[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]


 
  DRUG RESISTANT INFECTIONS IN THE COMMUNITY: CONSEQUENCES FOR PUBLIC 
                                 HEALTH

=======================================================================

                                HEARING

                               before the

                         COMMITTEE ON OVERSIGHT
                         AND GOVERNMENT REFORM

                        HOUSE OF REPRESENTATIVES

                       ONE HUNDRED TENTH CONGRESS

                             FIRST SESSION

                               __________

                            NOVEMBER 7, 2007

                               __________

                           Serial No. 110-65

                               __________

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              COMMITTEE ON OVERSIGHT AND GOVERNMENT REFORM

                 HENRY A. WAXMAN, California, Chairman
TOM LANTOS, California               TOM DAVIS, Virginia
EDOLPHUS TOWNS, New York             DAN BURTON, Indiana
PAUL E. KANJORSKI, Pennsylvania      CHRISTOPHER SHAYS, Connecticut
CAROLYN B. MALONEY, New York         JOHN M. McHUGH, New York
ELIJAH E. CUMMINGS, Maryland         JOHN L. MICA, Florida
DENNIS J. KUCINICH, Ohio             MARK E. SOUDER, Indiana
DANNY K. DAVIS, Illinois             TODD RUSSELL PLATTS, Pennsylvania
JOHN F. TIERNEY, Massachusetts       CHRIS CANNON, Utah
WM. LACY CLAY, Missouri              JOHN J. DUNCAN, Jr., Tennessee
DIANE E. WATSON, California          MICHAEL R. TURNER, Ohio
STEPHEN F. LYNCH, Massachusetts      DARRELL E. ISSA, California
BRIAN HIGGINS, New York              KENNY MARCHANT, Texas
JOHN A. YARMUTH, Kentucky            LYNN A. WESTMORELAND, Georgia
BRUCE L. BRALEY, Iowa                PATRICK T. McHENRY, North Carolina
ELEANOR HOLMES NORTON, District of   VIRGINIA FOXX, North Carolina
    Columbia                         BRIAN P. BILBRAY, California
BETTY McCOLLUM, Minnesota            BILL SALI, Idaho
JIM COOPER, Tennessee                JIM JORDAN, Ohio
CHRIS VAN HOLLEN, Maryland
PAUL W. HODES, New Hampshire
CHRISTOPHER S. MURPHY, Connecticut
JOHN P. SARBANES, Maryland
PETER WELCH, Vermont

                     Phil Schiliro, Chief of Staff
                      Phil Barnett, Staff Director
                       Earley Green, Chief Clerk
                  David Marin, Minority Staff Director

















































                            C O N T E N T S

                              ----------                              
                                                                   Page
Hearing held on November 7, 2007.................................     1
Statement of:
    Burns, James, M.D., M.B.A., chief deputy commissioner for 
      public health, Virginia Department of Health, Richmond, VA; 
      Elizabeth A. Bancroft, M.D., S.M., medical epidemiologist, 
      Los Angeles County Department of Health Services, Los 
      Angeles, CA; Robert S. Daum, M.D., professor of pediatrics, 
      University of Chicago, Chicago, IL; Steven L. Walts, ED.D., 
      superintendent of schools, Prince William County Schools, 
      Manassas, VA; and Eric Gayle, M.D., Bronx regional medical 
      director, Institute for Family Health, New York, NY........    55
        Bancroft, Elizabeth A., M.D., S.M........................    84
        Burns, James, M.D., M.B.A................................    55
        Daum, Robert S., M.D.....................................    88
        Gayle, Eric, M.D.........................................   180
        Walts, Steven L., ED.D...................................   173
    Gerberding, Julie, M.D., M.P.H., Director of the Centers for 
      Disease Control and Prevention.............................    11
Letters, statements, etc., submitted for the record by:
    Bancroft, Elizabeth A., M.D., S.M., medical epidemiologist, 
      Los Angeles County Department of Health Services, Los 
      Angeles, CA, prepared statement of.........................    86
    Burns, James, M.D., M.B.A., chief deputy commissioner for 
      public health, Virginia Department of Health, Richmond, VA, 
      prepared statement of......................................    57
    Daum, Robert S., M.D., professor of pediatrics, University of 
      Chicago, Chicago, IL, prepared statement of................    91
    Davis, Hon. Tom, a Representative in Congress from the State 
      of Virginia, prepared statement of.........................     9
    Gayle, Eric, M.D., Bronx regional medical director, Institute 
      for Family Health, New York, NY, prepared statement of.....   182
    Gerberding, Julie, M.D., M.P.H., Director of the Centers for 
      Disease Control and Prevention, prepared statement of......    15
    Towns, Hon. Edolphus, a Representative in Congress from the 
      State of New York, prepared statement of...................   203
    Walts, Steven L., ED.D., superintendent of schools, Prince 
      William County Schools, Manassas, VA, prepared statement of   176
    Watson, Hon. Diane E., a Representative in Congress from the 
      State of California, prepared statement of.................   205
    Waxman, Chairman Henry A., a Representative in Congress from 
      the State of California, prepared statement of.............     4


  DRUG RESISTANT INFECTIONS IN THE COMMUNITY: CONSEQUENCES FOR PUBLIC 
                                 HEALTH

                              ----------                              


                      WEDNESDAY, NOVEMBER 7, 2007

                          House of Representatives,
              Committee on Oversight and Government Reform,
                                                    Washington, DC.
    The committee met, pursuant to notice, at 9:20 a.m., in 
room 2154, Rayburn House Office Building, Hon. Henry A. Waxman 
(chairman of the committee) presiding.
    Present: Representatives Waxman, Towns, Davis of Virginia, 
Duncan, Issa, Foxx, and Bilbray.
    Also present: Representative Matheson.
    Staff present: Phil Barnett, staff director and chief 
counsel; Kristin Amerling, general counsel; Karen Nelson, 
health policy director; Karen Lightfoot, communications 
director and senior policy advisor; Sarah Despres, senior 
health counsel; Steve Cha, professional staff member; Teresa 
Coufal, deputy clerk; Careen Auchman and Ella Hoffman, press 
assistants; Zhongrui Deng, chief information officer; Leneal 
Scott, information systems manager; Kerry Gutknecht, William 
Ragland, and Bret Schothorst, staff assistants; Earley Green, 
chief clerk; David Marin, minority staff director; Larry 
Halloran, minority deputy staff director; Jennifer Safavian, 
minority chief counsel for oversight and investigations; Ashley 
Callen, minority counsel; Patrick Lyden, minority 
parliamentarian and member services coordinator; Brian 
McNicoll, minority communications director; Benjamin Chance, 
minority clerk; Ali Ahmad, minority deputy press secretary; and 
Jill Schmalz, minority professional staff member.
    Chairman Waxman. The meeting of the committee will please 
come to order. Today we will examine a growing threat to public 
health--the spread of drug resistant infections. In particular, 
we'll hear about a bacteria called methicillin-resistant 
staphylococcus aureus [MRSA]. At the outset I want to commend 
Ranking Member Tom Davis for his interest and leadership on 
this issue.
    In fact, Mr. Davis was the person who first suggested 
holding this hearing. Under Mr. Davis' leadership, the 
committee held multiple hearings on public health preparedness, 
and we're working together to continue active oversight in this 
crucial area.
    MRSA infections can occur anywhere. Traditionally, we have 
thought of them as confined to hospitals, nursing homes and 
other health care settings. But now we're learning that drug 
resistant staph infections can be contracted at schools and 
other places where people congregate. This has alarmed parents 
across the Nation.
    In October, researchers at CDC published a major study in 
JAMA, the Journal of the American Medical Association. The 
study estimated that there are about 94,000 cases of serious 
MRSA infections every year in this country and nearly 14 
percent of these infections are due to exposures in the 
community. The researchers also estimated that over 18,000 
deaths each year are due to MRSA in both the community and 
healthcare segments. That's far more deaths than previously 
believed.
    In fact, it is more deaths each year than caused by AIDS, 
though it is about half of the number of deaths from influenza. 
At the same time, we've heard about personal tragedies with 
MRSA. In the last month alone, two otherwise healthy young 
people died from MRSA, a 17-year old boy in Virginia and a 12-
year old boy in Brooklyn. In response to the reports of deaths 
associated with MRSA infection, many schools have begun to look 
for cases and to take steps to try to clean their facilities.
    Since there are 94,000 MRSA infections each year it is not 
surprising that school districts across the country have found 
cases. Parents and the public are rightfully concerned about 
community-associated MRSA. Mr. Davis and I and other members of 
the committee share this concern, which is why we are holding 
this hearing today. We want to understand how to prevent the 
transmission of drug resistant staph infections in the 
community. What steps should schools, gyms and households be 
taking to reduce the risk of MRSA infection? Does it actually 
make sense to try to disinfect entire school districts? We will 
also examine what the Federal Government and State and local 
health officials can do to combat MRSA. We'll hear two messages 
from our expert witnesses; one reassuring and one worrisome. 
The reassuring message is that there are simple steps that we 
can take to protect ourselves and our children from this 
infection. We can limit the spread of MRSA with basic measures 
like frequent hand washing and keeping wounds covered.
    Also reassuring is the fact that doctors already have drugs 
that can treat MRSA and more are in development. The worrisome 
message is that MRSA is a symptom of a larger problem of drug 
resistant infectious disease. This is not a new problem. But in 
recent years, antibiotic use has increased, which has led to 
more drug resistant bacteria. According to the Centers for 
Disease Control antibiotic resistance has been called one of 
the world's most pressing public health problems. Antibiotic 
use is no longer limited to the appropriate use of fighting 
antibiotic sensitive bacterial infections. Unfortunately 
antibiotics are inappropriately prescribed for a host of 
ailments that antibiotics can't actually treat. These include 
certain ear infections, the common cold, and flu. Antibiotics 
have also made it into our food supply and experts have raised 
the concern that this too could be increasing resistance. While 
this hearing will focus on MRSA, and in particular, on MRSA 
infections in the community, future hearings will examine other 
aspects of the growing threat posed by growing resistant 
infectious disease. In the spring, the committee will hold a 
hearing on infections in hospitals where drug resistance is 
particularly widespread. We will also have to look at the root 
causes of antibiotic resistance and consider what we can do to 
curb the burgeoning overuse of antibiotics.
    Today we're fortunate to have some of the Nation's top 
experts on MRSA to help us understand the risks of community-
based infections. We'll first hear from Dr. Julie Gerberding, 
the Director of the Centers for Disease Control and Prevention 
about Federal efforts to address community associated MRSA.
    Our second panel we will hear from Dr. Jim Burns, the 
deputy health commissioner of Virginia about Virginia's recent 
experience with MRSA. We'll also hear from Steven Walts, the 
superintendent of Prince William County schools about efforts 
being taken by school districts to reduce the risk of MRSA 
infection and to educate parents about MRSA. And from my own 
district of Los Angeles, Dr. Elizabeth Bancroft, an 
epidemiologist with the Los Angeles County Health Department 
who will talk about the public health implications of community 
associated MRSA.
    We'll hear from Dr. Eric Gayle, a family practitioner at a 
community health center in the Bronx. And finally, we will hear 
from Dr. Robert Daum, a leading expert in community-associated 
MRSA, and a pediatrician who treats children who have become 
sick from MRSA infections. I hope that the experts before the 
committee today can help us understand the type of threat we 
are facing, what steps families, communities and government 
should be taking to minimize the risks. I thank all of our 
witnesses for being here today and I want to recognize the 
ranking member of the committee Congressman Tom Davis for his 
opening statement.
    [The prepared statement of Chairman Henry A. Waxman 
follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    Mr. Davis of Virginia. Thank you, Mr. Chairman. Thank you 
very much for holding the hearing on the alarming emergence of 
antibiotic resistant staph infections in new settings. Long 
recognized in health care facilities, where virulent drug 
resistant germs can thrive, invasive MRSA infections have 
recently been detected in unexpected places and in growing 
numbers. We requested this hearing to explore the causes, the 
implications and appropriate responses to this festering 
threat, and we appreciate the committee's timely attention to 
an important public health concern.
    According to published comments by one of today's 
witnesses, old diseases have learned new tricks with hard-to-
treat infectious strains penetrating local schools, athletic 
venues, prisons and community centers. The so-called superbug 
outbreak dominated local news and brought unwelcome but needed 
attention to the dangers of a microbe that is all around us.
    In my district in Northern Virginia, at least 20 MRSA cases 
have been identified in Prince William County. Dr. William 
Walts, the superintendent of schools there, has been battling 
the problem aggressively, monitoring student and faculty health 
in helping translate obscure medical jargon to an 
understandably anxious community. He's here to share his 
firsthand experience with the committee today, and we welcome 
his testimony. When it comes to assigning blame for the spread 
of MRSA infections, almost no one comes to the argument with 
literally clean hands. Overuse of the antibiotics and spotty 
environmental sanitation health care facilities allow superbugs 
to walk out the door.
    Once in the community, carriers spread the infection 
through poor surgical wound care, sharing personal items like 
razors, and inadequate personal hygiene. But there's some good 
news. In the battle against nature's resilience and guile in 
spawning drug resistant germs, we have two disarmingly simple 
and effective weapons; soap and water. Thorough hand-washing 
and disinfecting commonly used surface areas can be very 
efficient in limiting the spread of infection. Since the 
primary route of transmission is direct person-to-person 
contact a little caution about crowding, skin contact, covering 
cuts, washing contaminated equipment and keeping yourself clean 
all go a long way in fighting MRSA in our midst.
    This is not the last antibiotic resistant organism we'll 
confront, and the emergence of MRSA raises important questions 
about the reach and sensitivity of disease surveillance and 
reporting systems. In response to the recent outbreak, the 
State of Virginia issued an emergency regulation requiring 
laboratories to report cases of MRSA. Twenty-two other States 
require MRSA cases to be reported to their public health 
authorities. But this drug resistant staph infection is not 
currently included on the list of nationally reportable 
diseases. We look to the Centers for Disease Control and 
Prevention for analysis of the net benefits and cost of 
expanding that and other Sentinel regimes.
    Protecting the public health requires vigilance and common 
sense. Whether the rate of community acquired MRSA infections 
is growing or we're simply getting better at diagnosing 
existing disease rates, a robust response to the spread of MRSA 
will help reassure a nervous public and better prepare us for 
the next superbug. Until a vaccine can provide what public 
health officials call herd immunity against drug resistant 
germs, information, or heard, H-E-A-R-D, immunity can be a 
powerful antibiotic. Every citizen can help fight the MRSA 
invasion by spreading the word about consistent application of 
routine personal and institutional hygiene practices.
    We'll hear from the CDC director and a second panel of 
distinguished experts this morning. We become their testimony 
and look forward for a frank but hopefully not too clinical 
discussion of a community-based response to a community health 
problem. Thank you Mr. Chairman.
    Chairman Waxman. Thank you, Mr. Davis.
    [The prepared statement of Hon. Tom Davis follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Chairman Waxman. We're going to limit the opening 
statements to just the two of us because of time constraints. 
But without objection, all Members will be given an opportunity 
to insert an opening statement in the record. Representative 
Matheson, who has been a very important leader in this whole 
effort, but is not a member of our committee, will be 
participating in the hearing, and I would like to ask unanimous 
consent that he be permitted to do so.
    Our first witness today is the distinguished head of the 
Centers for Disease Control and Prevention, Dr. Julie 
Gerberding. Dr. Gerberding, we want to welcome you to our 
hearing today. While it seems awkward to put you under oath, it 
is the practice of this committee that all witnesses that 
testify before us testify under oath. So thank you for rising.
    [Witness sworn.]
    Chairman Waxman. The record will indicate that you answered 
in the affirmative. Your prepared statement will be made part 
of the record in its entirety, and we want to recognize you to 
make your opening oral presentation.

 STATEMENT OF JULIE GERBERDING, M.D., M.P.H., DIRECTOR OF THE 
           CENTERS FOR DISEASE CONTROL AND PREVENTION

    Dr. Gerberding. I am very happy to provide a chance to 
provide a CDC perspective on this really important health 
problem. Preventable infectious diseases are always an issue. 
Preventable drug resistant infections are an even more critical 
public health issue. And this particular problem with 
methicillin-resistant staph aureus [MRSA], in both hospitals 
and communities, is a problem that deserves our full attention. 
It is always tragic when young healthy people acquire any 
preventable disease and it upsets the community and the 
schools, and people really do get alert to a problem.
    In this case, this problem is not as new as it seems from 
the news. It is a problem that actually has been going on for 
more than a decade. But we are grateful for the chance to shine 
this bright light on it and hopefully think through what else 
we can do to help prevent such tragic deaths. If I can have my 
first graphic, I would like to just make a couple of really 
important framing points. I started my training at San 
Francisco General Hospital in the laboratory with one of the 
world's experts on staph aureus, Dr. Henry Chambers. So I 
worked with this organism from the very first days of my 
infectious disease training. And I know this organism. It is a 
bad bug. I like to think of it as the cockroach of bacteria 
because staph aureus are everywhere, they're survivors, they 
last a long time on surfaces and it is just about impossible to 
get rid of them.
    Staph infections generically are a very important cause of 
both health care and community-acquired blood infections. And 
when it enters the blood, it causes a high mortality. It is 
also, by far, the most common cause of skin and soft tissue 
infections, the kind of ordinary things that we grew up with 
and that people get whenever they have a skin wound. Antibiotic 
resistance and staph aureus emerged from the very beginning of 
the penicillin era.
    In the late 1950's, early 1960's, our Nation was mesmerized 
by the problem of penicillin resistant staph aureus in 
nurseries and spread into the community. These organisms evolve 
resistance much faster than we can evolve immunity or evolve 
new drugs and vaccines to combat them. So they will always be 
one step ahead of our drug store. And that is fundamentally the 
challenge.
    If we use the antibiotics, we eventually lose their 
effectiveness. And so the overarching lesson here is that we've 
got to learn to be much more prudent in our use of antibiotics 
and only use them when they're absolutely essential. On the 
next graphic, I'm illustrating another very important point 
about staph aureus. And that is that it is everywhere. On this 
graph, we have gone across the United States and screened 
people's noses for staph in their nose. And what you can see is 
that about a third of the people in our country at any given 
time have staph aureus in their nose.
    So if you look to the right of you and look to the left of 
you, one of the three of you has a good chance of being a 
carrier of staph aureus, at least at this moment in time. So it 
is an everywhere organism. And it isn't the kind of thing that 
we're going to be able to completely eliminate. But very 
subtly, this graphic also shows that in 2001/2002, only a small 
proportion of our population was carrying the methicillin-
resistant staph. And it has only gone up to be about 1\1/2\ 
percent. But that is an increase, and it is a statistically 
important increase, and it represents more than a million 
people. So we do have this organism colonizing people's noses 
everywhere around our country every day. And that means that we 
have to look at that as the generic issue.
    On the next graphic, I am showing a report from CDC's MMWR, 
which we have used to constantly and continuously update people 
on the problem of staph aureus. But this is really the first 
report that identified fatal infections among children who had 
inquired this community methicillin-resistant staph aureus. And 
when this report came out, I think a lot of people were 
skeptical. They thought oh, no, no, no, these kids must have 
had some connection with the hospital because that's where most 
of these drug resistant organisms are.
    But in this case, there was no association with the 
hospital. And it was the Sentinel that told us that this bad 
bug was circulating in the community, and although rare could 
certainly, on occasion, cause very serious and fatal diseases 
in kids. So on the next slide, we had to change our vocabulary. 
We had to distinguish from the location where bacteria are 
acquired; i.e., some bacteria are acquired in hospitals, some 
bacteria are acquired in communities from the places where 
infections actually develop.
    So some infections occur in the hospital, but that bacteria 
might have been obtained in the community. Some infections 
occur when people are in the community, but they might have 
actually picked the bacteria up during their last 
hospitalization. So it has gotten very complicated to sort out 
where are they being acquired versus where does the infection 
actually manifest itself. And part of that is because you can 
acquire it and carry it for a long period of time before you 
actually develop the disease. One of the helpful things that by 
chance has aided our understanding of how these organisms 
spread is that most of them that are causing this community 
problem that is the focus of our attention today belong to a 
particular family. And they have a unique fingerprint. And so 
we can track them by their fingerprint. It is called the USA300 
strain. But we can track them because they are different from 
the vast majority of staph that occur in the hospitals.
    So we are able, in our special laboratories, to say this 
particular staph probably arose from the kind that we would see 
affecting patients in hospitals and long-term care settings 
versus this one over here is the pattern that we generally see 
in the community.
    Now, of course, they still mix up because people in the 
community end up going to the hospital and then that organism 
can secondarily spread. But we know a lot about these community 
staph aureus because we can track their fingerprints. And what 
we have learned about them so far on the next slide is that 
they are a very common cause of garden variety minor skin and 
soft tissue infection, which usually doesn't require any 
treatment at all; just simply cleaning the wound with soap and 
water or draining it if there's a boil or an abscess.
    Serious invasive disease like we're hearing about in the 
news this week is fortunately extremely rare, but it is tragic 
and it is preventable, and when you look at it over time it 
does represent a serious threat. Generally, these community 
infections occur in healthy people. You don't have to be 
debilitated or have a chronic disease. They tend to sometimes 
occur in outbreaks like athletes that share athletic equipment, 
are injured with turf burns or have the kinds of cuts and 
scrapes that linemen get on the football team. They occur in 
clusters of Native Americans, native Alaskans and aboriginal 
Australians.
    We don't know exactly why that is, but some of it has to do 
with shared personal items. In one of the native Alaskan 
outbreaks it was related to sweathouses where the staff were 
colonizing the benches that people sat in when they were in 
their communal sweathouses, and so there may have been a 
tendency to move the staph from one person to the other that 
way. And there have been some very serious outbreaks in prisons 
where people are crowded together. They share toiletries, 
razors, towels, and, in some cases, they don't actually have 
soap.
    So hygiene in those environments is a very key factor in 
preventing or promoting transmission. I think the bottom line 
here is that not all staph are alike. Some of them tend to 
cause worst disease than others. Some are adapted to hospitals, 
some are adapted to the community. But all of them can be 
prevented. And that's what I wanted to emphasize in my last 
graphic. CDC has aggressive programs in the health care 
environment for preventing infections of all types. And we have 
proven beyond a shadow of a doubt that you can drive staph 
infections down to a minimum, particularly the invasive ones 
caused by catheters that infect the bloodstream.
    But we also believe that in the community, there's a lot we 
can do. And I have a number of the educational materials and 
posters that we've been using for schools and coaches and 
athletes. There's great material on the Web. This is out also 
on the Education Department Web sites disseminated to schools 
around the country. Just trying to send the message that we 
have to get back to basics. As you said, Mr. Chairman, in your 
opening statement, it is hand hygiene, it is not sharing 
personal materials that could be contaminated with someone's 
staph, it is taking care of wounds and keeping them covered, it 
is noticing when a wound looks angry and purulent and then 
seeking medical attention to be sure that it doesn't require 
treatment.
    For doctors it means when you are going to use an 
antibiotic for a wound like this you probably need to culture 
it so that we know what the organism is and whether it is in 
the resistant family. And I think one macro point to make in 
the context of these children who have been affected and the 
concern about the schools is that we need school nurses. In our 
country today, only about a third of schools have a full-time 
school nurse.
    We in the government are depending on schools to be 
involved in nutrition and fitness, in safety, in hygiene as it 
pertains to these kinds of problems, in pandemic preparedness, 
in immunization programs. And our schools just simply don't 
have access to the health professionals that they need to 
recognize the prevention tools and to take the steps necessary 
to protect our children from this and any other health threat 
that could be emerging among our school children. So that is 
something I wanted to draw your attention to, because it hasn't 
been part of the conversation so far, and I think it is very, 
very important for a broad set of health issues and 
particularly this one. So thank you for allowing me to have a 
chance to frame the issues and I look forward to answering your 
questions.
    Chairman Waxman. Thank you very much for that excellent 
presentation.
    [The prepared statement of Dr. Gerberding follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    Chairman Waxman. Let me start off the questioning by asking 
you how worried should parents be, how worried should people be 
about getting these infections that are resistant to 
antibiotics? Is there a range of infection and are there some 
that we need to worry more about than others? If you could put 
it in perspective. Is MRSA the tip of the iceberg of more 
problematic infections and what would you advise parents to do.
    Dr. Gerberding. It is hard to put this into perspective, 
even with us with our expertise. But I think it is important 
that parents recognize that kids get scrapes and cuts and minor 
wound infections all the time. And the vast majority of these 
are the same that we grew up with and are not a cause for alarm 
or concern. They need to be handled with common sense; keep the 
wound clean, keep it covered and seek help if it looks bad or 
gets pussy. But I also recognize that when something like this 
tragedy occurs in your community, it does raise everybody's 
sensitivity and concern.
    And we want to assure parents that schools are taking the 
steps to protect them. But protection also has to occur in the 
home. There are the same issues around hygiene and hand-washing 
and wound care in our households that we are concerned about in 
the schools. So the common sense back to basics are the way to 
manage the threat. And just to not wait if a child has a wound 
that looks particularly bad, but to get it checked out.
    Chairman Waxman. So MRSA sounds like it is more a skin 
problem than any other kind of infection, is that what we're 
concerned about?
    Dr. Gerberding. These community MRSA are almost entirely 
skin and soft tissue. They tend to stay on the surface of the 
skin. There's some biological reasons for it. The bacteria 
probably has adapted some characteristics along with its 
resistance that allow it to be particularly good at infecting 
skin and relatively efficient at being transmitted from one 
skin problem to another.
    So the bacteria itself is designed to do this very well. 
But sometimes it does have the trick, the unfortunate trick of 
being able to invade more deeply and cause very severe ugly 
skin infections very quickly or it can enter the bloodstream 
and cause infection of the whole blood system called blood 
poisoning if you will, and that, of course, is a very, very 
serious disease and very difficult to treat.
    Chairman Waxman. Is it also very rare?
    Dr. Gerberding. It is fortunately very, very rare. We don't 
have complete data for the United States, but we estimate that 
about 200 children will get a serious MRSA infection, and even 
of those 200 people who get the bloodstream form of this the 
vast majority of them will be treated and survive.
    So we're not talking about thousands and thousands of kids, 
but we're talking about some children. And we have to take each 
one of these children to heart and try to do the prevention 
steps that will help.
    Chairman Waxman. Now, I cited earlier a recent Center for 
Disease Control paper that was published in the Journal of 
American Medical Association that found there are 94,000 
serious MRSA infections each year, and there are 18,000 deaths 
from MRSA, more than from AIDS. Now, when you hear a figure 
like that, that sounds pretty serious. That's not the kind of 
thing you're describing as being routine.
    Dr. Gerberding. The paper is a very important first study 
of the problem. But there is a little bit of apples and oranges 
mixed in there, because it is describing both the community 
MRSA that's our focus today, as well as the MRSA that occur in 
the hospital. So we are adding them all together to get the 
94,000 figure. That is a high number and we can bring that 
number down. In fact, we have some evidence that probably the 
number of these infections in hospitals is going down because 
of the emphasis on improving safety in hospitals and preventing 
some of the underlying causes of these infections.
    So this study has sent an alarm that is a big problem that 
we need to address it aggressively. But the piece of it that is 
the discussion we're having today is a small proportion of that 
94,000.
    Chairman Waxman. When we hear about antibiotic resistant 
infections and people dying from those infections should 
parents think that's what's going to happen to their children 
if they have some contact with a bug?
    Dr. Gerberding. Absolutely not. As I mentioned, about a 
third of the people in this room have staph. And even the 
nonresistant staph can still cause very, very serious disease. 
And the vast majority of us will never have a staph infection 
because we don't have the predisposing conditions or because 
our immune system is able to protect us. So they're everywhere 
if you look, but they don't cause disease very often, and when 
they do they generally cause this very minor form of disease.
    Chairman Waxman. Thank you very much. Mr. Davis.
    Mr. Davis of Virginia. Could you explain the difference 
between the community-based MRSA we're talking about and the 
hospital? Are they transferrable? Are they mutations of the 
same? Are they just germs that act the same?
    Dr. Gerberding. This is a fascinating perspective and there 
are some controversies in here, so I'm going to share with you 
my understanding based on my previous work and what I've been 
able to accumulate from experts. But there are people who see 
this a little bit differently. In the hospital, the staph 
aureus have been transmitted there for a long time. And they're 
resistant to many things besides methicillin. Most of them are 
resistant to anything we have in the hospital, except one or 
two drugs. So they're highly resistant.
    Mr. Davis of Virginia. They're just mutations that have 
survived; everything else is killed off along the way?
    Dr. Gerberding. Exactly. Because we use so many powerful 
antibiotics in the hospital that only the survivors persist. I 
like to think of them as somewhat weak staph in the sense that 
they probably aren't as capable of causing disease in healthy 
people as their sensitive cousins because they've had all this 
evolutionary pressure to evolve and adapt. And they pay a price 
for having all this resistance. They're not in their native 
staph. Don't get me wrong, they can still cause very important 
infections. But they tend to evolve infections in people who 
have catheters, which allow the staph to crawl into the 
bloodstream, or people who have to be injected with needles or 
on dialysis for their diabetes, or just people who are 
generally weakened and quite ill.
    They're vulnerable because they're sick, but they're also 
in an environment where they have lots of catheters that create 
an independent way for the staff to gain entry. And they're 
surrounded by an ecology of staph in the hospital where those 
hospital strains live.
    Now, in the community, you don't have those factors. I 
mean, we're talking about healthy children here. And the 
community staph are resistant to penicillin and their resistant 
methicillin, but fortunately, they're usually very easily 
treated with other inexpensive garden variety antibiotics. So 
they haven't had this tremendous pressure to change that we're 
seeing in the hospital environment. Perhaps they're a little 
bit fitter, meaning they are more robust and they can be more 
easily transmitted to one healthy person to another.
    Mr. Davis of Virginia. And can be more virulent as a 
result?
    Dr. Gerberding. Well, the virulence is tricky, but they do 
tend to have a particular toxin. It's called the PVL toxin. 
You'll probably hear from an expert about this, Dr. Daum. But 
most people believe that this toxin probably does increase the 
ability of this, at least USA300 community strain to cause more 
skin disease. What it does is it basically explodes your white 
blood cells that surround the infection, and that sets off a 
cascade of inflammation and pus and the kinds of things that 
you would associate with a more severe skin infection. Whether 
that's the only explanation or not, we're still learning.
    Mr. Davis of Virginia. About 22 States require that MRSA 
cases be reported, but it is not a nation-wide reporting 
requirement. I understand that the CDC doctors get data from 
the States on a voluntary basis, is that correct?
    Dr. Gerberding. There are several ways that we get data. 
But the information we published was from a set of States that 
we pay to do very thorough and intensive surveillance. That's 
why we have such confidence that in those areas we have a 
complete picture on this invasive staph aureus. Part of the 
reason that we did that was to find out what value there would 
be in making staphylococcal infections reportable.
    I have a bias from a CDC perspective that if you measure 
things they tend to improve. So I'm always going to lean in the 
direction of measurement. But the question is not should we 
measure and report, the question is what should we measure and 
report. We can't report everybody who's got staph in their nose 
because that would be a third of our Nation. We can't report 
every skin infection that comes in because we would just have 
nothing but reams of paper coming in. But we probably could 
take a look at the value of reporting the invasive infections, 
the ones that enter the bloodstream or those that cause 
fatalities.
    Part of the reason for doing that is that it is an 
indicator we need to look at where that infection was acquired. 
Maybe there is a problem with the disinfection of athletic 
equipment, or maybe that's the tip of the iceberg of a cluster 
that we need to engage in so that we can protect other people 
in the short-run and learn things that we can adapt in other 
similar environments. So the purpose of reporting is mostly to 
try to intervene in a way that protects other people from 
infection.
    Mr. Davis of Virginia. Are you satisfied with the reporting 
requirements that--not requirements--I'd say that the lists 
that you're getting are accurate?
    Dr. Gerberding. The Sentinel study that we published, I 
have a great deal of confidence in those data. And the people 
who did that study are looking at, OK, we know we can't afford 
to do this kind of intensive assessment everywhere. That would 
not be a good use of taxpayers' dollars. So what can we do that 
is feasible? And we move into this era of electronic laboratory 
reporting and electronic health records, reporting will get 
much easier, much less burdensome. CDC has actually 
demonstrated that the tool that we were using for biosense for 
surveillance for terrorism attacks is easily adapted to look at 
methicillin-resistant staph infections.
    So when you make reporting inexpensive and automatic and 
not detracting from health care providers' time, then we'll be 
able to, I think, have a conversation about a very robust 
system that makes sense.
    Mr. Davis of Virginia. The schools are using bleach-based 
cleansers. Are there other effective cleansers that can be 
used?
    Dr. Gerberding. There are a number of surface disinfectants 
that are approved by the Environmental Protection Agency for 
disinfection, and it is written on the bottle so it is easy for 
someone who has that responsibility to know whether it is an 
improved germicide and for what use.
    Mr. Davis of Virginia. That's why school nurses----
    Dr. Gerberding. Exactly, where you need that kind of 
expertise.
    Chairman Waxman. Thank you, Mr. Davis.
    Mr. Towns.
    Mr. Towns. Thank you very much, Mr. Chairman. Let me thank 
you so much for coming and sharing, and I respect the fact that 
you've been involved in this for so many years. What can you 
tell us about what causes antibiotic resistance like MRSA? How 
does this develop in the community?
    Dr. Gerberding. Bacteria multiply very fast, so they go 2, 
4, 8, 16, 32, 64. They're just constantly growing. That's their 
business. And every time they divide, there's a chance that 
they could make a genetic mistake despite a random chance. 
Sometimes those genetic mistakes cause them to die. They're 
lethal. But sometimes those genetic mistakes give them an 
advantage if they happen to be exposed to an antibiotic. So 
mutations occur frequently because they're always growing. And 
if you have one resistant bacteria in your body, that bacteria 
probably will eventually just go away on its own. But if we 
gave you an antibiotic, that bacteria would survive and the 
rest would be killed and then that bacteria would take over and 
grow 2, 4, 8, 16, 32 and become the dominant bacteria.
    So it is a practice of survival of the fittest. And over 
time, this happens enough in a population of patients or in a 
community where there's antibiotic use that you end up 
switching from most people having the sensitive bacteria to 
most people having the resistant bacteria. Now, staph also have 
another trick, because once they figured out how to do this, 
you know, to get the genes to create the resistance, that gene 
doesn't stay put.
    And they have developed a very clever strategy for moving 
that gene in a little piece of DNA called a cassette. And they 
can transfer it to other staph bacteria that aren't already 
resistant. So those bacteria don't have to go through the 
process of evolution, they can just pick up this new piece of 
genetic material because it gives them a selection advantage 
when they're exposed to antibiotics as well. So one part of it 
is just evolution of bacteria, but the big piece is that we 
expose these bacteria to drugs, and the survivors are the ones 
that have the preexisting capacity to be drug resistant.
    Mr. Towns. I'm concerned about coaches, for instance, in 
these little leagues that just sort of really have no idea 
what's going on. And when you say that, well, it was posted on 
the Web site, these are people that don't have computers. What 
can we do to be able to get information out? I'm concerned 
about the fact that----
    Dr. Gerberding. These are the kinds of things that we're 
sending out to schools through the athletic associations. We're 
working in partnership with organizations that support coaches 
and trainers and athletes, little leagues, those sorts of 
things. So we're trying to get the information out. And 
individual schools are picking these things up and also getting 
them out to the school system. I'm not satisfied that we've 
gotten this information everywhere that it needs to be. And not 
to harp on the issue of school nurses, but I think in a school 
environment, you need somebody who is really thinking about the 
health aspects of the athletic program or the health aspects of 
the classroom. And that is a really important resource for 
making sure that the school is doing the right thing for 
athletes or for any other potential hazard.
    Mr. Towns. Do you feel that we need a national registry? 
I'm sort of thinking, now that we're focusing on this, and I 
really appreciate the fact, Mr. Chairman, that you and the 
ranking member are having this hearing, because I think it 
provides us an opportunity to really focus on this. Because I'm 
wondering, this has been going on for a long time and now we're 
beginning to sort of focus on it more. Because I can think on 
my own in terms of situations of strange deaths with people 
back over through the years. And I just sort of wondered, and 
now wondering, did it have anything to do with--and I'm sort of 
saying, if we don't have a central kind of registry, we don't 
really know in terms of how much is going on. And does that 
bother you that we don't have a central registry?
    Dr. Gerberding. Well, separate the community from the 
health care environment. Because in the health care 
environment, CDC has a registry. We have a system to allow us 
to track infections that occur among patients in hospitals. And 
several States now are reporting all of their hospital 
infection data to CDC using this kind of tool. And we hope that 
soon they'll be reporting it publicly so that if we see the 
results, people will be more motivated to do the things 
necessary to improve.
    But in the community it is harder. We have some diseases 
that are nationally reportable. But I think we're going to be 
able to do a lot better with that. Again, when our laboratories 
are connected electronically, this will become something that 
can be generated automatically and doesn't require someone to 
fill out a report every time they see a patient with an 
infection.
    So we're just on the brink of being able to do this in a 
much more efficient way so that people in the local health 
department can know there's a problem in their community as it 
is emerging. They don't have to wait until, in retrospect, we 
figure it out.
    Mr. Towns. Mr. Chairman, I see my time has expired. But I 
still feel that we need to have a central person that's going 
to be responsible for this. I notice the State of New Jersey 
has moved forward with legislation. And of course, I think 
that's really--I'm sure they're doing it out of frustration, 
but I think it should be done at the Federal level.
    Dr. Gerberding. I don't disagree with you. I think it 
should be done at all levels. The school needs to know what's 
going on in the school. The local health department needs to 
understand the community. The State has great responsibility 
for prioritizing things in the State. But we do, too, at CDC. 
And we fund and support and we create national and 
international guidelines. And yes, we would very much like to 
be able to have a comprehensive picture of the whole problem, 
not just the MRSA problem, the whole problem of preventable 
infectious diseases. Again, if we measure it, I know we will be 
able to fix it. But if we don't know the scope and magnitude it 
is very difficult to guess where we should put our effort.
    Chairman Waxman. Thank you, Mr. Towns. You said you 
appreciated our holding this hearing. As I mentioned earlier, 
this was at the suggestion of Representative Tom Davis. But I 
do want to indicate that the idea was staff driven. Mr. Issa.
    Mr. Issa. Thank you Mr. Chairman. Thank you for holding 
this hearing, regardless at whose insistence it was at. I would 
like to characterize, not just your testimony, but sort of the 
picture that you laid out. Because I think, hopefully, as the 
``Committee on Government Oversight and the Reforms 
Necessary,'' perhaps should be our name, it will lead to 
something positive. This is a 50-year old problem that the 
finest minds, our physicians and health care professionals, 
have either been unable to successfully end, they've only coped 
with, and in some cases, since you're still printing the 
plastic card today that says get the catheters out, they've 
been a participant in the delivery of that.
    Because a catheter, for example, is not just about--it is a 
pathway, it is a pathway where fingers touch. And in fact, the 
person putting it in or adjusting it or taping and retaping may 
be part of the process too that helps get it there. So our 
hospitals, even though you want to separate these, and I think 
it is appropriate to separate, it has a number 300, does that 
mean that there's a 299, a 298 and so on?
    Dr. Gerberding. There's 100, 200, 300, 400, 500.
    Mr. Issa. And then there's subgroups?
    Dr. Gerberding. Yes.
    Mr. Issa. There's a lot of these?
    Dr. Gerberding. Yes.
    Mr. Issa. Basically staph kills more people in America than 
AIDS, all staph, including all the hospital staphs. More people 
die in which that's the primary cause leading to their death. 
So this is not an insignificant problem as a whole. You've been 
dealing with it for 50 years and you haven't vaccinated and you 
haven't successfully killed staph. Nor from your testimony do I 
think you're going to, is that fair to say?
    Dr. Gerberding. I think it is very unlikely we're going to 
eliminate staph aureus has a human pathogen. But I do believe 
that we can have a tremendous impact on the infections that it 
causes, particularly, those infections in health care 
environments.
    Mr. Issa. I'm viewing the less sanitary world outside the 
hospital and saying, OK, we failed in the hospital where 
essentially ever since we got the curtains out of the operating 
room, we've been cognizant of these things and trying to fight 
them.
    So as much as I would like to believe that every gym locker 
room is going to get cleaned based on public awareness, I'm not 
buying it. What I am concerned about are what we should be 
funding your organization or you as an umbrella organization 
should be working with other organizations to do in the way of 
vaccine development. Particularly, I would like you to comment 
on the impact this could have on the military because they 
don't have any of the luxuries of really good hygiene at 
certain times in a war effort.
    They certainly don't have the ability to spread out and 
isolate each other at will. And if, in fact, somebody were to 
use the ugliest of staph infection ever found, could they 
potentially weaponize it. So looking at it from a standpoint of 
where we put our funding into vaccines, into reserve 
antibiotics that would be used, only in a case of an outbreak, 
or only when we see something where nothing else is working and 
we want to stop an epidemic, if you will.
    So I've given you a lot of questions, but I would like you 
to characterize it. What my concern is we have the 50-year 
problem that we haven't been able to do anything but work with. 
It is now out in the community in a less-informed and harder to 
inform, and even if informed and even if they did everything 
that a doctor would do or his health care professional team 
would do in a hospital, you wouldn't do any better than you 
would in a hospital which is, in some ways, a miserable failure 
since that's where you go to get staph infections that can 
really be nasty. Can you put it in that light so that we get 
some inkling not what you are doing, which is important, but of 
what we should be empowering you to do beyond that?
    Dr. Gerberding. I would like to start with the perspective 
of the hospital or the health care environment. Because one 
thing that's changed in about the last 5 years is that this is 
becoming unacceptable to have one of these infections in the 
hospital. And that simple change in attitude is resulting in 
some phenomenal changes in infection rates. We have in our 
reporting system half of some of our intensive care units have 
had no staphylococcal infections in the last year, so they 
truly are eliminating the problem.
    Mr. Issa. So it is like the curtains out of the operating 
room?
    Dr. Gerberding. So you can do something about it? So I 
don't want to lose sight of that, because the key to that is 
the commitment and the believe that you should not have staph 
infections when patients come to the hospital. But I think your 
broader question is really important. Our vaccine story for 
staph is not robust. There was a vaccine that went into 
clinical trial in a very hard to vaccinate population of 
people, dialysis patients. And unfortunately the vaccine did 
not prove to be effective at preventing staph infections in 
that group.
    Not many vaccines are effective in people that ill. But we 
have some prototype work underway, not CDC, but many people 
have prototype work under way for second generation vaccines. 
But they're not getting the boost that I would like to see them 
have. They're not getting the focused attention. And there's 
actually a very tight coupling here between pandemic influenza 
and staphylococcus. Because one of the things that we have 
observed is that when children get influenza, they're prone to 
get complicated bacterial infections.
    When adults get influenza, they're prone to get complicated 
pneumonias. Very often, it is a staphylococcus pneumonia. So as 
we're preparing for pandemics and stockpiling antivirals, we've 
got to think about stockpiling drugs to treat the complicating 
bacterial infections, including MRSA, since that's likely to be 
a big killer in the context of any serious outbreak. So the 
antibiotic pipeline is not robust. It is not robust for 
anything right now. But it is certainly not robust in this 
direction.
    So we need to look at our vaccine pipeline, both in the 
research that NIH is doing, as well as the work that goes on in 
the private sector. We need to look at the drug development 
pipeline. And then I think we've got to think about new 
approaches. Traditionally, the approach to a bacterial problem 
was to kill the bacteria. And unfortunately, as I've already 
said, that results in replacement with a resistant form, or 
substitution with a different player, not necessarily a better 
one. There are novel approaches in investigation right now that 
don't concentrate on trying to kill the bacteria. They actually 
concentrate on trying to prevent it from doing damage. And so 
they're like lasers going in to destroy certain parts of the 
bacteria as opposed to a bomb that blows the whole thing up. 
And I think those novel, you know, next generation strategies 
are not proven yet, but really something that needs a lot more 
attention and focus. And it is exciting to me what I've learned 
so far, but the pipeline is long and it is not very wide.
    Mr. Issa. Thank you. Thank you Mr. Chairman. This was very 
informative.
    Chairman Waxman. Thank you, Mr. Issa.
    Mr. Cummings.
    Mr. Cummings. Yes. Thank you, Doctor, for your testimony. I 
just want to--this whole thing of hospitals and infections 
should concern all of us. A person goes in the hospital trying 
to say, for example, address a hernia, and the next thing, you 
know, they are sicker than they would have been if they had not 
gone into the hospital. And you've said something just a moment 
ago that I just want to know the extent of it. You said 
operating rooms have become better at dealing with staph 
infection. Is that what you said?
    Dr. Gerberding. I said intensive care units.
    Mr. Cummings. Intensive care units. And what is your 
measuring tool? No. 1. And are there best practices? Johns 
Hopkins is located smack dab in the middle of my district, and 
I know they had some kind of campaign trying to get doctors to 
do more with regard to washing their hands and things of that 
nature. But I think we need--I mean, that's very significant, 
because you've got healthy people who are literally going in, 
and I'm not just talking about Johns Hopkins, of course. But 
I'm just saying what have you all learned from that, that 
intensive care less staph infections, what have we learned that 
we can put out there to transfer to other hospitals?
    Dr. Gerberding. We've learned a lot. And that little card 
you have in front of you is a summary of some of the science 
that we have accumulated that defines certain best practices 
that we believe are really critical. So we've learned, first of 
all, that the most important step is to commit to the concept 
that it is not OK to have these infections that you've got to 
do something about and you've got to drive the infection rate 
down.
    The second very important factor is that you can't just do 
one thing. You have to take a comprehensive approach and not 
think that there's a magic bullet. Oh, we'll all wash our hands 
more or we'll all screen patients. Those things are not magic 
bullets. You've got to systematically exhibit the best 
practices across the board. You've got to control antibiotic 
use. You've got to get the catheters out of patients because 
they're the biggest risk factor. And very often patients have 
catheters for convenience, not because they actually require 
them medically for as long as they're left in. But the science 
that supports these recommendations has been codified in a 
document called the Infection Control Precautions For Multi-
Drug Resistant Organisms. And we have put out the 
recommendations of what the best practices are. But we've also 
said in your hospital you must measure these things. And if you 
find that your infection rates are not going down, then you 
need to do the next generation of interventions, which are even 
more important.
    Mr. Cummings. Is that information out to the public? 
Because one of the things that I've noticed just from living is 
that people seem to be driven by money. So if a hospital has a 
record of infecting its patients, and the patients know about 
it and the patients have choices, and in Baltimore, you've got 
50 million advertisements for hospitals and so apparently 
somebody is competing for patients, it seems as if that would 
be not only--cause them to say, wait a minute, we're going to 
lose business, we're going to have some problems if we don't 
address it. So is there some data base that a patient could go 
to? And if there's not would that be a good idea?
    Dr. Gerberding. It is coming. More and more States are 
requiring that this information be reported. And some States 
are requiring that it be made public right away. CDC is 
facilitating that with our tools because we do know how to make 
these measurements accurate and reliable. But I also want to 
just read you a headline from something that came out in August 
2007, because the headline is: New Medicare Regulations Are 
Adopted to Reduce Hospital Infections and Medical Errors. 
Medicare will withhold payments to hospitals for failing to 
keep patients safe. So what CMS is preparing to do, at 
Secretary Leavitt's insistence, is not paying for things that 
are avoidable applications of care.
    Mr. Cummings. I see my time is running out, but let me ask 
you this: Should we in the Congress back that up? Because you 
have Secretary Leavitt, now you're going to have another 
Secretary in a year and a half. Do you understand what I'm 
saying.
    Dr. Gerberding. I believe I do.
    Mr. Cummings. Are those things that we ought to be doing? 
Because this goes to the health of our people. And I'm just 
wondering what you think.
    Dr. Gerberding. First of all, these are regulations and 
they last for a long time once they're enacted. But I think I 
would like to have a conversation. We would really like to sit 
down and think, OK, we've done this so far, what else could we 
do to really make this a permanent part of hospital culture, 
and, for that matter, any health care setting. So that we are 
not only relying on best practices in kind of a proactive way, 
but there's also an incentive in that we're aligning the 
payments that we make for care with the quality and safety of 
the care that's provided.
    Right now, perversely, if someone has a surgical procedure, 
they may be reimbursed at a certain rate. If that procedure is 
complicated by an infection, more money is paid. Well, that's 
perverse. It doesn't result in a strong incentive to solve the 
problem.
    Mr. Cummings. Thank you very much, Mr. Chairman.
    Chairman Waxman. Thank you, Mr. Cummings.
    The Congressman from Tennessee, Mr. Duncan.
    Mr. Duncan. Thank you, Mr. Chairman.
    And I am sorry I didn't get here in time to hear your 
testimony. But there was a Washington Post story from October 
19th that said these MRSA staph infections are reaching 
epidemic levels. And just trying to skim through your 
testimony, I see that you have a sentence in here that says, in 
2005, there were 94,360 serious MRSA infections. Maybe you have 
covered this already when I wasn't here, but has this reached 
epidemic levels? And I think I did hear you say just a minute 
ago something about some progress or good efforts that were 
being made. But is this 94,000 number, would that be higher 
today, and is this going up fast or----
    Dr. Gerberding. Short answer, sir, is I don't know because 
that was the first time we ever took a look that way, and we 
have to repeat it to know whether it is going up or down. But 
we can make some inferences: 85 percent of those patients in 
that study were people who acquired their infection in the 
hospital. And we have, from other kinds of information sources, 
the suggestion that hospital infections are going down and that 
the proportion of them related to this particular bacteria may 
be going down as well. Right now, about 8 percent of all 
preventable infections in hospitals are associated with this 
bug.
    But on the community side, I believe we would guess that 
the infections are increasing. I am saying that because AHRQ 
has data showing there are more visits for skin and soft tissue 
infections generically over time, and the small proportion of 
those that actually get swabbed and cultured so we know what 
the bacteria is, the proportion that are caused by MRSA is 
increasing. So we suspect there are more skin infections in 
some communities and that a greater proportion of those may be 
caused by this organism. But we don't have quite the solid 
evidence for that. There is a bit of extrapolation in that 
statement, and we need to do more studies to verify that as a 
broad issue. Certainly true in certain communities, but we 
don't know nationally whether that is the case.
    Mr. Duncan. Even as we speak, just this past weekend a 
member of my staff here came down with a staph infection, but 
they told her that this is not a MRSA staph infection, and they 
have told my other staff members that they don't need to do 
anything or don't need to be worried. Are there many, many 
different kinds of staph infections?
    Dr. Gerberding. Yes. There are many different kinds. And 
that is one of the fascinating things about this bacteria. They 
are not all alike. We lump them together when we talk about 
them, but they are independent families of staph, and they 
behave in different ways. So when we have the specialized 
laboratory resources, we can predict certain things about a 
particular strain of staph. For example, if your colleague had 
a methicillin-sensitive staph, it is unlikely to be related to 
this problem we are talking about today with these serious 
infections in healthy kids. But there is not always a way to 
know that up front. And I think the most important message is, 
again, kind of back to basics that you should respect skin and 
soft tissue infections, take care of them, keep them covered, 
try not to touch them, and if you do, be sure you clean your 
own hands and don't pass your staph onto somebody else. But 
more importantly, especially in communities where this problem 
has emerged, to make sure that if you see a wound that is 
getting angry or filling with pus or the surrounding area is 
getting redder and redder or the person has a fever, then not 
to wait and to get to the doctor.
    Mr. Duncan. Well, I first heard about this just a few years 
ago in a meeting with some Members of Congress. And one former 
Member from Missouri told us that a 57-year-old county 
executive or county mayor of a suburban county to St. Louis had 
gone into the hospital for some minor surgery and had gotten a 
staph infection. And 3 weeks later, he died. And since then, I 
have heard and read a lot of things about this, and it is 
getting kind of--there is a lot of concern about this. And so I 
am glad we are holding this hearing. But I will tell you, maybe 
this is a little impolite or unpleasant to bring up, to bring 
up at this time, but I remember 5 or 6 years ago, Dateline had 
a hidden camera in a men's rest room at one of the major 
airports, and they obscured everybody's faces, but they showed 
that something like two-thirds of the men were leaving the rest 
room without washing their hands. And everything I read and 
hear, hand washing is about the best thing that you can do to 
try to hold this down.
    Dr. Gerberding. I couldn't agree with you more. I think 
soap and water is, you know, the cheapest intervention that we 
have and extremely effective. Hand hygiene of any kind, the 
alcohol preps, I think you have one sitting up there, that is a 
very important part of just constantly disinfecting your hands. 
What happens is, especially in hospitals, if you touch 
something that is carrying one of these staph, it is sitting on 
your fingers. You may not end up carrying it yourself, but you 
can pick it up and move it someplace else. And that is where 
the hand washing just becomes so important, because you 
eliminate that transfer. If you are a carrier of staph, you 
protect others. And if you happen to be in an environment where 
someone else has been present with the staph, then you won't 
pass it onto yourself or someone else.
    I also want to emphasize, however, that this isn't 
something that is just floating around in the air or that we 
need to exaggerate the way it is spread. It is spread by very 
close personal contact. And primarily the major force of 
transmission outside the hospital are skin wounds.
    Mr. Duncan. Well, I think it is important that we call more 
attention to this.
    And thank you, Mr. Chairman.
    Chairman Waxman. Thank you very much, Mr. Duncan.
    Ms. Watson.
    Ms. Watson. I want to thank you, Mr. Chairman, and ranking 
member for having this hearing today. We have all been 
following the stories in the local area about schools closing 
down. And I just want you to clarify for us, we see those 
beautiful, colorful posters that you hope to get out. When 
should a school close down and disinfect? What are the signs? 
Not all schools, you have already made that point, have the 
health care personnel there. And I don't think they are going 
to have them in anytime soon. We found on our desk these cards. 
Would it be a good thing to send these cards out to every 
school? Should the school personnel carry these cards? Should 
we send them home when we find one case of staph? Should we 
close down the whole school and disinfect? Can you clarify the 
procedures for us?
    Dr. Gerberding. Thank you. You know, we have a lot to learn 
about this, so I am going to tell you our best perspective 
right now, and we will learn more as we investigate behind the 
scenes. In general, when there is a case of this kind of staph 
infection in a school, it is linked to something like the 
athletic program or to some potential environmental exposure. 
And it is a signal for schools to take a look at their general 
housekeeping and particularly the housekeeping in the gymnasium 
or the locker rooms or areas where kids who have skin wounds 
might come in contact with each other. I mean, the wrestling 
room is a great example of that. The wrestling mat, for 
example, needs to be properly disinfected at periodic 
intervals. So this is a point where the school should review 
their procedures for environmental hygiene. There is generally 
no need to go in and disinfect the whole school, because that 
isn't how this organism is transmitted. From a public health 
perspective----
    Ms. Watson. Let me just query that a bit. We don't know how 
it is transmitted. And I was going to ask you about soaps and 
disinfectants.
    Dr. Gerberding. The local health officers who are 
involved----
    Ms. Watson. Let me just say this, so you can give me a more 
comprehensive answer. We are talking about schools where 
children come from all kinds of environments and they are 
there. It could be spread through athletic activities, it could 
be brought from home and so on.
    Dr. Gerberding. Exactly.
    Ms. Watson. What guidance do you give the school personnel, 
since we have had two incidents in the surrounding areas? And I 
am just wondering, and you mentioned prisons before, too, and 
the fact that some of them don't even have soap. Are there some 
guidelines that we could send out to our schools? Maybe this 
ought to be distributed. So can you be a little clearer as to 
how we can protect, prevent in our schools?
    Dr. Gerberding. The card that you have is targeted for 
hospitals. But it would be very easy for us to make a tool like 
that for schools. And I think that is a great idea, and we will 
look around and see how we can afford that. But I think we can 
figure out a way to get something like that accessible to 
teachers and trainers and coaches and anybody else who has a 
stake in keeping the school a safe and hygienic place. You 
asked me the question about closing schools. And I don't want 
the impression to be that, if there is a case of this 
infection, that it is necessary to close the school. Sometimes 
a decision is made to close the school because you do need to 
pause and buy some time to go in and inspect and understand 
what happened and also to reassure parents that you are taking 
every step. So I would never say it is wrong to close a school 
for a variety of reasons. But it is not necessary, generally 
speaking, from an infection prevention perspective, to do that. 
It is necessary to assure that the school has a proper hygienic 
environment, using common sense principles of hygiene. And many 
have presented those. And I have, you know, these examples of 
various posters that you will find in a lot of schools already. 
They are made in collaboration, this one, for example, is with 
the Massachusetts Department of Public Health, the CDC and HSS, 
and this is for athletics on a football team. And these kinds 
of things are in the locker rooms and reminders of avoiding 
skin, keep your hands clean, shower after you play a sport, use 
a clean towel, keep your cuts and scrapes clean. So we are 
using a multimedia effort to inform students as well as 
schools, but I think we can do a lot more, and I want to be 
able to do that. So this is an opportunity for us to really 
have a broad campaign around preventing infections in schools 
and homes. And MRSA is a good hook for getting that message 
across.
    Ms. Watson. My time is almost up. And I just want to say 
this, as a former teacher and school psychologist and 
administrator, I know that current budgets--I am from the State 
of California--current budgets don't allow auxiliary personnel, 
because our constitution in our States only require two people 
in a classroom, the student and the teacher. So the first to go 
are the school nurses and other auxiliary personnel. Is it 
possible that CDC can put out some guidelines to the public 
health departments in counties throughout the country or to 
States so that they then will take some action to prevent this? 
It is awful frightening, with the news coverage that we have 
today, to know that young people are contacting the staph 
aureus, and they are dying. And I think we can prevent it. And 
I think, you know, you go into some schools, the toilets are 
dysfunctional, they don't have soap in them. So it might be, 
you know, we can require--of course, we can't do it federally, 
but they certainly could do it statewide--require that there is 
disinfectant soap in every single rest room. We have to do 
something so these new growths of pathogens don't take a 
foothold and spread across this country in an epidemic fashion, 
which can happen very easily in schools. And thank you so very 
much.
    Dr. Gerberding. Thank you. My mom was a teacher, and most 
of the members of my family were teachers. And I know exactly 
what you are talking about in terms of school budgets and the 
priorities that have to occur there. And I was impressed when I 
was learning about the school interface with this problem how 
much guidance and evidence has been produced by CDC and 
Department of Education and many State health departments. But 
I don't think that we have systematically assured it has gotten 
to all the places, to the PTAs, to the parents' groups. And 
this is a really good reminder for us we have to market more 
effectively what we have and fill in the gaps that we are 
missing. Thank you.
    Chairman Waxman. Thank you, Ms. Watson.
    Mr. Lynch.
    Mr. Lynch. Thank you, Mr. Chairman. I also want to thank 
the ranking member for his work on this. And thank you, Dr. 
Gerberding. I want to sort of turn the question around a little 
bit. If these infections were indeed treatable, if these 
infections were not drug-resistant, we wouldn't be here today. 
And there seems to be a real history of inaction on the FDA's 
part to incentivize the development of vaccines and other 
antibiotics that would be able to treat these new infections. 
Now the fact of the matter is there are some countries, Mexico, 
countries in Central America, South America, where you can 
actually buy antibiotics over the counter like we do aspirins. 
And so what is happening in those countries is there is a 
breeding ground, basically, for super bugs, because they evolve 
over time and become resistant to those antibiotics. But there 
are some things that we are doing in our own country that I 
think are problematic as well. And I wanted to talk to you this 
morning about some of these antimicrobial soaps. I have one 
here. It is a hand sanitizer. This one is Avant, I guess; it 
uses ethanol. It has alcohol in it. And it physically disrupts 
the bacteria on the skin. There is another one out there, 
Purell, that is similar to this. And that is fine; it doesn't 
use antibiotics. But there is another one here; this is 
antibacterial soft soap. And what is happening is, 
commercially, some of these producers, manufacturers are 
actually capitalizing on the fear that is out there. And this 
one has triclosan in it. And that is an antibiotic that doesn't 
need to be in this. But what we are fearful of is that this is 
contributing to the problem, and that the more products that 
are out there that have antibiotics in them and don't need to, 
it is creating, more resistance out there in the pathogens that 
we see. So what I want to know is what are we doing about this? 
Here we are allowing producers, manufacturers in this country 
to put out stuff that has, you know, antibiotics in it, 
creating more of a problem. And there are obviously some very--
this one has ethanol in it, you know, it is a green product, 
where it is doing the job. I mean, can we ask these people to 
take this stuff off the market? And what is the efficacy of 
those efforts, if any?
    Dr. Gerberding. Let me first say that you are bringing up a 
dimension of this that is very sophisticated, it is the 
dimension of the balance between pretending that we could 
possibly live in a sterile environment and common sense that 
would dictate, let us do the sensible things that we learned in 
kindergarten to try to protect ourselves and others from 
infections. And I do agree with you from a societal 
perspective, we are enjoying the marketing of the fear for any 
number of health hazards that is feeding a lot of unnecessary 
motivation to use many of these types of products. And right 
now, we don't have any evidence of resistance emerging to the 
compounds that are in these products. For example, alcohol, it 
would be almost impossible for a bacteria to develop resistance 
to alcohol just by the mechanism of how it works. So they are 
relatively unlikely. Although with triclosan, there has been 
some very preliminary worrisome suggestion that certain 
bacteria are developing the ability to exude it from the cells, 
and they could become resistant. It is not a problem, and we 
have been using these drugs for a long time, these compounds. 
So I am not going to say, it won't happen. But that is not my 
major concern with them right now. My concern is that we are 
creating an environment where people are misunderstanding the 
hazards that actually exist, and they are misapplying this kind 
of technology and these kinds of products in ways that actually 
don't result in better health and, in some cases, might make 
matters worse. I mean, just an extreme example of that, if your 
hands are filthy and you rub some alcohol on it, you are really 
not cleaning your hands. You may be removing some things but 
are actually not able to disinfect your hands properly. So you 
need soap and water to be able to accomplish that. So I 
recognize that we are delivering a message that says hand 
hygiene is important, soap and water, and there is a role for 
these products.
    We know from science in hospitals, where we have looked at 
their use and what happens to infections when they are used 
properly, that they can really be an important contributor to 
patient safety. But their overuse in other environments is not 
necessarily constructive and really diverts people from 
important steps.
    Mr. Lynch. Thank you. I have limited time, so let me just 
ask you the other side of this, the first question I mentioned. 
What are we doing? I am working with a group called the 
Alliance for the Prudent Use of Antibiotics. And they are 
concerned that there aren't enough manufacturers out there that 
are trying to develop new antibiotics. They say we have a small 
family of tools in our toolbox, and we need more. What are we 
doing to help that effort to have drug manufacturers look at 
some of this stuff? It may not be the most lucrative stuff, but 
government does have an ability to incentivize research and 
development in certain areas. And if you would, would you share 
with us any thoughts on that? Are we doing anything in that 
direction? Thank you.
    Dr. Gerberding. I would just say that Dr. Levy from the 
Alliance is a good friend of mine. And so I am well aware of 
the work that is going on with the Alliance. And there is some 
very important steps that are being taken there. The pipeline 
for antibiotics is attenuated for a lot of reasons. In part, 
the reasons have to do with the complexities of drug 
development and the fact that there aren't very many 
blockbuster ideas around anymore. They have sort of run out of 
new approaches to defeating these bacteria. And so the great 
ideas seem to be drying up. I don't believe that is the end 
story here, but I think there has been a dramatic attenuation 
of what is in the pipeline to try to solve these problems. And 
part of the recognition is that these drugs have a shorter and 
shorter life span of utility because the bacteria are so 
quickly able to develop resistance. And it is so expensive and 
so legally expensive to try to bring a drug to market that it 
gets very complicated. I think we can do more. And as I 
mentioned, the investments that NIH and the private sector are 
making in completely different approaches that are much more 
laser in orientation as opposed to blasting the bacteria in 
orientation, there are some very exciting and innovative 
strategies. I personally think for staph aureus we need a 
vaccine. There are people we know are at risk for this 
infection. And if we can develop a vaccine that prevents 
invasive disease and reduces the infection rate we will really 
save lives. And I think we need a concerted and very aggressive 
effort in that regard.
    Mr. Lynch. Thank you. I yield back.
    Chairman Waxman. Ms. McCollum.
    Ms. McCollum. Thank you.
    Thank you, Dr. Gerberding. I want to just followup on two 
issues about how we go about identifying this type of staph 
that we are talking about today. One of the things that some 
States have been doing, Minnesota has been doing, and I quote 
from a Pioneer Press article, one of our newspapers, proposed 
State guidelines would require hospitals to test all high-risk 
patients for MRSA, isolate those with positive tests, and 
encourage all workers and visitors to stop the spread of 
disease by washing their hands. It goes on to cite one 
hospital, Southdale has cut its hospital-acquired infections 
this year partly because it screens all patients in the 
intensive care for the presence of this before it becomes a 
problem. All caregivers are paying more attention to infection 
control. And I am assuming by caregivers they are even 
including those who will be giving care possibly at home 
further instruction on hand washing and that as well. But then 
it goes on to say that the strains of this in hospitals are 
somewhat wimpy compared to the strains circulating in the 
community. And that is what has everybody I think really, you 
know, with heightened awareness with these unfortunate two 
deaths. But community cases often surface as skin infections in 
healthy people. Hospital cases often attack patients already 
weakened by surgery or other illnesses. So I am just wondering, 
just to make sure that--because we go out and talk to people in 
the community--just so that we are clear, the hospitals, what 
is the testing? I saw something just for a few seconds on 
television, it was a nose swab. What is the CDC talking to 
hospitals about doing? To followup on another Congress Member's 
suggestion, what should we be doing to work with either with 
the Governors Association, State boards of health or with you 
so that there is a unified message going out? We don't have so 
many things tripping over themselves that nothing happens. And 
then here again even with the schools, school nurses are 
something that I am very upset that we have seen disappear in 
our schools for a whole host of reasons, this being one of 
them. But maybe you could speak to that and what the CDC might 
want Congress to do or not to do to be helpful here again with 
schools, school nursing, school administrators, coaches' 
renewal, coaches' certificates which States certify and offer. 
What can we do to be helpful? And what are the types of things 
that you would want a Member of Congress, if a mom came up to 
me worried about their child in school, if a person came up to 
me worried about a loved one in a hospital, what do I need to 
know so that either I point them in the right direction and so 
that I don't give out misinformation?
    Dr. Gerberding. Let me start with prevention in the 
hospital and other health care settings. What CDC has done is 
to bring the best experts together and to really look at the 
science and the best practices and try to draw conclusions 
about, what do we know is at least the basic set, we call them 
the tier one recommendations, that everybody should do? And we 
have published those, like we do our other infection control 
guidelines, and they are picked up by infection control 
professionals, which we do have in hospitals, thankfully, to 
implement them. What those recommendations say are basically 
you need to measure your problem and you need to reduce it. And 
if you are not reducing it with the basic recommendations that 
we have offered, you have to move to a much more aggressive and 
expensive set of interventions, which include aggressive 
screening, aggressive isolation, and a variety of other steps.
    Now you might ask, why wouldn't we screen and isolate 
everyone up front? And there are several reasons for that. 
First of all, the evidence indicates that is not necessary to 
drive your infection rates down. There are many hospitals that 
have seen 60-plus percent reduction without taking that 
particular approach. But more importantly, in hospitals where 
this has happened, they have been able to show that patients in 
isolation get less care. And what happens is the doctor doesn't 
go in as much. The nurses don't go in as much. The bed sores go 
up. The other infection and safety problems increase. And so 
there is a ying and a yang. If you are going to isolate 
someone, you have to commit to making sure that you provide the 
same attention and care that you would be able to provide them 
if they weren't in a room that was filled with barriers that 
you had to change your clothes to go in and out of and so 
forth. So there are aspects of this from a comprehensive 
approach to patients that I worry about. I was a hospital 
epidemiologist. It was my job to execute these kinds of 
programs at San Francisco General Hospital. And one of the 
things that I am aware of is that about 8 percent of the 
problem is staph, but there are a whole lot of other bacteria 
that also cause deadly infections in hospital patients. And you 
have to have a program that deals with infections, not just 
with this particular bacteria, if you really want to improve 
the safety of your patient care. So the problem is much bigger 
than what we are addressing today. And it takes a comprehensive 
and a generic solution. But it can be done. And our whole point 
is, do it. And let us measure and report that you are 
successful while you are at it.
    Chairman Waxman. Thank you, Ms. McCollum.
    Mr. Sarbanes.
    Mr. Sarbanes. Thank you, Mr. Chairman.
    Thank you for your testimony. I became aware of MRSA when I 
was first elected last year. A lawyer who was in my law firm 
gave me a 10-page handwritten discussion of this and sort of 
handed it to me and said, nobody's talking about this; you need 
to know about it. And so when the hearing was called, I was 
very anxious to come and understand more about the issue. We 
have had some questions about how the various practices that 
are out there that are increasing the resistance to antibiotics 
are something that we need to be concerned about. I want to 
just focus a little bit on what is being done with respect to 
animal feed and the introduction of fairly heavy antibiotic use 
in animal feed within that industry, and whether that is 
contributing to this kind of resistance. Maybe you could just 
speak to that generally. And then I have a specific question on 
that.
    Dr. Gerberding. This has been a subject of a great deal of 
scientific scrutiny from people in the agriculture side of the 
House as well as on the public health side of the House. And I 
think particularly deep analysis has been done in some European 
countries. I believe the evidence strongly indicates that the 
use of certain antibiotics in animal feed were a major driver 
for one of our most feared drug-resistant organisms, 
vancomycin-resistant enterococci, but that there is also an 
association with drug use in animal feed with the emergence of 
resistance in some more common enteric pathogens like 
salmonella. And so just as what happens in people is, if you 
have an infection and you treat it, eventually the bacteria 
will learn to be resistant to it. Of course, the same thing 
happens in the intestinal track of animals. Over time, they 
become resistant to these antibiotics. And the problem is, they 
are not over there, and they are over here. We are all mixed 
together. They are in our food supply. We work with them on 
farms. We have very intimate contact. That is why most of the 
new infectious diseases people have developed in the last 20 
years have come from animals. So, of course, our drug-resistant 
infections could emerge from animals, or the genes that cause 
that resistance could move from an animal bacteria to a human 
bacteria. So it is an important issue.
    And I think, in Europe, where they have tackled it in a 
very systemic way, they have been able to show that you still 
get good yields from your chicken production or your pork 
production, and that it actually doesn't interfere with the 
livelihood and productivity of your industry if you do this in 
a sensible and prudent way. Beyond that, what I can say about 
the United States and the current status of our own regulations 
around certain antibiotics and animal feed, I am not up to date 
on that, so I would have to get back with you on the current 
status, but I know we have taken similar steps in the United 
States.
    Mr. Sarbanes. I appreciate that. I guess there is an 
antibiotic that treats meningitis called Ceftriaxone, and there 
is a very close drug to that which is being used in animal feed 
called cefquinome. And I mean, meningitis is something that 
causes, obviously, high anxiety in the public. And right now, 
we are in a position to treat it with this one particular 
antibiotic, or at least it is a key antibiotic in the treatment 
regimen to combat meningitis. Are you concerned that the FDA 
allowing the use of this cefquinome in animal feed could create 
a problem with the treatment of meningitis?
    Dr. Gerberding. I am not properly briefed on that, so I 
would need to get back to you for the record on this particular 
issue. I will just say, generically speaking, wholesale use of 
antimicrobials drives drug resistance, and if we are creating a 
ecology of resistance that is relevant to human health, then it 
is a concern to me.
    Mr. Sarbanes. Is the FDA, as it is regulating the use of 
antibiotics in animal feed, are they working into that analysis 
the effect it could have on the antibiotics that are being used 
to treat human conditions?
    Dr. Gerberding. There are several organizations that have a 
stake in this; FDA, USDA, CDC among them. But about 5 years 
ago, people came together--actually a little bit longer than 
that now--and developed a comprehensive plan for dealing with 
antimicrobial resistance, which really should be revisited 
because it was a fantastic, comprehensive approach to 
systematically addressing the problem on a national and 
international scale. And this was one of the main issues in 
that report. And there were 10 Federal agencies that 
contributed to it. It is quite good, and I would be happy to 
make it available to you.
    Mr. Sarbanes. I appreciate that. I know the AMA and 
Infectious Disease Society have addressed this issue of 
cefquinome and their concerns about it, and they are hoping 
that the FDA will regulate against that usage. So I would be 
encouraged to hear more information about that.
    Dr. Gerberding. Thank you.
    Mr. Sarbanes. Thank you, Mr. Chairman.
    Chairman Waxman. Thank you, Mr. Sarbanes.
    As I indicated earlier, Mr. Matheson is joining our 
committee for this hearing. He is on the committee that has 
legislative jurisdiction over these issues and has been a 
leader with legislation to deal with resistant strains of 
antibiotics.
    Mr. Matheson, I want to recognize you for questions.
    Mr. Matheson. Thank you, Mr. Chairman.
    And thank you for the opportunity to participate on this 
hearing's committee today. Dr. Gerberding, I want to ask you 
about the Federal response to the problem of drug resistance. 
It is not a new problem. In 1995, a report from the Office of 
Technology Assessment said that drug resistance was a growing 
problem and we needed some basic, commonsense public health 
measures to address the issue. In 1998, the Institute of 
Medicine also put out a report on drug resistance and said some 
similar things to the OTA report. In 1999, the GAO reported 
that data on drug-resistant bacteria were limited and raised 
concern this problem might get worse. So, in 2000, Congress 
enacted a law that set up a task force to coordinate Federal 
programs on antimicrobial resistance. I understand that the CDC 
played an informal leadership role for this task force. The 
task force identified some top priority items, like creating a 
national surveillance program. And that was 7 years ago. I want 
to know, in your view, in the past 7 years, has the 
administration done a good job in addressing this problem and 
in implementing the recommendations of that task force that was 
set up?
    Dr. Gerberding. You know, I would have to go back and look 
one by one at the recommendations. And I didn't prepare that. I 
was part of that task force, so I am very familiar with the 
process. And you know, the experience of bringing 10 agencies 
together with the whole universe of stakeholders was something 
that I don't think had ever really been done before in 
government. And I do know that some aspects of the program were 
funded, and that my division, the division I initially directed 
when I came to CDC, was one of the beneficiaries of the 
investment in the antimicrobial resistance budget line for CDC. 
So, clearly, some things have happened. But CDC will be working 
with our other partners to reconvene that task force this 
winter. And we expect to go line item by line item through it 
and understand, OK, what did we do? What remains to be done? 
And where do we go from here? What was resourced? What wasn't 
resourced? What are the gaps? And let us refresh this and get 
the show on the road.
    Mr. Matheson. I appreciate that. I will offer you a couple 
of gaps that were key recommendations that the task force made 
that haven't been implemented, such as a comprehensive national 
antibiotic resistance surveillance plan, and I think there is 
still a need to research the most effective infection control 
practices. And I am glad to hear the task force is going to be 
coming back together.
    Dr. Gerberding, as you may know, I have introduced 
legislation, and Chairman Waxman has cosponsored as well, 
called the STAAR Act. And it is an effort to strengthen our 
response to antimicrobial resistance. I am just wondering if 
you have had a chance to review this legislation, and if so, 
what you think of the provisions related to surveillance, 
prevention, control and research.
    Dr. Gerberding. Yes, I did have a chance to review it, and 
thank you. I would say that there is one perspective that is 
good news and will make this a lot easier. And that is, we are 
in the process of switching from traditional approaches to 
surveillance to very contemporary approaches to surveillance, 
relying on electronic medical records and the connectivity that 
we have created. CDC is going to be funding eight enormous 
contracts with large States or health care organizations to be 
able to utilize anonymized data about various things, including 
infections and drug resistant infections that will allow local 
health officers and State health officers to have much quicker 
and much more efficient and much, I think, more robust 
information in a timely way about these problems as they 
emerge. So the technology now allows us to do something very 
inexpensively that before we would have had to invest a ton of 
money to even get off the ground. That is exciting, and we are 
doing it. The other provisions in the act I think also reflect 
a comprehensive approach. And it would be good to compare what 
is in the proposed legislation with what the task force thinks 
the priorities are so that we could refresh and stay in 
lockstep as that moves forward.
    Mr. Matheson. Sure. I certainly am open to any suggestions 
that you have for that legislation as we try to move it 
forward. So I make that just a general request of you and am 
interested in your input.
    Dr. Gerberding. Thank you. Thank you.
    Mr. Matheson. Again, Mr. Chairman, I thank you for the 
opportunity to participate in the hearing, and I yield back.
    Chairman Waxman. Thank you very much, Mr. Matheson.
    Mr. Bilbray.
    Mr. Bilbray. Thank you, Mr. Chairman.
    Doctor, as the chairman well knows, in my previous life, 
before coming here, I supervised the health program for 3 
million people in San Diego County. And obviously, my 
information is very dated, so I would ask you to sort of update 
me on the latest. One of the issues that we were addressing was 
the creation of these resistant strains through incomplete 
treatment, antibiotic treatment. Is that still a concern out 
there about the fact that a patient's ceasing treatment after 
the symptoms have left but not completing the entire treatment?
    Dr. Gerberding. That certainly is one of the factors that 
promotes resistance, incomplete killing of the organism and 
leaving some of the stragglers around to benefit from their 
reduced susceptibility and emerge. That probably has not been 
an important issue for staph infections, but it probably is an 
important contributor to some streptococcal infections and some 
other common community problems. So when people are prescribed 
an antibiotic, they must take it for the duration that the 
doctor prescribes it.
    Mr. Bilbray. OK. I want to say this, because I think it is 
important that the chairman and the committee keep it in mind 
when we talk about other things, one of the big concerns we 
had, Mr. Chairman, was that, especially in the population of 
the homeless community, where you had mental illness, substance 
abuse and basically a feeling of not wanting to be under the 
jurisdiction of anybody, we had a real problem with trying to 
maintain a lot of people in the homeless community to finish 
their treatment. And our health department was always concerned 
about that. And we were sort of caught in between the ability 
to protect the public health but not wanting to step on the 
civil liberties of the homeless. And I think that we almost err 
so far over to one side, because the public's perception of 
civil liberties was so that it doesn't affect us if somebody 
doesn't finish their treatment. And I think that we need to 
talk about this openly that, yes, it does. And just as we 
require people to be vaccinated if they are going to go to 
school and expose other people's children, we need to be a 
little more outspoken about the fact that, even if it means 
requiring people to finish treatment, we need to be a little 
more forceful on that than we have in the past. Is that still a 
legitimate concern?
    Dr. Gerberding. I like to answer questions like this with 
science. And I can certainly say the quintessential example of 
a scientific yes is in the case of tuberculosis. You have to 
finish your tuberculosis treatment in order to be protected 
from TB and prevent the emergence of drug resistance. And it is 
important for the individual, but it is of essential importance 
to public health as well. So to the extent that the science 
would support aggressive interventions, we would certainly--we 
would want to go in that direction.
    Mr. Bilbray. I appreciate that, and I think you have given 
us sort of a guidance there in that we need to make sure that 
our civil law and our criminal law and our resources for 
treating are reflected by good science and that we make sure 
that we move into those areas of requiring people to finish 
treatment when and where it is only proven to be needed for the 
public health, as opposed to doing it universally or to ignore 
the problem universally, which is to a large degree, none of us 
have wanted to take on that tough public relations problem, 
explaining to the media why this person had to be put into 
custody because they were chronic violators of the, you know, 
the finish-the-treatment argument. And that has been a concern 
in that population. And it is one that I think we just need to 
be frank and brave enough to raise.
    Dr. Gerberding. You are raising an issue that I think is 
very important for the committee to understand. And that is the 
kind of research that you are describing is very practical 
research. This isn't the kind of thing that excites people to 
write RO1 NIH grants, but this is such important knowledge. And 
we need mechanisms to be able to ask and answer these very, 
very down-to-earth, in-the-trenches kind of questions about 
what is working, what isn't working. It is the application of 
all this biomedical knowledge in the communities and in the 
streets, in your case, that we just need to take our science 
that last step so that we can answer these questions. We call 
it learn-as-you-go research. But it is kind of the evaluation 
and the applied evidence to answer the question, well, what is 
the best way to do this? Or what is the harm from taking that 
step? Or what does it cost? Or what is the best method for 
getting things disseminated? And we have some real gaps across 
the board in all of these issues related to preventable 
infections and drug resistance, whether it is what works in the 
hospital or what works in the community or what works in the 
school. We need to get answers so that we are able to provide 
something other than it is common sense when so much is at 
stake.
    Mr. Bilbray. Thank you, Doctor. And I will just say that 
one of the great privileges I had as chairman of the county was 
to go and work 1 day in a certain department. And when going 
out into the community with the health expert to triage and, 
you know, make contact with the homeless community specifically 
for health reasons, that is only through their practical 
knowledge and their practical application was I able to learn 
that. So I hope to be able to bring that to the forum. Thank 
you very much.
    And thank you, Mr. Chairman, and I yield back.
    Chairman Waxman. Thank you, Mr. Bilbray.
    Dr. Gerberding, that completes the questions from the 
members of the committee. You have done an outstanding job and 
given us a better perspective of this issue. And I thank you so 
much for it.
    Dr. Gerberding. Thank you.
    Chairman Waxman. We have a second panel that we are going 
to hear from and question, but we are going to break now and 
return at noon, or as soon thereafter as the Joint Session of 
the Congress has been completed. So we stand in recess until 12 
noon.
    [Recess.]
    Mr. Towns [presiding]. I would like to welcome our second 
panel.
    As with our first panel, it is our committee policy that 
all witnesses be sworn in. So please rise and raise your right 
hand.
    [Witnesses sworn.]
    Mr. Towns. Let the record show that each witness answered 
in the affirmative. I would briefly introduce each witness. Dr. 
James Burns is chief deputy commissioner for public health at 
the Virginia Department of Health.
    Welcome.
    Dr. Elizabeth Bancroft is a medical epidemiologist from Los 
Angeles County Department of Health Services.
    Welcome.
    Dr. Robert Daum is a professor of pediatrics at the 
University of Chicago.
    Welcome.
    Dr. Daum. Thank you.
    Mr. Towns. Dr. Eric Gayle is a family physician in New York 
City who practices at a community health center in the Bronx.
    Dr. Steven Walts is Superintendent of Schools in Prince 
William County, VA. And of course, he is from the ranking 
member's district.
    Let me begin with you, Dr. Burns.
    Welcome all of you.
    Dr. Burns.

     STATEMENTS OF JAMES BURNS, M.D., M.B.A., CHIEF DEPUTY 
COMMISSIONER FOR PUBLIC HEALTH, VIRGINIA DEPARTMENT OF HEALTH, 
   RICHMOND, VA; ELIZABETH A. BANCROFT, M.D., S.M., MEDICAL 
    EPIDEMIOLOGIST, LOS ANGELES COUNTY DEPARTMENT OF HEALTH 
 SERVICES, LOS ANGELES, CA; ROBERT S. DAUM, M.D., PROFESSOR OF 
   PEDIATRICS, UNIVERSITY OF CHICAGO, CHICAGO, IL; STEVEN L. 
WALTS, ED.D., SUPERINTENDENT OF SCHOOLS, PRINCE WILLIAM COUNTY 
  SCHOOLS, MANASSAS, VA; AND ERIC GAYLE, M.D., BRONX REGIONAL 
  MEDICAL DIRECTOR, INSTITUTE FOR FAMILY HEALTH, NEW YORK, NY

             STATEMENT OF JAMES BURNS, M.D., M.B.A.

    Dr. Burns. Mr. Chairman, distinguished members of the 
committee, I am honored to be testifying before you today. And 
I would like to thank the chair and the committee members for 
convening this hearing on a very timely public health topic and 
for providing Virginia with the opportunity to discuss the 
public health impact of community acquired methicillin-
resistant Staphylococcus aureus.
    The recent death of a teenager in Virginia and the closing 
of several schools as a result attracted intense media interest 
in MRSA, the likes of which we have not seen in Virginia since 
we had three cases of inhalational anthrax in 2001. We were 
contacted by numerous local, State and national news 
organizations, and our central office staff and local health 
directors gave countless interviews. Conservatively, we spent 
more than 2,000 staff hours, over 2 weeks, on this issue.
    Community concerns were not limited to parents and 
students. A local office of the Department of Motor Vehicles 
closed when an employee was reported to have a MRSA infection 
on her arm. The closure was despite the recommendation of her 
physician and the Health Department to not close the office.
    In addition to many individual contacts with the media, 
citizens, local and State officials, and a statewide press 
briefing, the Health Department provided many online resources, 
worked with the Department of Education to draft guidance for 
local school divisions, which was transmitted to them, and 
worked with the State Human Resources Department to provide 
guidance to State agencies. And that is in addition to all the 
individual contacts that the local health departments had with 
those similar situations at the local level.
    The messages we have emphasized in our communications are 
ones that we have heard here today; that, in spite of this 
unfortunate case, serious MRSA infections are generally 
associated with hospital patients receiving invasive 
procedures, and that skin and superficial MRSA infections are 
generally mild. Also, those wishing to decrease their 
relatively small chances of becoming sick from MRSA should wash 
their hands frequently, cover cuts and scrapes until they are 
healed, avoid contact with other people's wounds and dressings, 
and to not share personal items, such as towels and razors. We 
emphasized that the spread of MRSA was mostly person to person, 
so general environmental cleaning is not generally indicated, 
though cleaning of certain kinds of exercise equipment between 
users and similar measures are reasonable.
    Among the most frequently asked questions by the public and 
media was how many MRSA infections occurred in Virginia each 
year. MRSA was not a reportable disease, and we could not 
answer that question. There was intense interest at all levels 
of the government in introducing legislation to address the 
public's concern. Governor Kaine determined that the most 
appropriate and the most effective strategy was for the Health 
Commissioner to use his existing statutory authority to add 
MRSA to the list of diseases required to be reported by 
laboratories. An emergency regulation was issued by the 
Commissioner on October 24th to establish this goal.
    Antibiotic resistance has been on our radar screen in 
Virginia for many years. Beginning in 2000, the Virginia 
Department of Health began working with the Centers for Disease 
Control and managed care providers in Virginia on an antibiotic 
resistance prevention program designed in two parts; a public 
education campaign and a health provider campaign. The public 
education campaign focused on convincing patients not to ask 
for antibiotics when they went to a doctor with respiratory 
infections, and emphasized the importance of finishing the 
entire course of antibiotics. We also evaluated physicians' 
prescribing patterns for pharyngitis, usually a viral infection 
not requiring antibiotics, and we were able to show a 
statistically significant decrease in those inappropriate 
prescriptions. The campaign received national recognition at 
the National Press Club in April 2001. We received grant 
funding from the CDC to support this effort. And our campaign 
continues today through a partnership with Anthem Foundation, 
that is the Blue Cross/Blue Shield company in Virginia, and the 
Medical Society of Virginia Foundation. We believe that such a 
campaign in every State would be useful in reversing, or at 
least slowing, the troubling trend toward increasing drug 
resistance.
    I would be remiss without taking this opportunity to thank 
the many Health Department employees in our local offices, the 
Office of Epidemiology and the Office of Public Information, 
who worked so hard to determine that there was no increased 
risk to the public as a result of this unfortunate case, and to 
communicate accurate and timely information to all requesting 
it. I also deeply appreciate the support provided by the 
Association of State and Territorial Health Officials, and the 
great support provided by our colleagues at the Centers for 
Disease Control. Thank you.
    [The prepared statement of Dr. Burns follows:]

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    Mr. Towns. Thank you very much, Dr. Burns.
    Dr. Bancroft, we will hear from you now.

         STATEMENT OF ELIZABETH A. BANCROFT, M.D., S.M.

    Dr. Bancroft. Thank you. I am pleased to be here to present 
a public health context of community MRSA.
    As has well been testified earlier today, the recent CDC 
study estimated there is approximately 94,000 invasive 
infections of MRSA in the United States each year. And this is 
greater than the combined number of infections caused by the 
most invasive bacterial organisms that we commonly follow in 
public health, including group A strep and pneumococcal 
disease, which is another important antibiotic-resistant 
infection. Furthermore, the number of estimated deaths 
associated with MRSA, approximately 18,000, exceeds the number 
of deaths due to HIV/AIDS, though all of those death with MRSA 
may not have actually been due to that organism. On the other 
hand, the estimated number of deaths due to MRSA is only half 
the estimated number of deaths due to influenza in the United 
States, to help put this disease into perspective.
    Community MRSA has been well described, occurs in those who 
have not had any significant exposure to healthcare in the year 
prior to their infection. It comprises only 14 percent of all 
invasive MRSA infections and has a rate of infection in the 
community, at least for the invasive kind, within the range of 
other significant community organisms. Furthermore, only 6 
percent of community MRSA cases results in invasive disease. 
The vast majority of community MRSA cases are skin and soft 
tissue infections, and many of these infections can be cured by 
a simple drainage procedure and may not even require 
antibiotics. In fact, we would prefer that doctors hold off on 
treating many of these cases with antibiotics so as not to have 
the organism develop further resistance to the antibiotics.
    Despite all the media attention on children with MRSA, the 
two CDC studies have demonstrated that school-age children 2 to 
17 years are at lowest risk for being diagnosed with community 
MRSA, at lowest risk for having invasive disease due to 
community MRSA and at lowest risk for dying due to community 
MRSA. So while the media attention is understandable on the 
children, the children actually have the lowest risk of 
acquiring this disease. Though community MRSA is relatively 
benign compared to healthcare MRSA, outbreaks of skin 
infections due to this organism tax the public health system, 
as can you see what happened in Virginia.
    In Los Angeles County, we have been addressing community 
MRSA since 2002, when we first investigated outbreaks of skin 
infections due to this organism in diverse settings, including 
the jail, men who have sex with men and an athletic team. We 
have developed extensive health education for consumers and 
healthcare workers, including some really gross pictures of 
skin infections in order to get people's attention. In 
conjunction with the CDC, we developed guidelines for 
preventing the spread of staph in community settings. And back 
in 2004, we actually disseminated those prevention guidelines 
to homeless shelters, schools and gyms.
    Though there has been a lot of media attention on children, 
our largest outbreak has actually been in the Los Angeles 
County Jail, where more than 3,000 cases of MRSA skin 
infections have been diagnosed in each of the past several 
years. The county has spent literally millions of dollars 
trying to reduce the spread of MRSA in the jail. And only now, 
after 5 years, are we seeing a leveling off of these 
infections, though I doubt we are actually going to completely 
eliminate these infections because of the close, crowded living 
conditions in the jail, because of the substandard hygiene that 
is often in a jail, and because these infections are often 
reintroduced into the jail by people in the community who have 
the infection and bring it into the jail.
    Separately, we have also had to address concerns by 
firefighters, police, paramedics, social workers and sheriffs' 
deputies and other first responders who are worried about 
getting this infection on the job. For example, I recently had 
a call by a social worker who refused to go into the home of a 
foster child because that child had MRSA. So there is a lot of 
hysteria surrounding this disease, especially in our first 
responders.
    Controlling community MRSA, as you have heard, or any 
outbreak of skin infections is not rocket science. We know the 
basics: hand washing, maintaining good hygiene, limiting 
sharing of personal items and keeping draining infections 
covered with a clean, dry bandage. However, there are still 
questions as to the role of the environment and the 
transmission of this infection; if and when to perform 
surveillance for MRSA, there are many pros and cons for 
performing surveillance; and how best to control outbreaks with 
minimal interventions and maximal impact. And we want and are 
looking forward to working with CDC and other public health 
agencies to address these questions. Thank you.
    [The prepared statement of Dr. Bancroft follows:]

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    Mr. Towns. Thank you very much, Dr. Bancroft.
    Dr. Daum.

               STATEMENT OF ROBERT S. DAUM, M.D.

    Dr. Daum. Good afternoon. I am delighted to have this 
opportunity to communicate information regarding what I 
consider to be epidemic community-associated MRSA disease in 
Chicago and in most locales in the United States. I am a 
pediatrician. I take care of patients, children with MRSA and 
severe MRSA infections all the time. I also have a laboratory, 
where I look at both basic and applied research questions 
related to MRSA.
    I am here today on my own support, because I feel that this 
is an important question that should be sort of discussed and 
dealt with. It is important to recognize that I have been in 
practice, in hospital-based infectious disease practice, in 
pediatrics since 1978, and I have never seen anything like what 
I have seen in the last decade. The problem is here; it is 
certainly not going away. In the last 6 weeks at our 
institution alone, we admitted five children to the hospital 
with severe invasive MRSA infections that require prolonged 
stays in the hospital, prolonged antibiotics and prolonged use 
of medical resources.
    When MRSA was first recognized in 1960, shortly after the 
introduction of it as an antibiotic, we had the good luck of 
having it remain confined largely to healthcare environments. 
But the situation changed dramatically in the mid-1990's when 
we started noticing MRSA infections in perfectly healthy 
children and adults in the community who had not had any 
healthcare exposure at all. These infections might be just skin 
and soft tissue infections for the most part, and that is true, 
but in fact, they are frequent and often require 
hospitalization for aggressive surgical drainage and prolonged 
antibiotics.
    What we realized fairly shortly after the onset of this 
epidemic in the community around the year 2000 was that the 
MRSA strains that were in the community were not what everybody 
thought was happening at first, and that is to say, the 
hospital strains migrating out into the community. These were 
novel strains that had arisen in the community, and they are 
both antibiotic-resistant, and they have virulence factors and 
virulence properties that the hospital strains do not have.
    It is important to understand that nothing is Black and 
White, and the hospital strains have migrated out into the 
community to some extent. But what is driving epidemic disease 
at our center and in most centers around the United States is 
in fact these novel strains that are out in the community. Work 
is going on as to try and identify what the toxins are, what 
the genes are that these novel strains have that are able to 
make it cause severe disease, but to date, they have not been 
found.
    I would like to call attention to a couple of slides very 
quickly that I brought. This is my assistant's concept of a 
pyramid. And you can see, as you heard this morning--I won't 
belabor it--that asymptomatic colonization is the most common 
manifestation by far and then skin and soft tissue infection. 
But at the top of that pyramid is a substantial health burden, 
in children and adults, of severe invasive disease that is 
really beginning to tax our healthcare system. We don't know a 
lot of information that we need to know about how this organism 
is so successful at spreading in the community. Household 
contacts are frequently themselves involved with these MRSA 
infections, implying that this is a very contagious disease. 
Other examples of close contact situations that you have heard 
about include daycare centers, military installations, 
correctional facilities and athletic facilities.
    Before this MRSA epidemic began, such evidence of spread in 
these groups was extremely rare and hardly ever described. In 
addition, there may be some racial and ethnic group 
predisposition. Native Americans, Pacific Islanders are two 
examples of groups that might possibly have some predisposition 
to this. Careful epidemiology badly needs to be done to 
determine what the exact risk of various members of our 
community are.
    We heard this morning that colonization rates 
asymptomatically are 0.9 or 1 or 2 percent. In some 
institutions where they are having epidemic disease, 
colonization rates of 9 or 10 percent have been reported. In 
most U.S. cities, community MRSA is now the most common 
pathogen isolated from skin and soft tissues presenting to 
emergency rooms. And USA 300, the so-called community strain, 
is responsible for 97 percent of them.
    So if we could see the next slide really briefly, and hit 
the first PowerPoint, whatever, necrotizing pneumonia is one of 
the severe community syndromes. That is normal long on the 
left. It looks like a sponge. Those white spaces are where we 
exchange oxygen. If we could press it again. This is a child 
with necrotizing pneumonia who died. Necrotizing pneumonia is 
all too common with this. And you can see those blue things in 
the field are staphylococcal colonies, and the red stuff is 
blood.
    Next slide, please. This is a child who died and with a 
novel staphylococcal syndrome caused by community MRSA strains. 
You can see the rash that he had made it look like a kind of 
meningitis called meningococcal disease that patients and 
teenagers are known to die from. This is a novel finding that 
has not been described before among staphylococcal disease.
    Next, and finally, these patients who died, this is the 
adrenal gland, which is an endocrine gland, sits on top of the 
kidney, nice normal layers of cells on the right. Next you can 
see that is this adrenal hemorrhage. And this is a mode of 
death from severe community MRSA disease. This was novel enough 
to get published in the New England Journal of Medicine. Before 
the onset of epidemic community MRSA, this was never seen 
before.
    So just to go very briefly to a couple more points, the 
MRSA epidemic has changed the paradigm of clinical practice. No 
longer can we use penicillins and cephalosporins for routine 
treatment of putative staph infections. We are forced to rely 
on older drugs like clindamycin and Bactrim now as the front 
line drugs. These drugs have not been adequately evaluated for 
community MRSA. They are tough horses to ride. They are old 
antibiotics. Vancomycin, the so-called antibiotic of last 
resort used to treat inpatients with severe community MRSA 
disease that needs hospitalization, is starting to erode, with 
global decreasing resistance noted across the country. 
Screening tests, people have been desperate enough to do 
something about this that they felt like they have to institute 
procedures that don't make a lot of purse sense to me 
personally, screening tests performed at the entrance to the 
hospital. The epicenter of community MRSA is no longer in the 
hospital. We spent the morning talking about it. But the 
problem has now shifted to the community. Identifying carriers 
at the door of the hospital has created a lot of anxiety among 
people that are colonized and not sick. They call, and they e-
mail me, what should they do now? We have no answers for them. 
We don't know what the notion is that someone is identified as 
a carrier, what their disease attack rate is.
    . If that is for me, I just want to finish by saying that I 
think this is the epidemic now. This is not like bird flu, 
which I am not denigrating the importance of that, which is 
something we do need to work on and prepare for, but this is 
happening now. Dr. Bancroft and the CDC authors of the JAMA 
paper concluded that this is a major and enormous public health 
burden. We need to fill the resources in with the multiple 
information gaps with how MRSA is spreading in our community. 
We don't know how that is happening, and we have a lot, a lot 
of missing information. Both the NIH and the CDC, in my 
opinion, have to massively increase their agenda and fund 
efforts to control this infection. The STAAR Act, as part of 
the Infectious Disease Society of America initiative, will go a 
long way to fill in this huge amount of missing information. I 
apologize for going over and thank you very much.
    [The prepared statement of Dr. Daum follows:]

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    Mr. Towns. All right. Thank you.
    Dr. Walts.

              STATEMENT OF STEVEN L. WALTS, ED.D.

    Mr. Walts. On behalf of Prince William County's 72,654 
students and their families, our 10,000 employees, our school 
board and our community, I thank the members of the House of 
Representatives Committee on Oversight and Government Reform, 
and in particular Ranking Minority Member Tom Davis, for 
inviting me to speak with you today.
    I am going to give you a firsthand account from the 
perspective of a school system and a school superintendent on 
dealing with the drug-resistant MRSA, which has affected us as 
the second largest school division in the State of Virginia. I 
am sure that I speak for every public school superintendent 
when I say that safety and security of our students is of the 
utmost importance. Without a safe learning environment, 
teaching and learning cannot happen.
    When most of us grew up, safety and school were synonymous. 
That has changed a little bit over the last 10 years, and we 
can take nothing for granted. Talking about safety, from 
senseless and desperate acts of violence to infectious 
diseases, school personnel have had to renew their diligence in 
keeping their environments safe. This is obviously a challenge, 
as most of our employees are teachers and are in roles that 
directly support instruction. We are not in the law enforcement 
business, nor are we of the medical profession, although we do 
have a number of school nurses who quietly perform heroic tasks 
each and every day. So we have to lean heavily on our 
partnerships that we have established with other agencies. And 
for the most part, those partnerships are working well. And 
then there is the challenge of making sure we are keeping our 
parents and our school communities and our larger public 
informed about what is going on in the school division. Of 
course, this ranges from many positive recognitions and awards 
to urgent communications, such as we have faced with the 
increase of MRSA cases.
    As I know you are aware, in addition to the legal 
implications, there is a delicate balance that we are required 
to walk from communications, privacy issues and the creation of 
public hysteria, which is pretty easy to happen with medical 
matters. In Prince William County Schools, as of Friday, 
November 2nd, we had 21 documented cases of MRSA, with 7 cases 
still considered open, meaning the student or employee has not 
received clearance from their doctor to return to school. And 
although we weren't required to do this, we began voluntarily 
reporting these statistics as a public service. While we feel 
this is our responsibility to our public, unfortunately there 
are some negative consequences to this. We do not know that any 
of these cases were actually contracted at our schools. But 
because we are reporting that people have the infection, the 
public may naturally make assumptions like, these were caught 
at school, and inadequate cleaning was a source of the 
infection. Like the flu, it is virtually impossible to know 
exactly where someone picked up the infection. But I can assure 
you, we are very diligent with our cleaning practices, and I am 
confident we are doing everything we can to keep our schools 
and facilities free of MRSA.
    The challenge and response, there is an excellent summary 
on our Web site, www.pwcs.edu, under announcements. There is a 
lot of information there, and you can see exactly what we have 
been communicating to our public. Initially, two athletic-
related cases of MRSA showed up within about a week of each 
other in mid-September at one of our 10 high schools. It is not 
uncommon for one or two cases to show up in a school 
environment each year. So this did not seem to be out of the 
ordinary. In fact, our athletic trainers have been on the 
leading edge of preventing and treating MRSA, since the 
athletic community was an area where this topic first became an 
issue. The school nurse and the athletic trainers sent a letter 
home to parents of the sports team involved, informing them of 
the case, and providing tips and precautions they should take.
    We also had an employee at a different school report a case 
of MRSA during the same timeframe. About 2 weeks went by, and 
then a student in another school reported a case of MRSA. And 
it just went on and on and on. The following week, a student in 
Virginia, not in our school division, actually died of MRSA, 
which greatly increased the public awareness of this. And then 
there were other cases that were generated, and a school, again 
not in Prince William County, closed.
    So, around October 17th through 19th, we had five more 
reported cases in Prince William County, and it was all over 
the national news media. So issues began to surface rapidly. We 
triggered a comprehensive division communication plan, and we 
have had countless staff members and departments basically 
working on this 7 days a week for the past 3 weeks. I am 
pleased to say that we are diligently communicating with our 
public, and we daily update on our Web site each afternoon all 
the established cases.
    We also have standards and protocols for each of our 86 
schools. So if a case arises, the principal can quickly put on 
a telephone recording automated message, send home a letter to 
students, post the information on their school Web site and 
work with us centrally to update our school division Web site.
    We have a lot of cleaning protocols that we use. We are 
paying particular attention to areas, such as gyms, showers, 
locker rooms, desktops, water fountains, door knobs and panic 
bars. We are following the procedures, and our schools are 
being disinfected as they are being cleaned nightly. Buses at 
schools with known MRSA cases have also been disinfected.
    Talking a little bit about the health issues, the Virginia 
Department of State Health has been in close contact with us, 
and we are working with our own medical consultant every step 
of the way. Our division communication plan focused on good 
hand washing, and included a parent tip sheet and other health-
related precautions.
    Unless our school personnel observe an unusual skin lesion 
firsthand, we are dependent upon the students or their families 
to inform us of an infection. And in some cases, we were not 
made aware of this until after the fact. Based on the inquiries 
of our own health service staff, we discovered that, initially, 
some of the students diagnosed with MRSA did not actually have 
that strain of the disease, but they were being prescribed with 
the antibiotics anyway. And of course, this strain of staph 
infection is already resistant to antibiotics, so to be assured 
that we can confidently communicate to the parents, we need to 
be confident that the medical community is treating these cases 
using best medical practice. Because staph in general and the 
MRSA strain included can be found anywhere at any time, in fact 
most of us most likely are carrying it on us today, the medical 
community cannot say definitely that the person infected is 
MRSA free without reculturing. And from what we know, that is 
not always being done. However, doctors are clearing students 
for school because it is not contagious if a sore is not open 
and since it is not an airborne infection. Since we know that 
MRSA can spread by contact with an infected open, oozing wound, 
we did decide not to let any students diagnosed with a 
confirmed case of MRSA participate in sports or physical 
activity if they had any wound whatsoever.
    A few final observations. I have asked what could be done 
to help school divisions in the future to better respond to our 
communities on such health-related issues, and I would respond 
with the following: The government, Federal, State, local, 
could help us to serve as a calming force with the public by 
alleviating unfounded fears, possibly through public safety 
announcements. Local, State or Federal health agencies could be 
out in front of the media so the media does not end up driving 
the message without the proper professional guidance and 
perhaps create a public hysteria in the process. A good example 
is our working relationship with law enforcement agencies and 
the media. If a criminal incident occurs at a school, the media 
asks us school-related questions and the law enforcement 
agencies questions pertaining to the criminal nature of the 
incident. The medical community, CDC, State and county health 
departments could quickly speak to the facts.
    Mr. Towns. Could you sum up, Dr. Walts? Could you sum up?
    Mr. Walts. Yes. In the case of MRSA, reinforcing with the 
public how it is contracted, and even when a student is 
diagnosed does not mean the infection was actually contracted 
at school. So we feel we have communicated our issues well, but 
we have those suggestions as other ways we could collaborate to 
work through these kinds of issues in the future. Thank you.
    [The prepared statement of Mr. Walts follows:]

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    Mr. Towns. Thank you very much, Dr. Walts.
    Dr. Gayle.

                 STATEMENT OF ERIC GAYLE, M.D.

    Dr. Gayle. Thank you for the opportunity to address the 
critical subject of methicillin-resistant staph aureus [MRSA], 
particularly in the context of how this affects vulnerable 
communities like the Bronx and the role that community health 
centers can play in this regard. I am a family physician who 
has practiced primary care in the Bronx, New York for the past 
9 years, and the Bronx Regional Medical Director for the 
Institute For Family Health, an organization that provides over 
75,000 people in New York State, most of them ethnic 
minorities, and the majority on Medicaid or uninsured.
    I am here today to provide testimony that speaks to the 
specific needs of my community in respect to MRSA and the 
critical role that community health centers play in the 
management of contagious diseases such as this. My most recent 
contact with community acquired MRSA was June 2007. Let me 
reassure you, as I reassure my patients, that MRSA has been in 
the community for many years and has been successfully treated 
well by community health center physicians for the most part 
without much fanfare. MRSA is significant to the health of the 
individual and to the community, mainly if it goes unrecognized 
and thus is improperly treated. The problem for community 
health center physicians is that oftentimes we are called upon 
to evaluate a patient only after the infection has 
significantly progressed and the patient is already ill and 
possibly toxic.
    This is because community health centers are known as 
places where people can seek care, even if they are uninsured 
or if they need care in their own language or even if they 
become ill in a crisis. We are truly a major part of what has 
been termed the community's health care safety net. Community 
health centers do their best work when they are involved in the 
prevention of illnesses. One can never do enough in the 
education of our patients and the public so that once there is 
a question about any illness or malady that they know that they 
need to contact their primary care provider immediately.
    This is the role that community health centers play and 
play so well. We are often the first contact for our patients 
for whatever their health concerns are. But tragically many 
families do not have a medical home, do not have a community 
health center such as ours to go to. We need to continue to 
grow and develop these vital community resources so that they 
are available everywhere. Where else will patients be educated 
to take care in their personal health, particularly as it 
relates to communicable diseases?
    We advise them that if they have open sores or rashes that 
they ought not to participate in contact sports activities, 
advise the kids not to share towels in gym or not to go to 
school or to work with any contagious illness.
    With MRSA now seemingly more prevalent, community health 
centers with electronic health record capabilities can closely 
monitor the patients they are seeing for possible outbreaks 
within a particular community and similarly alert community 
providers of any clusters of infections being seen. With the 
dramatic media coverage of this infection, MRSA, there is no 
better place for the community and for patients to receive 
important information about this disease and the necessary 
precautions that one must take than their local community 
health center. Emergency rooms and hospitals have neither the 
time nor the opportunity to spend in the education of the 
patients about properly hygiene techniques. Most of which we 
have heard already today. I would caution all that we need to 
remember that we are living in time where our communities are 
constantly being reminded of the many other serious and 
contagious illnesses that are out there.
    In communities where there are immigrants from multiple 
nations and where international travel is common these include 
West Nile virus, Avian flu, tuberculosis and the risk for both 
epidemics and pandemics. Community health centers are the 
medical home for millions of patients nationally. And our 
patients are provided not only high quality accessible and 
affordable health care, but extensive health education. In the 
case of MRSA, a major role has been the dispersal of large 
quantities of reassurance.
    I want to mention one other point in closing. The Institute 
for Family Health where I work has installed a state-of-the-art 
electronic medical record system which is integrated into the 
central surveillance system of the New York City Health 
Department. Every night, all the patient encounter information 
from the day's visits stripped of any identifying information 
is downloaded to the Health Department for analysis. The Health 
Department looks for any symptoms like rash or boils that might 
be appearing at the higher than normal frequency that day.
    This kind of network gives the Health Department and thus 
all physicians in the community a jump-start on containing an 
outbreak of infection illness. My patients, your constituents, 
deserve this type of investment in their health. This can only 
occur if there is funding provided for electronic medical 
records in the community health centers allowing for 
integration of health center systems with public health 
departments to get more accurate and more timely information 
out to the public.
    Thank you for listening and for the opportunity to address 
the committee. Continued support to provide a community health 
center home for all vulnerable people and to provide 
information technology and support of the providers who work 
there will ultimately work to contain any spread of 
communicable disease in the community and any spread of the 
panic that may accompany it. Thank you.
    [The prepared statement of Dr. Gayle follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Towns. Thank you very much, Dr. Gayle. Let me thank all 
of you for your excellent testimony. Now we move into the 
question and answer period. And let me start with you, Dr. 
Walts.
    You know, when a situation occurs in a school, parents get 
up in arms. And they will say, well, I'm not taking my son or 
my daughter back to that school. And of course, others will get 
involved and say you should not. And then somebody from the 
school will indicate the fact that the school is now safe. And 
then they will say to you, you are not a medical doctor, you're 
not in a position to evaluate whether or not the school is 
safe. How do you handle a situation like that? Because we 
always look at things legislatively and want to know if you 
need any help in terms of legislation.
    Mr. Walts. Well, we use a variety of strategies. We 
communicate with people in different ways because different 
ways of communication people can relate to. For example, we 
have an auto-dialer system. Again, it is up to the parent if 
they choose to be a part of that. But we'll put out a message 
using that auto-dialer system. We've got a very good Web site 
where we have a link. In fact, this was our lead story.
    If you pulled up the Prince William County Web site during 
the height of this, that's the leading link. And there again, 
it would talk about facts related to MRSA. Preventive things, 
like the washing of the hands with soap and water, because you 
almost have to barrage people with a variety of communication 
methodologies talking about the facts, because otherwise they 
jump to conclusions that are just simply not helpful. And 
thinking, for example, that you have to close the school down, 
we were already using the chemicals that schools that have 
closed to disinfect were using because they weren't using that 
beforehand, so there was no reason to close schools. But when 
you see something on the news that some other school division 
is doing, then you're right, it really gets to almost a public 
hysteria point of view.
    We work a lot with the press through this also to help us 
get the messages out. Of course, some of the issues with that 
is you never get them enough information fast enough. So that's 
why we would like to have more help from health departments and 
that sort of thing in terms of getting on the front lines of 
these kinds of issues.
    Mr. Towns. Thank you very much. Thank you. Dr. Daum, I 
understand you've done a significant amount of research in this 
area. I wanted to learn more about why these infections are 
becoming resistant. I also want to understand if this is a 
situation that is actually getting worse or it is a situation 
where we have better reporting at the present time.
    Dr. Daum. Thank you for the question. I'll take the first 
part of the question, first question first. It turns out that 
what the community MRSA epidemic represents in my mind is a 
convergence of antibiotic resistance and virulence so that the 
resistance happens by means of a small piece of DNA, which we 
call a cassette, which actually can move from strain to strain. 
And when it moves from strain to strain, the sensitive strain 
it lands in becomes a resistant one. So the organism is 
obviously looking to acquire these cassettes because there's 
lots of antibiotics in our environment and it is better able to 
survive.
    But it also turns out that virulence is a factor as well. 
And so that a strain that receives a cassette becomes a more 
fit pathogen, better able to survive on our bodies and in our 
environment if it also has virulence genes that allow it to do 
so. So what you have here is really two forces working against 
us humans. And that is that it is both antibiotic resistant and 
more virulent. The second part of your question I think had to 
do with--can you remind me? I'm sorry.
    Mr. Towns. Actually, in terms of a better record reporting, 
better reporting now. Do we have a better reporting, period?
    Dr. Daum. I think it was related to how I know it is 
increasing. We did a study at our institution where, in a 
period of 3 years in the late 1990's, we showed that it had 
increased 25fold at our institution. And that's not as good as 
population based data to be sure, but it does give you a sense 
of what's going on. At Texas Children's Hospital, Dr. Kaplan 
and his colleagues have reported a similar very dramatic 
increase. At Driscoll Children's Hospital in Corpus Christi, 
they have also counted MRSA infections and it is a dramatic 
increase. And these are all healthy people or, for the most 
part, healthy people coming in from the community.
    So I think there's at least three institution-based data 
that I can summon quickly to mind that suggest that it is 
increasing dramatically. I'll toss in my own clinical 
experience, if you would. And that is before this started in 
the late 1990's I never saw anything like this. I didn't see 
these severe syndromes I showed you, and I also didn't see 
children coming by the flocks to have their abscesses drained 
or getting admitted to the hospital at the rate that they are 
now.
    Mr. Towns. Thank you very much. I yield to the ranking 
member, Mr. Davis.
    Mr. Davis of Virginia. Thank you, Mr. Towns. Dr. Burns, let 
me ask you, with regard to the MRSA case in Bedford, it is 
unclear from your testimony whether the young man succumbed to 
CA MRSA or HA MRSA. Do you have any definitive answer on that?
    Dr. Burns. I don't have a definitive answer. And as you 
appreciate, I'm sure better than I, that talking about an 
individual case creates some HIPA issues. However, the mother 
did hold up the death certificate on television, so I think 
she's kind of provided that document in the public. And that 
document lists the cause of death as staph aureus sepsis.
    In an individual case, as we heard this morning, it's 
virtually impossible to determine where this strain came from; 
whether it originated in the community and was acquired in the 
community, whether it originated at a hospital and was acquired 
in the community and the various combinations. I'm not sure 
this individual case would inform our decisionmaking. 
Certainly, we would be more comfortable using a series of 
cases. I think that's all I can tell about this case.
    Mr. Davis of Virginia. The question is if you identify a 
MRSA case, but you don't know exactly what kind of strain it is 
or what antibiotic it is going to respond to, isn't that 
correct, isn't that one of the difficulties in this?
    Dr. Burns. Well, you're asking kind of two questions.
    Mr. Davis of Virginia. I'm asking anybody who can answer 
two.
    Dr. Burns. You're asking the genetic question and the 
antibiotic resistant question. By definition, MRSA has been 
going to the laboratory and antibiotic sensitivity has been 
determined, so you know it is resistant to methicillin. And 
usually, if you've made that determination, you've done a 
complete sensitivity on it, so you know other antibiotics that 
it is both sensitive to and resistant to.
    And that would virtually always be the case when you're 
culturing staph that you would be doing a sensitivity on it, 
especially in this day and age. Doing the genetic testing is a 
completely different issue. That wouldn't routinely be done for 
community strains.
    Mr. Davis of Virginia. But early diagnosis is important and 
treatment in some of these cases, is that fair to say? Does 
anybody want to take a shot at that? Dr. Gayle.
    Dr. Gayle. I want to say that it is going to take a couple 
of days at least. Because you can look at the presentation of 
the case and still not be certain whether or not you're dealing 
with community acquired MRSA. You have to do the culture. And 
you may presumptively begin treatment. But then, once the 
culture and sensitivity comes back and identifies the strain 
and what medications are--the bacteria sensitive to that, then 
you can make changes in the management. But I don't think 
you're going to be able to look at the case and say 
specifically that it is MRSA.
    Mr. Davis of Virginia. Dr. Walts, let me just ask on your 
Prince William cases. You mention in your testimony you've had 
a strong working relationship in place with local law 
enforcement. That kind of goes with the job out there. I've 
seen that work. Not the same relationship with the public 
health community and in the relationship with the media. Could 
you try to describe each of those? With the public health 
community, what was preexisting, how we are changing that and 
then managing the media is a difficult issue in a time like 
this.
    Mr. Walts. I would say with the health community, what I 
would like to see is them stepping up and taking more of a 
proactive role in helping the community to understand it from a 
medical perspective. The preventive care, the realities and the 
factual information around what this is to prevent hysteria. 
Because again, as you pointed out, I'm not a medical expert. So 
when I'm out there delivering all the information from the 
school division, I think it would be helpful to parents and 
certainly helpful to us to have the medical experts out there 
in the same way that we've carved that kind of a relationship 
with law enforcement.
    Any time we have a criminal type of matter, we will talk 
about it from the education perspective, but then the police 
cover the criminal perspective. A lot of times we'll even do 
joint interviews with the press, that sort of thing. So that 
would be really helpful. Right now there hasn't been a lot of 
that.
    Mr. Davis of Virginia. Dr. Gerberding talked about school 
nurses and how important they are. Can you give me, from a 
school superintendent's perspective, where they fit into this?
    Mr. Walts. Well, I will say absolutely they're critically 
important. And with the complexities of health care these days 
and the issues that have occurred in schools, the complexities 
of medications and that sort of thing, I have a lot more 
confidence when I know that I have a full-time nurse in every 
school. I wish I could say that we did in Prince William 
County, but I'm glad to say that we have 69 nurses covering 86 
schools. And we've increased the numbers of nurses every year 
pretty dramatically. I'm going to tell you, I'll say before 
I've even told my own school board, I'm going to be asking for 
more next year, because simply managing these issues over the 
last few weeks has just put the system on absolute overload.
    Mr. Davis of Virginia. I'll be happy to join in a letter in 
support of that with the new school board. Could I just ask one 
last question. Dr. Daum, you talked about in your testimony 
that MRSA really has not invaded all the regions of the 
country. Which regions are the lucky ones who have been spared 
at this point?
    Dr. Daum. That's a great question, and I don't know every 
little one. But I can tell you that most people believe that we 
in the Midwest were the first to notice it in the late 1990's. 
And you heard from Dr. Gerberding that the four children that 
died in Minnesota and North Dakota, we actually had described 
it in the Journal of the American Medical Association a year 
before that. So the Midwest, I think, is blamed or credited 
with being the first place to really observe this rapid 
upswing. Next, reports became clear from many centers in Texas 
and the gulf coast that they were having the same kind of 
problem with a greatly increased volume of skin and soft tissue 
infections with the occasional severe infection and death.
    The west coast appeared to come up to speed next, along 
with Alaska. And the California centers almost up and down the 
west coast have had trouble with community MRSA. And curiously, 
the east coast, the Northeast in particular, have been the last 
to sort of come up to speed. But Atlanta now is reporting a 
huge problem. And we didn't get to see Dr. Gerberding's data 
this morning, but in her JAMA paper, the city of Baltimore was 
such an outlier in terms of having higher rates than every 
other region in her network that they actually didn't include 
them in the mean calculations because they were so high.
    So I think the important thing with regard to your question 
is that every place where it comes it hasn't gone away and it 
is coming to new places every day.
    Mr. Towns. Thank you very much. Congresswoman Norton.
    Ms. Norton. Thank you, Mr. Chairman. I'm troubled by, 
indeed, what you just said about how the disease just seemed to 
emerge first in the Midwest and then you said the west coast 
came up to speed. And I know we in the east coast had this 
great knowledge to come forward only recently. And you 
mentioned in the 1990's when it was first noted. Of course, 
we're not talking about the new disease. This isn't like AIDS. 
This isn't that kind of new thing that everybody ought to 
believe is the end of the world. And that, therefore, is 
something that we would have thought we would have known of as 
a nation. That's really my question.
    These statistics, which apparently have emerged for the 
first time, and I'm pleased that professionals of CDC did the 
JAMA article that told us about the 90-some thousand cases. 
18,000 deaths, that's very troublesome. A disease that's been 
known for a long time, known to be drug resistant for a long 
time. My interest is in how the public health system works so 
that, yes, it is very workmanlike, very professional. And I 
commend CDC for going to a peer review journal, informing the 
profession. But again, this is not--basically what they told us 
about was the incident of the disease. The reason I'm 
particularly concerned, frankly, is that this committee and one 
of my other committees, the Homeland Security Committee, have 
been very concerned about how people get to know that they 
should take precautions in a period when all kinds of 
deliberate carrying of germs could occur.
    After 9/11 everybody is alert for that possibility. Even 
have had testimony here about what began as some attempt by the 
administration to control--to vaccinate some professionals 
ahead of time, and that stalled. But what I'm trying to find 
out is whether you believe that the present system of 
monitoring and informing the public is sufficient. When we 
hear--we do get everybody's attention once someone sits down 
and does the statistical work. But one is left to wonder 
whether we are now waiting for the next JAMA article to find 
whether there is a disease in our midst.
    Should the CDC have told us about what was beginning, maybe 
this is for Dr. Bancroft, in the midwest. What, is it Dr. 
Daum's testimony, then became very visible in the midwest. 
Well, I'm sitting over here in the east coast with a lot of 
folks and it has become a real issue here only recently.
    One would wonder why once you begin to see a trend in one 
part of the country, whether there is a mechanism for alerting 
people throughout the country, especially when some of what can 
be done washing hands and the rest of it, might have prevented 
some of these 18,000 deaths or the spread from wherever they 
occur, in hospitals, prisons, wherever they are. So I'm really 
concerned about the early warning capability of the CDC and 
whether it is working.
    Dr. Bancroft. Well, speaking as a local public health 
official, I will say that this entity of community MRSA has 
been written up in medical journals and public health journals 
since the 1990's. And we've been working with CDC since early 
2002 when it was first identified in Los Angeles County, as had 
many other groups. In fact, the CDC has sponsored quite a bit 
of research on this. Dr. Daum is a recipient of CDC grants 
researching and looking at the prevalence of this.
    I think one of the reasons it came to such public attention 
now where it has been otherwise quite vigorously described in 
the medical and public health literature, but why it has come 
to media attention now, was it was almost a perfect maelstrom 
of information of the JAMA article coming out the same week 
that a child died of MRSA, of community, or what we assume to 
be, but don't know to be community MRSA in that same week. I 
think for the public----
    Ms. Norton. How might it have happened? How might the 
entire country have become alert before somebody died and we 
had a kind of crisis atmosphere, at least created here for a 
while?
    Dr. Bancroft. You know, it's a great question, because 
we've been trying to work with the media in Los Angeles County, 
the school districts, for example, for many years on this. We 
sent out our guidelines for the prevention of how to prevent 
spreading this bug back in 2004 to the school districts, and 
have been giving lectures to doctors in school districts.
    Ms. Norton. Well, did CDC send anything out that time? Did 
CDC send out anything in the 1990's for example when it began 
to develop in the Midwest?
    Dr. Bancroft. It did have that MMWR, which is basically a 
public health notification, it is an official CDC notification, 
in 2000, about the deaths that occurred in 1999 in the Midwest. 
And subsequently there have been multiple MMWRs and multiple 
articles in the CDC journal emerging infectious disease about 
this.
    Ms. Norton. I'm trying to find out whether or not your 
school superintendent, your Congresswoman, your mayors, your 
laypeople who do not have access and do not want access to the 
professional literature were alerted, should have been alerted, 
whether or not our system in the post 9/11 period has a way to 
say nationally, look everybody, there's something out there, it 
is not a crisis, but this is what is occurring in some parts of 
our country. The reason I ask this from the point of view of 
the layman is we aren't talking about something only doctors 
can deal with.
    You tell me that there are precautions that children can 
take in school, that people can take in restaurants, God help 
us people can take in hospitals that I don't think they 
understood they could take because you were left to deal in LA 
County to hear your testimony, and others of course dealt as 
they should have where they were located. This is a Nation. 
We're not dealing with how this hops from one country to 
another as in Europe.
    So I'm just trying to find out if you have a national 
public health network, is it working here and what can this 
committee do to make sure that before there is an outbreak, 
before there's something sensationalized in the papers that now 
we got to go into our neighborhoods and say, just a moment, 
this is not like AIDS, this 18,000 people dying. So then you 
leave it to laypeople like us to have to put it back in 
perspective, because there's been no national understanding of 
what has happened.
    That is my complaint. Not that they didn't do the 
professional job. That was excellent what they did. But they 
didn't tell me, they didn't tell my constituents, they didn't 
tell the people who come in contact with the very people who 
may be spreading it.
    Dr. Daum, did you have something you wanted to say?
    Dr. Daum. Yes. I think the most important message I would 
like to give at this point is that to be constructive about 
this. And that is to say that if you believe the perspective 
that I've tried to provide, that the epicenter of MRSA is not 
now in the hospitals, but it is actually in the community. I 
think you've heard threads of that over and over again.
    Ms. Norton. We have a school, a whole school, and those 
kids haven't been in the hospital.
    Dr. Daum. I understand. We have our jail facilities, we 
have the households of patients, we have a lot of evidence of 
spread to new people, new kinds of folks that weren't really 
MRSA high-risk people before this began.
    Mr. Towns. The gentlewoman's time is expired. I would be 
delighted to give her second round.
    Ms. Norton. Thank you very much Mr. Chairman.
    Mr. Towns. Definitely. Let me move forward. Congressman 
Matheson.
    Mr. Matheson. Well, thank you, Mr. Chairman. Again, I 
appreciate the opportunity to participate in this hearing as 
not a regular member of the committee, and I'm pleased to have 
a chance to participate today. Dr. Daum, you're probably aware, 
my wife is a pediatric infectious disease doctor in Salt Lake 
City.
    Dr. Daum. She's probably unsupported.
    Mr. Matheson. Well, that's a discussion I hear a lot at the 
family dinner table. I appreciate your being here today, and 
wanted to ask you a couple questions. First, it is my 
understanding that Illinois is the only State in the country 
that's passed legislation that requires active surveillance of 
MRSA in hospitals. Do you think that's a model that other 
States and other countries should be following? What do you see 
the strengths and weaknesses of the Illinois model.
    Dr. Daum. First of all, let me begin by saying thank you 
for being one of the sponsors of the Star legislation. I think 
that's an important step to really getting the resources that 
this community, MRSA and other infectious disease antibiotic 
resistant infections really requires of us. I'm not pleased 
with our law in Illinois. What's happened, for those that don't 
know, in the last couple of years is a screening test is now 
available where you can take a swab of someone's nose and 
determine whether they have a MRSA DNA in their nose 
secretions. And while on the one hand one could conjure of some 
valuable things to investigate with that test, knowing that the 
germ or the DNA more properly is in someone's nose, does not 
really inform about the risk for subsequent infection. And so, 
first of all, it is a very expensive intervention. It costs 
several hundred dollars a test. The bill in Illinois, the price 
of it is being charged to the patients.
    Second of all, our law is on admission only to ICUs. And 
I've already begun to field phone calls from people who are 
well, had a positive test and don't know what to do. They've 
been to doctors. They can't get rid of it. We don't know what 
the intervention is to tell someone about with a positive test. 
There's one. And now a new university hospital in our State is 
contemplating screening of everyone standing at the door of the 
hospital and screening everyone who comes in. And again, you 
can imagine a healthy woman coming to deliver a baby gets 
screened, finds out she's positive, she's perfectly well and 
goes crazy with anxiety about what she should do now and 
there's no intervention we have.
    So although at first glance it sounds like it is a good 
thing to do. And in intensive care units it may have some use 
in decreasing spread in that high-charged environment. The 
epicenter of the problem is in the community now. And screening 
at the entrance to the hospital is not going to do anything but 
spend a lot of money and create a lot of anxiety.
    Mr. Matheson. That's helpful. You mentioned the Star Act 
that I've introduced, along with Congressman Waxman. I was 
wondering if you could just describe what you see as the 
strengths in the bill and can you speak in particular about the 
antimicrobial resistance, clinical research and public health 
network.
    Dr. Daum. So I think that MRSA, community MRSA, the 
epidemic we're having, coupled with other ongoing problems, 
most of which are at this moment based in hospitals, such as 
extended-spectrum beta-lactamases and organisms like 
klebsiella, which are nosocomial infections, are health care 
problems that we've approached in a piecemeal way. And what 
excites me about the Star Act is the idea that we as a society 
will take a proactive approach and create centers around the 
country with a central focused office and bureau here that will 
start to proactively look at the magnitude of these issues so 
that we're not getting a paper like the one that came out in 
JAMA well into the epidemic and saying, wow, these numbers are 
really high. We'll know all along.
    They also provide for novel interventions to try and 
contain the spread of antimicrobial resistance infections. That 
part of it excites me as well. And the part that excites me the 
most, and is also part of this, is to create novel research 
strategies in the lab and at the bedside to understand why 
resistant organisms are so successful making their way in our 
community and intensive care units with the goal to try to 
prevent that from happening. I see this bill as potentially 
resulting in new therapeutic strategies, new infection control 
strategies and ultimately perhaps even new prevention 
strategies. So I'm very excited about its scope and the idea 
that it creates a diverse effort from investigators and public 
health people around the country.
    Mr. Matheson. That's very helpful. I need to take you 
around with me when I'm trying to get people to co-sponsor the 
bill.
    Dr. Daum. Let's talk.
    Mr. Matheson. One last quick question. My time is expired. 
Can I just get one quick one in? Do you feel right now the 
Federal Government has, in place, an adequate--has the 
capability to adequately--is able to respond to antimicrobial 
resistant germs when they manifest itself somewhere? Do you 
think the Federal Government is set up to deal with that right 
now?
    Dr. Daum. I think that the JAMA paper for me was very 
exciting in that it gave numbers to what I believe I've been 
seeing clinically for the last 10 years. And the numbers are 
incredibly high. And I believe that this declares what I've 
been saying, is that this is an epidemic. It is an epidemic in 
our communities of MRSA infections, and they're novel 
infections. They're not the hospital germs that have moved out 
into the community. They're new germs. And I think that it 
gives us a real chance to immobilize. I think the mechanisms, 
to answer your question, are in place. NIH knows how to put out 
notices that were interested in research in a certain problem. 
CDC has begun to more aggressively fund extramural programs, 
and needs to continue to do that to look for better ways to 
deal with this.
    So I think that if the agencies that are in place respond 
and say this is an epidemic, this is not about the hospitals, 
this is not about disinfecting a school or two, this is a major 
epidemic and we need to understand why and intervene, that yes 
the mechanisms are in place. But they need to be resourced. The 
Star bill is a mechanism of doing that. There are probably 
others. And they need to be mandated. And I hope that's 
something that comes out of this hearing today. That we've 
convinced you that there is an epidemic on, that the epicenter 
is in the community and that some of our public institutions, 
like the jails and the military and the athletic facilities are 
clearly involved in this, but we need to understand exactly 
how.
    Mr. Matheson. Thank you, Mr. Chairman. I yield back.
    Dr. Bancroft. May I add something to what Dr. Daum said, 
which is I think it is important to have the Federal Government 
have the resources to respond to this epidemic, but also to 
support the local and State public health resources. Because 
we're really the front lines of this epidemic. The first calls 
come to us when there's a problem. And what we look forward to 
CDC is to help set up the science behind the recommendations 
that then we will be applying on a regular daily basis. So I 
appreciate that there needs to be support for the Federal 
Government, but also for local and State health centers.
    Mr. Towns. Thank you very much. On that note, Dr. Bancroft, 
do we really have the mechanism in place to determine how many 
cases?
    Dr. Bancroft. That's a great question. As Dr. Gerberding 
said earlier today, in those areas where they did the 
surveillance that the JAMA article is based on, yes they had a 
great mechanism for determining every case of invasive MRSA. 
But that particular mechanism took a lot of resources. Most of 
us at local and States don't have that resources to follow 
every case of MRSA.
    Mr. Towns. Thank you. Dr. Gayle, isn't there a short window 
for treating invasive MRSA? You talk about administering a 
culture. How long will that take?
    Dr. Gayle. Well, the culture and identification and 
sensitivity of any bacteria generally takes about 3 days. And 
any clinician, if they're suspicious of something that's going 
on, something that doesn't look quite normal, will begin 
treatment. Whether the treatment is adequate is going to be 
determined by the sensitivity of the bug.
    So you basically have 3 days in which you can start 
treatment, which could probably quiet the infection but not get 
at it to kill it. And then after you've identified the strain 
and the sensitivity, change the antibiotic that will 
effectively kill the bacteria.
    Mr. Towns. Thank you.
    Dr. Daum. I think that Dr. Gayle's points are right on the 
money, but they apply to the common manifestation of community 
MRSA, which is the skin and soft tissue infection. 
Unfortunately, that is the commonest manifestation, as I showed 
you on the slide. I just want to remind everybody that 
fortunately uncommon, but there is a manifestation of this 
disease that does not present as a skin and soft tissue 
infection, but presents as an overwhelming body-wide infection 
and has the potential to cause death in previously healthy 
people in 12 to 24 hours.
    I showed you a picture of one of the children who died. I 
showed you the skin rash and the adrenal glands and the lungs 
of such a child. We work with some of the parents who this has 
happened to. Because as you might imagine, they're kind of 
overwhelmed. But there's no quick test to do, which is what 
your question goes to, I think, to diagnose those children. Our 
emergency room is on very high alert, as are probably most 
other ERs now in our country for these severely ill folks. We 
have the antibiotics ready to go, the fluids ready to go. The 
supportive care evidence based or not ready to go. But the 
mortality is still high. And that's one of the reasons people 
have called repeatedly today, and I among them, for a vaccine. 
Because the tip of the iceberg of this epidemic, fortunately 
less common, I don't want to be an alarmist here, kills faster 
than we can treat it.
    And it is not just a question about better antibiotics. And 
I just wanted to emphasize that because it goes to your 
question. It also has changed, to come back to Dr. Gayle's 
point one more time, this epidemic has also changed how we 
practice medicine. It used to be we had a skin and soft tissue 
infection or an abscess and we could take a penicillin or 
cephalosporin compound and reliably treat, didn't need to do a 
culture. The MRSA epidemic has changed that.
    We now recommend a culture. Incision and drainage, as Dr. 
Bancroft said. But that the antibiotic has to be guessed at, 
and it takes several days to know whether it is the right 
choice or not. And it is not a penicillin or a cephalosporin. 
It is one of these old-timey drugs that we don't even know how 
well they work. So it isn't about antibiotic resistance in that 
sense. That it has changed how clinicians must respond to a 
skin and soft tissue infection now as compared with 10 years 
ago. I hope that's helpful.
    Mr. Towns. Very helpful. A couple of you indicated that the 
government should do certain things. And I think you were 
talking about government agencies. But you know we're 
government too. So what specific suggestions do you have to us? 
And I know you might have some concerns about Members of 
Congress getting their nose under the tent. Are there any 
specific recommendations or suggestions?
    Congressman Matheson, of course, and Congressman Waxman 
have a piece of legislation, I think, that you're looking at. 
But are there any other suggestions or recommendations that you 
feel that Congress should be involved in or should get involved 
in legislation of any sort? So let's go right down the line. I 
know, Dr. Walts, you have already made your request.
    Mr. Walts. I've got one more.
    Mr. Towns. You have one more? Dr. Burns. Let me just go 
right down the line. And I know your situation is a little 
different.
    Dr. Burns. Not surprisingly, my first request would be 
continued support for health departments at the local level, 
because that is where the rubber meets the road. I thought it 
was almost breathtaking that the centers for Medicaid and 
Medicare services did what they did for nosocomial acquired 
infection. So basically they're saying if your practices are 
such that you're creating a nosocomial infection in the 
hospital, again, focus on the hospital. But if that happens in 
the hospital, you're not going to get paid for that patient. I 
think that's an incredibly powerful tool. I think it sends a 
great message.
    And I think that and 100,000 Lives Campaign are two very 
effective methods to get the attention of the hospital system. 
I think it is not as obvious how such a kind of simple idea 
could affect community acquired infections, because it is kind 
of everybody doing what we do that creates the risk. It is back 
to the issue about what kind of resources do we have to get the 
public's attention. And I think that's the issue. It is not the 
fact that people at the Federal level, the State level and the 
local level aren't trying to get these messages out. But we 
have an almost unlimited number of public health messages that 
we want to get out, and we're competing with a very noisy and 
effective advertising world where they're trying to get their 
message out too.
    So there's a limited capacity for people to hear messages. 
And it tends to happen around something like this. Where for 
reasons that I still don't understand something gets the 
public's attention and then they start paying attention. And if 
we could figure out how we could get people to pay attention I 
think we could be much more effective in getting our messages 
out. You obviously can't legislate that.
    Mr. Towns. Dr. Daum, and I'm on Congressman Davis' time 
now. Go ahead.
    Dr. Daum. Does that mean I shouldn't talk or I should talk 
fast?
    Mr. Davis of Virginia. No, take your time.
    Dr. Daum. I think there's a number of things that you can 
do. The first thing, as you've heard from the different vantage 
points seated at this table, and I think we all have slightly 
different stakeholders in this problem, that education and the 
ability to cope with the need for education by the public is a 
major problem and needs to be resourced and expanded. So that 
we need to understand better how to react to hearing that a 
case came from the school or that this screening program is 
being proposed for the hospital and educate the public about 
what's going on. I know that's easy to say. But I think that 
we've heard this morning and this afternoon that we haven't 
done a very good job of it despite our best intentions.
    More importantly--sorry. A larger scale of the problem, I 
think, is really accepting. And I heard all day long that we're 
having trouble accepting this. Really accepting that what's new 
about this is that it is not about dirtier hospitals, it is not 
about better recognition of infections in hospitals. It is a 
community-based epidemic. The hospital problem has always been 
there. It needs attention, it needs work, it needs to be 
enhanced. But the community problem is new. And we have--we're 
a very wealthy country and we have the ability to resource 
these things and create programs to ask the research questions 
to find out what we need to know and then the interventions to 
act.
    What's happened is we don't have the knowledge base. And so 
when a case comes from the school that close it and disinfect 
it, well, people are angry and upset, those are natural kinds 
of impulses, but they won't help control MRSA epidemics in the 
community to appreciable extent.
    So what can you do? I think that you can say there is an 
epidemic on, it is in the community and we need resources to 
deal with it. We need the CDC to mobilize and say this is a 
problem now; new programs, new money directed at this, and 
other antibiotic resistance infections as well. We need the NIH 
to ask what are the science questions that we need to know. 
Someone asked this afternoon how are these strains causing this 
trouble in the community, what do they have? Those are basic 
science questions. But we need to know them. Perhaps they're 
vaccine targets when we find out the answers.
    So NIH also needs to create problems that says there's a 
community MRSA epidemic on, antibiotic resistance is a problem, 
we need expanded programs to deal with it. The Star bill is one 
way to do it, it's a good way to do it, but there's other ways. 
And so what can you do? I think that you can say this is an 
epidemic and it needs attention and it needs it now.
    Mr. Towns. Thank you very much. Dr. Walts.
    Mr. Walts. In addition to the ones I already gave, I know 
that you had distributed this morning a card, and it was a 
sample of something that had been distributed to hospitals 
throughout the country. And someone raised the question, do you 
have something similar that's been developed for schools, a tip 
sheet? And the doctor said, well, that's a good idea, we could 
see if we can try to locate resources for that.
    So again, from my perspective as a school person, that to 
me would be an outstanding thing to have and probably fairly 
easy thing to do if there was just the money to put it together 
and distribute it. So sometimes simple things can really help 
tremendously inform the public, especially from a school 
perspective.
    Mr. Towns. Thank you. Thank you very much. Dr. Gayle, and 
very quickly.
    Dr. Gayle. I would say that you need to be able to identify 
the community-based centers. And the only way to do it is if 
its through central surveillance. And I'll give you an example. 
I work in the Port Chester section of the Bronx. And this past 
summer, there was at least three cases of Legionnaire's disease 
that were identified. Because we are hooked into the New York 
City Department of Health, once they were notified that there 
was a cluster of that particular infection in that particular 
community, they sent out a bulletin immediately to my two 
medical centers in that community and said this is what we're 
seeing, look for these signs for Legionnaire's disease.
    So each time a patient presented with symptoms that looked 
like Legionnaire's disease, there was a best practice alert 
that popped up on the computer screen that says think of this 
as a possibility for this particular patient. And so the doctor 
had it right there in front of his mind while he's seeing the 
patient whether or not this particular case could have been a 
Legionnaire's case. So central surveillance right at the point 
of care where you get information from the community as to 
what's happening now and then sending out the information to 
the respective centers in that particular community could be a 
great deal of help in identifying cases early.
    Dr. Bancroft. Quickly two areas. One, CDC does have money 
for some surveillance given to local and State health 
departments for surveillance in teaching about antibiotic 
resistance. But frankly it is not enough. There are limited 
funding for those positions in the State and local health 
departments. And I think it is extremely important to better 
delineate the epidemiology who is getting this disease. But not 
just the basic demographics of who is getting the disease, but 
being able to interview the patients themselves and ask about 
the risk factors, their practices, their behaviors that may be 
underlying why they're getting that disease.
    So CDC needs additional funds to be able to distribute out 
to better do those studies, and also to support surveillance. 
And the second area really comes down to hospital MRSA. Dr. 
Daum has talked about the new epicenter of this disease being 
in the community. But still, as of this point, 85 percent of 
MRSA, at least the invasive MRSA is hospitals. Right now in the 
local health departments, we inspect restaurants far more 
regularly than we inspect hospitals. That's true on a national 
level as well. We'll inspect restaurants one to four times a 
year. We inspect hospitals once every 3 years. I think more 
resources to inspect hospitals in order to help them have 
better oversight that they meet those inspection control 
standards that we know if applied will decrease MRSA and other 
infections.
    Mr. Towns. Thank you. I yield to the ranking member. It is 
all yours.
    Mr. Davis of Virginia. Thank you. I'll try to be brief, but 
I very much appreciate what the panel has had to offer. Dr. 
Burns, the emergency reporting requirements that were issued a 
few weeks ago required labs do the reporting. How did Virginia 
officials settle on that as being the best means for tracking?
    Dr. Burns. As you could imagine, it did take a lot of 
debate and discussion to decide on the most efficient method to 
do it. But it came down to the fact that to diagnose MRSA you 
had to have a laboratory test. So it is not a clinical 
diagnosis, it is a laboratory diagnosis. So since it is a 
laboratory diagnosis, why make the doctor report it when the 
laboratory already has the data, and the laboratories are 
generally much more oriented toward just adding another disease 
to the list of diseases they report, and then it happens 
automatically. There's not a one at a time kind of situation. 
So it is cheap, it is exactly the data we want, it is 
effective, the system is already in place, it was easy.
    Mr. Davis of Virginia. What do we do with the data 
reported? Are school districts made aware of the reported 
cases.
    Dr. Burns. What we're asking the labs to report is MRSA 
from a normally sterile part of the body. So it doesn't include 
all the skin and superficial infections. So we're looking at 
bone, bloodstream, things like that. We don't anticipate that 
this will be a tool that will be useful at the school level. 
But we do think that it will be useful in helping us keep track 
of the tip of the iceberg. And by understanding what the tip of 
the iceberg is doing, both over time and by location, we can 
better target our deeper investigations to see what's actually 
going on.
    And the thing I forgot to mention earlier about the other 
reason why it is real attractive to do the laboratory data is 
in public health we always like to know the denominator, we 
like to know something about the population that the number of 
diseases comes from.
    So if you just take the number of diseases coming into the 
emergency room and you haven't thought about what part of the 
community they represent, you really kind of just have a 
popularity contest about who goes to that hospital. So by doing 
this laboratory-based reporting we know that we have the entire 
universe and so we will have valid data for us to make 
conclusions on over time.
    Mr. Davis of Virginia. Thank you. Dr. Daum, you mentioned 
in your testimony that the skin and the soft tissue infections 
associated with MRSA often resemble spider bites. Now, if a 
physician were to look at this, this skin infection as a spider 
bite and treat it that way, is that a potentially fatal misstep 
for the patient.
    Dr. Daum. It is true that spider bites are commonly the 
story that patients will tell who come in with a community MRSA 
skin and soft tissue infection. I had a slide but not enough 
time to show it today that shows the mismatch of where epidemic 
diseases occurring and where those kinds of spiders live in our 
country. And it is amusing to hear in Chicago where the spiders 
do not live how often patients will nevertheless tell you that 
this started with a spider bite. And what I've learned to do 
then is say, have you seen the spider, and the answer is no.
    So I guess it is recognition of something that looks like a 
spider bite in a place where they don't live is helpful. It is 
a bit of a conundrum here, because when anything that breaks 
the skin, including an insect bite, can actually predispose the 
staphylococcal infection. Staph lovesbroken skin. So that it is 
possible that a spider bite in sections of the country where 
they do live, could, in fact, set off a community MRSA 
infection as well.
    So I think a physician has to be concerned when he or she 
sees something that looks like a spider bite that this could be 
a community MRSA infection. I think that your question though 
goes to an issue of progression. And in the skin and soft 
tissue infection, a very, very small percentage of them 
progress to more severe disease. So that I think that 
physicians need to be thoughtful about what they're seeing, but 
that an abscess today does not mean you're going to have a 
severe sepsis tomorrow.
    Mr. Davis of Virginia. I'm just confused on--this is going 
to be my last question. Dr. Gerberding, in the first panel, 
talked about how these staph, these germs are everywhere. 
They're in people's noses and all over. And you're talking 
about how they're more regional in their manifestations.
    Dr. Daum. So we're both right.
    Mr. Davis of Virginia. I knew that. I was just trying to 
get it together and understand how you were both right.
    Dr. Daum. So staphylococcus aureus, which is what we are 
really talking about today, and MRSA is a subset of those, is a 
very well adapted human pathogen. My guess is if the history 
book could be open, it has been living in us and on us for 
centuries. And a well-adapted pathogen doesn't want to kill 
everybody. That's the last thing in the world it would want to 
do, because then it has no place to live. So what staph really 
are happiest doing is living in your nose usually, but could be 
on your skin or even somewhere else rarely, and just sit there. 
Eat what you eat, breathe what you breathe, and its ultimate 
goal, divide. It really doesn't want to cause disease.
    Disease is an unfortunate result of breakdown between our 
body's defenses and a germ's ability to live on us in peace. 
Dr. Gerberding is absolutely right. Staphylococcus aureus is 
everywhere. About a third of us right now have it on our 
bodies, even though presumably none of us have kind and soft 
tissue infections. And that's true. That's changed a little bit 
because now there's sometimes MRSA, a methicillin-resistant 
staph aureus. But it is the same staph aureus. Any disease is 
an uncommon outcome of interaction between this bug and one of 
us. It likes to just live peacefully among us.
    So I think that goes to your question that she sort of 
posed. The difference is as if they perceive that they don't 
have enough food, they perceive that the conditions where 
they're living aren't the right ones, then they begin to 
secrete their toxins and begin to destroy tissues. The body 
then begins to respond to it and you get something that a 
doctor would call an infection.
    Mr. Davis of Virginia. Thank you. That's it. Thank you all 
very much.
    Mr. Towns. Thank you very much. Let me just say that the 
chairman has indicated we will have another hearing in the 
spring on hospital acquired MRSA and resistant strains. I also 
would like to thank all the witnesses for their testimony. And 
I hope that this hearing has provided some comfort to the 
public that while MRSA is a genuine concern, there are some 
practical simple steps that people can take to protect 
themselves and their children. At the same time the witnesses 
have made a very compelling case that we have to do more to 
combat infections in the community and in the health care 
setting. And also that we need to take the issue of antibiotic 
resistance very seriously. I look forward to pursuing these 
issues in the coming months. And as I've said that there will 
be another hearing in the spring. Without objection the 
committee stands adjourned.
    [Whereupon, at 1:35 p.m., the committee was adjourned.]
    [The prepared statements of Hon. Edolphus Towns and Hon. 
Diane E. Watson follow:]

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