40 percent of the 
Federal expenditures. Did any of that get in as the problem 
became greater in Allen County?
    Ms. McMahan. We've received $1,000 directly from the State 
for mosquito control.
    Mr. Souder. And what about in Illinois?
    Dr. Lumpkin. In Illinois I think the total funding, as 
someone mentioned before, was about $1.6 million. We made 
available, as I also said, about $3\1/2\ million that we pulled 
out of another fund to accelerate the payments.
    Mr. Souder. As the problem developed later in summer, did 
you receive any boost-up in the supplemental?
    Dr. Lumpkin. We received for the entire State in August--we 
received a total of about $400,000--an additional 350,000 in 
    Mr. Souder. Thank you. Mr. Cummings.
    Mr. Cummings. Dr. Lumpkin, do you know what your request 
    Dr. Lumpkin. The way the funding was allocated to us, we 
were told what we could apply for, so we basically applied for 
about 100,000 more than they said we could, and we were funded 
for all that we asked for.
    Mr. Cummings. And what did you use those funds for?
    Dr. Lumpkin. Well, those funds were restricted. We were 
particularly told that they were not for mosquito abatement. So 
we used those to enhance some of our activities in our 
laboratory. We also used them to develop a PSA that we then put 
out for the media, as well as other surveillance activities.
    Mr. Cummings. Dr. McMahan, the--I take it that this is--I 
guess this has kind of strained your Agency a bit, huh?
    Ms. McMahan. Oh, definitely. As I mentioned in my report, 
over $280,000 was necessary over and above the normal moneys 
that are spent on vector control. And that doesn't account for 
all of the time that myself, the administrator, we've had one 
public health nurse that's been devoted exclusively over--for 
the past 3 months investigating cases, the environmental 
investigators that need to go out and, you know, investigate 
the cases to identify sources. It's been a tremendous strain, 
    Mr. Cummings. So how do you make up for that. In other 
words, are you sort of deficit spending or what? I mean----
    Ms. McMahan. Well, we've been very fortunate. First of all, 
we've worked long hours. But we've been very fortunate that our 
county council has appropriated the moneys that we have needed. 
They have been very responsive to our need and have 
appropriated the funds when requested.
    Mr. Cummings. What would you like to see the Federal 
Government do to be of assistance? And are you satisfied--and 
this is to you to Dr. Lumpkin--with the CDC and what they've 
been doing and the other agencies?
    Ms. McMahan. Well I think there's been a lot of educational 
support from the Centers for Disease Control. Their Web site 
has been very helpful. They have sent updates with respect to 
issues like blood transfusions and organ transplant issues. I 
think what we need is more support at the local level. I think 
the need is so great at every level for funding that our State 
is in desperate need of funds; that when money is allocated at 
the State level, very little can trickle down to the local 
level. Not because of greed but because of need.
    And so it would be nice if there were a way that local 
departments of health would be able to apply for resources to 
actually provide treatment, the intervention, the adulticiding, 
the larvaciding, and all of those sorts of things. Those are 
expensive, and as it is right now, we've received $1,000 for 
surveillance this year. So our county has for--you know, over 
$280,000. So I would like to see more funds given at the local 
    Dr. Lumpkin. I think that there are a number of things that 
we would--where we could appreciate assistance. First of all, I 
think that given the experience that we had last year, we need 
to look at addressing next year differently. West Nile is here. 
It's here with a vengeance. And we would be looking for 
assistance from the Centers for Disease Control in developing a 
public information campaign that I think needs to be national 
in scope reflecting West Nile.
    People need to know that they place themselves, their 
families, and their neighborhoods at risk by having containers 
that hold water that will breed mosquitoes. People need to 
understand the importance of wearing long sleeves and long 
pants when they go out at dawn, dusk, and early evening. That 
message needs to be repeated and repeated frequently. And it 
needs to be done in a way that--where people are--can address 
    To tell you the truth, doing public service announcements 
that are put on at 4 o'clock at night, 4 o'clock in the 
morning, or, you know, odd hours, is not going to do much to 
help people learn what they need to do about West Nile. You 
need to spend money to get that message out.
    There are some other concrete things that we need 
assistance in. Obviously we're going to run into trouble in 
April in our local health departments, and funds available for 
emergency funds for mosquito abatement I think is important. In 
addition, I think that there needs to be a national fund for 
public health emergencies. We've seen them come. We need to be 
able to respond, and respond quickly, without exhausting local 
and State resources.
    Our State is facing anywhere from a $1 to $2 billion 
deficit in our budget coming up, as many States are. And our 
ability to respond to these kind of things are certainly 
    The USEPA needs to look at the issue of municipal pesticide 
application, particularly in dealing with mosquito abatement 
control. Using larvicides, there needs to be special licenses 
that are available so that we can actually get these treatments 
out without expending large sums of money or hiring private 
    There are limited things that can be trained, particularly 
with larviciding. In Illinois, for instance, we established the 
1-hour course and the special licensing for people who just do 
larviciding in the catch basins throughout the city of Chicago 
and other places.
    Resources and research are crucial. We need to better 
understand as far as how it impacts, how it grows, what's 
involved with the bird population, to what extent are we going 
to see resistance in the bird population that would prevent the 
spread of the disease. So there a number of things that I think 
are on the agenda for Federal action.
    Mr. Cummings. I thank you.
    Mr. Souder. I'd like to ask, Dr. Akhter, you noted in your 
testimony that the West Nile is spreading in different ways and 
taking on different forms. Should we be concerned that like 
other viruses this may mutate and become more harmful, and do 
you have any evidence of that?
    Mr. Akhter. Mr. Chairman, we don't have any evidence at the 
moment. But I think this is the kind of thing we need to look 
at other viruses of similar type: how have they behaved in the 
past and what they might do, and that's why the need for a 
think-tank. We just don't need to have the firm evidence here. 
We need to have accurate projections, some reasonable 
projection on the basis of which we would take evasive actions 
to make sure that it would not do the damages that it would do 
    Mr. Souder. Well, I want to thank each of you for your 
testimony that Dr. Akhter was--it has been very challenging 
when we look at the international changes which are going to 
accelerate in the growing diversity of the communities all over 
the country and the trade and the items that we bring in that--
how we address that between our universities and the research, 
and possibly tapping in, as you said, into retired experts and 
others; because it's clear we're weaker on the predictability, 
and even when there are patterns. But if you're doing hand-held 
calculators and trying to react out of low budgets, it's very 
difficult to do predictive behavior. If you're drowning in 
alligators, it's hard to predict where the next thing's coming.
    I also appreciate, Mr. Wichterman, your specific comments 
on--it's interesting to look at where there are at least 
somewhat success stories and then say, well, we might not even 
be able to execute those if we are not paying attention. And 
how to make sure that you have product available to do what the 
mosquito control districts do, that's another whole challenge.
    And it's been very informative at the local level, both 
statewide, and I know the Indiana Board of Health has been very 
active, too, and I'm sure in Cook County specifically.
    But it's been a good mix of a panel, and if you think of 
additional thoughts or if you want to approach anybody else in 
your States or organizations to give additional testimony in 
this record, clearly my guess is that there will be, 
particularly in the midwest as we get into the fall season, it 
won't be as high on the agenda.
    Congress is going to adjourn. This will probably restart up 
again the next session of Congress, and we need to look at it 
as we move through that budget process and in the authorizing. 
This is an oversight committee our goal is to identify where 
some of the holes were and try to see what might move into the 
legislative process. So I thank you for being part of our 
hearing. I encourage you to stay involved. Thank you for your 
work at the grassroots level. With that, the hearing stands 
    [Whereupon, at 4:30 p.m., the subcommittee was adjourned.]