. fin INVASIVE STREP A: WHAT DO WE NEED TO KNOW? Y 4. G 74/7: ST 8 Invasive Strep A: Uhat Do He Heed t. . HEARING BEFORE THE HUMAN RESOURCES AND INTERGOVERNMENTAL RELATIONS SUBCOMMITTEE OF THE COMMITTEE ON GOVERNMENT OPERATIONS HOUSE OF REPRESENTATIVES ONE HUNDRED THIRD CONGRESS SECOND SESSION JULY 28, 1994 Printed for the use of the Committee on Government Operations m ^^cir^ov^'^^ FFP21 »95 ''^fe«£,, U.S. GOVERNMENT PRINTING OFFICE 85-648 CC WASHINGTON : 1994 ForsalebytheU.S.GovernmentPrintingOffice SuperintendentofDocuments,CongressionalSalesOffice,Washington,DC 20402 ISBN 0-16-046471-4 . ' INVASIVE STREP A: WHAT DO WE NEED TO >, KNOW? Y 4. G 74/7: ST 8 Invasive Strep A: Uhat Do He Heed t. . HEARING BEFORE THE HUMAN RESOURCES AND INTERGOVERNMENTAL RELATIONS SUBCOMMITTEE OF THE COMMITTEE ON GOVERNMENT OPERATIONS HOUSE OF REPRESENTATIVES ONE HUNDRED THIRD CONGRESS SECOND SESSION JULY 28, 1994 Printed for the use of the Committee on Government Operations % a FFR 2 I 895 U.S. GOVERNMENT PRINTING OFFICE 85-648 CC WASHINGTON : 1994 ForsalebytheU.S.GovemmenlPrintingOffice SuperintendentofDocuments.CongressionalSalesOffice.Washington.DC 20402 ISBN 0-16-046471-4 COMMITTEE ON GOVERNMENT OPERATIONS JOHN CONYERS, Jr. Michigan, Chairman CARDISS COLLINS, Illinois WILLIAM F. CLINGER, Jr., Pennsylvania HENRY A. WAXMAN, California AL MCCANDLESS, California MIKE SYNAR, Oklahoma J. DENNIS HASTERT, Illinois STEPHEN L. NEAL, North Carolina JON L. KYL, Arizona TOM LANTOS, California CHRISTOPHER SHAYS, Connecticut MAJOR R. OWENS, New York STEVEN SCHIFF, New Mexico EDOLPHUS TOWNS, New York CHRISTOPHER COX, California JOHNM. SPRATT, JR., South Carolina CRAIG THOMAS, Wyoming GARY A. CONDIT, California ILEANA ROS-LEHTINEN, Florida COLLIN C. PETERSON, Minnesota DICK ZIMMER, New Jersey KAREN L. THURMAN, Florida WILLIAM H. ZELIFF, JR., New Hampshire BOBBY L. RUSH, Illinois JOHN M. MCHUGH, New York CAROLYN B. MALONEY, New York STEPHEN HORN, California THOMAS M. BARRETT, Wisconsin DEBORAH PRYCE, Ohio DONALD M. PAYNE, New Jersey JOHN L. MICA, Florida FLOYD H. FLAKE, New York ROB PORTMAN, Ohio JAMES A. HAYES, Louisiana FRANK D. LUCAS, Oklahoma CRAIG A. WASHINGTON, Texas BARBARA-ROSE COLLINS, Michigan BERNARD SANDERS, Vermont CORRINE BROWN, Florida (Independent) MARJORIE MARGOLIES-MEZVINSKY, Pennsylvania LYNN C. WOOLSEY, California GENE GREEN, Texas BART STUPAK, Michigan Julian Epstein, StaffDirector Matthew R. FLETCHER, Minority StaffDirector Human Resources and Intergovernmental Relations Subcommittee EDOLPHUS TOWNS, New York, Chairman HENRY A. WAXMAN, California STEVEN SCHIFF, New Mexico THOMAS M. BARRETT, Wisconsin JOHN L. MICA, Florida DONALD M. PAYNE, New Jersey ROB PORTMAN, Ohio CRAIG A. WASHINGTON, Texas BERNARD SANDERS, Vermont (Ind.) Ex Officio JOHN CONYERS, JR., Michigan WILLIAM F. CLINGER, JR., Pennsylvania Ronald A. Stroman, StaffDirector J. ALLEN HILL, Professional StaffMember MARTINE M. DiCROCE, Clerk MARTHA MORGAN, Minority Professional Staff (ID CONTENTS PagB HearingheldonJuly28, 1994 1 Statementof: Broome, Claire V., M.D., Deputy Director, Centers for Disease Control andPrevention 3 Kaplan, Edward L.,M.D., professorofpediatrics, University ofMinnesota Medical School, and professor, division of epidemiology, University of Minnesota School ofPublic Health, and head, World Health Organiza- tion CollaboratingCenterforReference andResearchonStreptococci ... 44 Morse, Dale L., M.I)., M.S., director, division ofepidemiology andcommu- nicable diseases, NewYork State DepartmentofHealth 55 Stevens, Dennis L., M.D., Ph.D, chief, infectious disease section, Veterans AffairsMedical Center, Boise, ID 14 Towns, Hon. Edolphus, a Representative in Congress from the State ofNew York, and chairman, Human Resources and Intergovernmental RelationsSubcommittee: Openingstatement 1 Letters, statements, etc., submitted forthe recordby: Broome, Claire V., M.D., Deputy Director, Centers for Disease Control and Prevention: Preparedstatement 6 Kaplan, Edward L., M.D., professorofpediatrics, University ofMinnesota Medical School, and professor, division of epidemiology, University of Minnesota School ofPublic Health, and head, World Health Organiza- tion Collaborating Center for Reference and Research on Streptococci: Prepared statement 47 Morse, Dale L., M.D.,M.S., director, division ofepidemiology and commu- nicable diseases, New York State Department of Health: Prepared statement 57 Stevens, Dennis L., M.D., Ph.D, chief, infectious disease section, Veterans AffairsMedical Center, Boise, ID: Article fromNew EnglandJournal ofMedicine, July 6, 1989, relating to severe groupA streptococcal infections 26 Preparedstatement 16 (III) INVASIVE STREP A: WHAT DO WE NEED TO KNOW? THURSDAY, JULY 28, 1994 House of Representatives, Human Resources and Intergovernmental Relations Subcommittee of the Committee on Government Operations, Washington, DC. The subcommittee met, pursuant to notice, at 10 a.m., in room 2154, Rayburn House Office Building, Hon. Edolphus Towns (chair- man ofthe subcommittee) presiding. Present: Representatives Edolphus Towns, Donald M. Payne, Steven Schiff, and Rob Portman. Also present: J. Allen Hill, professional staffmember; Martine M. DiCroce, clerk; and Martha Morgan, minority professional staff, Committee on Government Operations. OPENING STATEMENT OF CHAIRMAN TOWNS Mr. Towns. The Subcommittee on Human Resources and Inter- governmental Relations will come to order. Today the Subcommittee on Human Resources and Intergovern- mental Relations looks at the public health concerns from invasive group A streptococcus. Millions ofpeople get some form of strep in- fection each year in the United States. Far fewer get invasive infec- tions but several thousand die each year. Our purposes in the hearing are twofold: first, to take expert tes- timony in a public meeting so that the public can be adequately and accurately informed about strep A and what they should do to protect themselves from its consequences; and second, to consider our current state of understanding about strep A, our facilities for monitoring and studying it, and determine whether those are ade- quate to meet the threat that we are facing. Most of us have read or seen reports of the flesh-eating bug. Necrotizing fasciitis is a gruesome condition, just as strep toxic shock is a scary one. As a grandparent, ofcourse, I know how often children have strep throat. If there is a comforting word in all of this, it is that children get 80 percent of the mild cases of strep, but only 10 percent of the inv—asive or seri—ous cases. What remains unknown is why some people of any age will get the mild form when exposed to strep, while others get the invasive form. Before the 1950's, the many threatening consequences ofinvasive strep made it a source of active concern to public health officials everywhere. Since then, our monitoring of strep has dropped dra- matically. (1) Today, it competes with many other infectious diseases for re- porting and monitoring resources. Is that a mistake we should cor- rect? Are our resources adequately arrayed to detect and respond to emerging infectious disease threats? At this time, I would like to yield to the ranking minority mem- ber ofthe subcommittee, Congressman Schiff. Mr. Schiff. Thank you, Mr. Chairman. First I want to thank you very much for holding this hearing. I think it is on a very important subject. As you indicated, group A streptococcus has been around for a long time, and has been the cause for a number of illness, most of which there has ordinarily been a speedy recovery from. Most recently I have seen in the press, reports of necrotizing fasciitis which I at least had not seen before in the media, and it at least suggests to me ifnot a new dis- ease, an outbreak ofthis disease. And what struck me was my recollections of HIV-positive and AIDS, when that came into the news in the early 1980's, and I be- lieve that those cases were reported in the press very much like necrotizing fasciitis is being reported now, as an unusual but ex- tremely rare disease. We have since learned that AIDS is not obviously a rare disease and it is an epidemic in portions of the United States and in por- tions ofthe entire world. And what I believe we should accomplish at this hearing is to determine, is there a similar threat from any A of the diseases that might be caused by group streptococcus, whether it is this particular disease that deals with the loss ofskin tissue and organ tissue or any other resulting disease. And I have to say, Mr. Chairman, nothing would please me bet- ter ifthe experts who are about to testify so state that this is some- thing that can be contained and is being contained. But I think the threat of this disease is significant enough that we don't want it to be another HIV, we don't want to find out 10 years from now that it really was something that we didn't do anything about. I look forward to the testimony. Mr. Towns. Thank you very much, Congressman Schiff. At this time, I yield to Congressman Payne for any opening statement he might have, or remarks. Mr. Payne. Thank you very much, Mr. Chairman. Let me commend you this morning for calling this hearing and for the leadership that you have taken in many ofthe issues relat- ing to health that we have been dealing with. I also wanted to ex- tend my regards to the panel of witnesses who have agreed to pro- vide us with their testimony. I think the media attention that has been devoted to the out- break of the so-called flesh-eating bacteria has probably contrib- uted to a general hysteria about the possibilities of a widespread epidemic. I would hope that during the course of this hearing that we would clarify the threat to the public health and correct some of the misinformation-feeding frenzy that has been created regarding the situation. This particular infection of necrotizing fasciitis actually develops in about 5 to 10 percent of cases of strep, which is about 1,000 to 1,500 cases overall. And this invasive infection develops in about 10 to 20 percent ofpediatric cases ofstrep infection. Additionally, there is some evidence that Native Americans may be more susceptible to invasive infections, especially in the South- west regions, where they are observed to suffer a higher incidence ofseveral bacterial diseases. One area study found African-Americans are twice as likely as whites to contract invasive strep A. The most vulnerable population are diabetics, immune-compromised persons, intravenous drug users, and alcoholics. These segments of the population often re- ceive little or no medical attention until their condition becomes critical because their access to medical care is restricted. Modern medicine has come a long way in virtually eliminating diseases that once proved fatal. We saw this with polio, scarlet fever, and rheumatic fever. However, in the last decade, we have dropped our guard on diseases like tuberculosis, committing fewer and fewer resources each year to protecting the public health. And now, as a result, there is a resurgence of a more hostile strain of tuberculosis, which is more difficult to treat and deadly. The greater issue at hand is that now that the health threat as- sociated with strep has been abated, the mechanisms necessary to ensure that there is not a resurgence of a strep epidemic are not in place. To my understanding, it remains to be seen if the CDC is suffi- ciently equipped to detect whether or not there is a recurring trend in the incidence ofinvasive strep in our population. Many times we move in the wrong direction of cutting in areas where we need to have increases, and increases in areas where we don't need them in our budgets, as we saw in the 1980's with defense and other areas ofgrowth, and we saw a reduction in the services needed, es- pecially ior vulnerable populations. Mr. Chairman, let me thank you again for calling this hearing today. I think there are some very important issues that need to be addressed, and I look forward to hearing the testimony of our witnesses. Mr. Towns. Thank you very much. Let me thank you and Congressman Schiff" for your opening statements. And I think that you are right, we need to collect infor- mation. At this time I would like to call on Dr. Claire Broome to come to the witness table, Deputy Director of the Centers for Disease Control. And Dr. Dennis Stevens, chiefofthe infectious disease sec- tion ofthe Veterans Affairs —Medical Center in Boise, ID. May I remind both ofyou first of all, let me welcome you to the hearing and say that your entire statement will be included in the record. Ifyou wouldjust summarize within 5 minutes and allow us to raise some questions with you, I think we will be able to accom- plish a lot more that way. So, Dr. Broome, why don't you begin. STATEMENT OF CLAIRE V. BROOME, MJX, DEPUTYDIRECTOR, CENTERS FOR DISEASE CONTROLAND PREVENTION Dr. Broome. Thank you, Mr. Chairman. I am Dr. Claire Broome, Deputy Director ofthe Centers for Disease Control and Prevention. I am pleased to respond to the subcommittee's invitation to provide testimony on severe infections caused by group A streptococci. Group A streptococci are bacteria which cause a wide variety of infections ranging from common, often clinically mild illnesses such as strep throat, scarlet fever, and impetigo, to rare and often severe infections such as pneumonia, necrotizing fasciitis, and streptococ- cal toxic shock syndrome. The initial site of infection is usually the nose or throat or the skin. Invasive infection develops when the organism gets through the usual body defenses leading to infection in the blood, lungs, or other normally sterile sites. Bacteria are transmitted person to per- son through respiratory secretions. Severe and fatal infections caused by group A streptococci have been recognized since the 1800's. Necrotizing fasciitis, which was first reported in 1918, is characterized by infection and destruction, or necrosis, ofsoft tissue. Necrotizing fasciitis usually begins with infection at the site of a break in the skin. About 15 percent of necrotizing fasciitis cases result in death. Streptococcal toxic shock syndrome was first reported in 1987. Streptococcal toxic shock syndrome is defined by the isolation of group A streptococcus from a normally sterile site and the early de- velopment of shock with involvement of multiple organ systems such as kidneys, lungs, and liver. The case fatality rate of persons with this syndrome exceeds 60 percent. To define the incidence of severe infections and identify risk fac- tors, CDC has collaborated with State and local health depart- ments to conduct surveillance for all group A streptococcal infec- tions where the bacteria were isolated from the patients' blood. These investigations showed an annual rate of bloodstream infec- tion between 3.5 and 6.8 cases per 100,000 persons, approximately 10,000 to 15,000 cases in the United States each year. Among these cases, 10 to 15 percent met the definition for strep- tococcal toxic shock syndrome, and 3 to 7 percent had necrotizing fasciitis. Rates of disease are higher in Native Americans and Afri- can Americans than in whites. The age group at highest risk is the elderly. What is CDC doing to monitor the occurrence ofgroup A strepto- coccal infection? We monitor these infections in several different ways. We do special epidemiologic and laboratory surveillance to get precise estimates ofthe rate, and that is the basis for the rates I havejust quoted to you. We also use the network of State and local health departments who are contacted by local physicians when clusters of cases occur. We also track bacteria sent to the CDC laboratory. CDC is one of only two institutions in the United States that can classify group A streptococcal isolates by M type, which is a way of subtyping the bacterium. The recent changes in the occurrence of severe infection and streptococcal toxic shock syndrome correspond to a dramatic in- crease in the proportion of strains oftwo particular subtypes, types M-l and M-3. Reports from other countries ofincreases in invasive group A streptococcal infections and M-l infections suggest an in-