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CDC News Conference Transcript
Update on Gonorrhea Treatment Recommendations and
April 29, 2004
JENNIFER MORCONE: Hi, this is Jennifer Morcone with the CDC Press Office. Thanks for joining us today. We have a two-pronged press conference today. For our first 30 minutes, we'll be talking about gonorrhea. In our second 30 minutes, we'll be talking about our new Foodnet data. Thanks for your patience, everyone on the line. At this point, I'll turn the call over to Dr. John Douglas, who will take it from here. Thank you, Dr. Douglas.
DR. JOHN DOUGLAS: Thank you very much. Good afternoon, and thank you all for joining us today. Again, I'm Dr. John Douglas. I'm the director of the Division of STD Prevention at the Centers for Disease Control. Joining me on the phone today is Dr. Kenneth Mayer. Ken's the Director of Medical Research at the Fenway Community Health Center in Boston, which is New England's largest health center serving men who have sex with men, or MSM. Today, we'll be discussing new findings on drug resistant gonorrhea in the United States, including data from a large multicity CDC surveillance system, as well as from health departments in Massachusetts and New York City. We'll also talk about CDC's recommendations for treating gonorrhea among gay and bisexual men. After that, Dr. Mayer and I will be happy to answer any questions. By now, you should have received a press release on the data and a copy of the MNWR article. If you haven't gotten these documents, please contact the National Center for HIV, STD and TB Prevention Office of Communication. Their number is (404)639-8895. Please note that the embargo for these data looked at at the beginning of this call.
Now, by way of background, with more than 350,000 cases reported in 2002, gonorrhea is the second most commonly reported infectious disease in the U.S. But estimates show that actual cases could top 700,000 cases a year. Gonorrhea is a serious infection. Untreated, it's a common cause of pelvic inflammatory disease in women, and can cause infertility in both women and men. Gonorrhea can also facilitate the transmission of HIV infection. For the last ten years or so, CDC has recommended that fluoroquinolone antibiotics, namely ciprofloxacin, ofloxacin and levofloxacin, as first-line treatment for gonorrhea in the U.S. Fluoroquinolone therapy is used widely because it's relatively inexpensive, can be taken by mouth and is a single dose treatment. However, for some time, we have seen increasing fluoroquinolone resistance in gonorrhea cases in specific regions of the country -- most notably in Hawaii and California. The prevalence of drug-resistant gonorrhea in these areas prompted the CDC to recommend that fluoroquinolones not be used to treat gonorrhea acquired by anyone in these states. That recommendation was made for Hawaii in 2000, and for California in 2002. Now, new data from CDC's Gonococcal Isolate Surveillance Project, our surveillance system which monitors anti-microbial resistance of gonorrhea, shows that outside of Hawaii and California, the proportion of gonorrhea cases resistant to fluoroquinolone antibiotics has more than doubled in the U.S. between 2002 and 2003, from 0.4% to 0.9%. Fluoroquinolone resistance was most pronounced among MSM, increasing from 1.8% of cases in 2002 to 4.9% in 2003. The proportion of resistant gonorrhea was 12 times higher among MSM than among heterosexual men in 2003. Fluoroquinolone resistance among heterosexual men also increased during the same period, but in a much slower level, from just 0.2% to 0.4%. I'd like to turn the call over to Dr. Mayer now, to discuss local findings from the state of Massachusetts and New York City.
DR. KENNETH MAYER: Thank you very much, Dr. Douglas, and good afternoon, everyone. The disproportionate impact of the fluoroquinolone-resistant gonorrhea on MSM has been particularly evident here in Massachusetts. Between January and August of 2003, the Massachusetts state lab institute found that the prevalence of drug resistant gonorrhea was nearly six times higher among MSM than among heterosexual men -- 11.1% for MSM, and 1.8% for heterosexual men. Fenway Community Health is a health center that has been serving the gay-lesbian-bisexual-transgender community in Massachusetts since the early '70s, and currently cares for more than 1,000 HIV-infected MSM, and large numbers of at-risk HIV uninfected men. And it's been particularly dramatic at Fenway, with 24 cases of fluoroquinolone-resistant gonorrhea last year, and already ten this year. So something approaching 40% of the increase reported by the state.
It's very important to keep the clinical context of this in mind, because many clinicians, despite CDC guidelines, out in the community have used quinolones because they are cheap and easy to administer orally, administered for treatment of uncomplicated cases of gonorrhea. But this increase really dramatizes the need to adhere to guidelines using ceftriaxone or other extended cephalosporins in the management of gonorrhea because of the high prevalence of quinolone resistance that we're now seeing. The other point I think that's very important to think about with relation to the resistant gonorrhea is that this is part of an overall secular trend of increasing cases of gonorrhea seen nationally, both of resistant and susceptible gonorrhea. So at Fenway, for example, there were approximately 50 cases of gonorrhea reported in 1988. About 150 cases reported last year. Likewise, there has been increases in syphilis as well. There was a low of three cases of syphilis reported at Fenway in 1998, and 51 cases reported last year. And although there may be increased awareness in the community--the at-risk communities about the increases in STDs, and there may be more screening, the absolute number of screenings for gonorrhea and syphilis did not increase appreciably over the last few years, so that we really do think that in Boston, as well as New York and other cities across the country, we're seeing true increases in the absolute numbers of new gonorrhea and syphilis infections, as well as this concerning problem of increased resistance. An even greater disparity between men who have sex with men and heterosexual men was observed in New York City between January and July 2003. The Bureau of STD Control at the city's Department of Health and Mental Hygiene found a prevalence of 12.5% for MSM, nearly eight times higher than the prevalence of 1.6% for heterosexual men. I'll now turn the call back over to Dr. Douglas to discuss the impact of these findings on the treatment of gonorrhea.
DR. JOHN DOUGLAS: All right, thank you very much, Ken. The data presented today show that drug resistant gonorrhea is a rapidly emerging health concern, particularly for gay and bisexual men. We also want to note that gonorrhea resistance, as Ken mentioned, is one of many serious STD prevention challenges facing gay and bisexual men today. Recently, we've seen a concerning increase nationally of syphilis among this population, as well as a significant increase in HIV diagnoses. There is mounting evidence these increasing STD rates are fueled by a variety of factors. These include relaxed safer sex practices, substance abuse, particularly the use of crystal methamphetamines, and the availability of the Internet as a method for meeting sex partners. As a result of the significant increase in fluoroquinolone-resistant gonorrhea, CDC is issuing new treatment recommendations for gonorrhea and men who have sex with men. Data shows the prevalence of fluoroquinolone-resistant gonorrhea cases among MSM nationally is now approximately 5%. This level of resistance is often used as a level at which a therapeutic regimen should be changed. For this reason, CDC is now recommending that fluoroquinolones no longer be used as first-line treatment for gonorrhea among MSM anywhere in the United States.
Instead, we now recommend the use of one of two injectable antibiotics as first-line treatment for MSM with gonorrhea. The choice of which antibiotic to use depends partly on the site of infection. For all three potential sites of infection, urogenital, anal-rectal and pharyngeal, CDC recommends an intramuscular injection of ceftriaxone at a dose of 125 milligrams. An intramuscular injection of another drug, spectinomycin, at a dose of two grams, is also an option for urogenital and anal-rectal gonorrhea. However, spectinomycin shouldn't be used for pharyngeal gonorrhea because it's not been proven sufficiently effective at that site. A third treatment option, potentially, is the oral antibiotic cefixime, used at a dose of 400 milligrams.
However, this drug is not, at the present, available in the United States. To treat possible chlamydia co-infection, CDC recommends that among MSM, as for other persons, each gonorrhea treatment regimen should be followed up with either a single one-gram oral dose of azithromycin, or a 100 milligram oral dose of doxycycline, taken twice daily for seven days. Alternatively, if chlamydia infection has been tested for and ruled out, the follow-up regimen is not necessary. You may have seen media coverage that indicated the CDC was changing gonorrhea treatment recommendations across the board. Please note that, given the current low prevalence of drug-resistant gonorrhea among heterosexuals, a change in overall treatment recommendations is not necessary at this time. To restate it, current recommendations are specific at this point only for men who have sex with men. Of course, continued surveillance is an integral part of CDC's strategy to ensure that treatment recommendations are effective in fighting gonorrhea among all populations. We will continue to monitor for resistant cases among MSM and heterosexuals, and will update treatment recommendations as necessary. So, at this point, we will open things up for questions.
OPERATOR: And if anyone does have questions at this time, please press star and one on your touch-tone phone. You will be asked to record your name, and then I will announce you prior to asking your question. But again, star and one on your touch tone phone. One moment for the first question. Our first question is from Maryn McKenna, from the "Atlanta Journal." Your line is now open.
QUESTION: Hi, thanks so much for doing this. Two questions. One, the first is, could we know what the 30 sites are that are surveyed by the Gonococcal Isolate Surveillance Project, or could you direct us to somewhere where that list could be found? And the second question is, could you maybe expand on your remarks about rising rates of HIV infection? Obviously, if there were rising rates of gonorrhea and syphilis infection, it would be reasonable to suppose that safe sex is not being practiced, and there's a higher risk of HIV being transmitted as well.
DR. JOHN DOUGLAS: Yeah. First of all, the 30 sites, I could read them out, but to save time, I won't. They can be found at our website, which is CDC.GOV/STD/GISP. You're from Atlanta. Atlanta is one of those sites. The second question, I think, was about the rising rates of HIV, and what we know about that? Did I get that question correctly?
QUESTION: Just if could you address that if, as you said, there were rising rates of gonorrhea and syphilis, does this portend a raising rate in HIV infection as well?
DR. JOHN DOUGLAS: It certainly raises lots of concerns. The best information we have about whether HIV is increasing among men who have sex with men comes from the National HIV Surveillance System. The most recent analysis of that data from the states which have had ongoing HIV reporting, which at this point in time are 29 states, indicated that between 1999 and 2002, there were increases, specifically approximately 17% increases in HIV diagnoses among gay and bisexual men. That's important to point out that reported cases of HIV infection are based on testing behavior, meaning that if more testing is occurring among gay and bisexual men, you'll have more cases diagnosed and reporting--and reported, so it doesn't truly prove that there is an increased number. But, if you will, we're pulling in several lines of information. That sort of data, the STD data, to triangulate our concern that we may be awaiting or potentially going to be seeing a true increase in HIV infection among MSM.
JENNIFER MORCONE: Okay, next question, please?
OPERATOR: Next question is from Fred Tasker with the "Miami Herald." Your line is now open.
QUESTION: Dr. Douglas, could you tell us why you think the rate of drug-resistant gonorrhea is higher in men who have sex with men than in heterosexual men?
DR. JOHN DOUGLAS: We don't know exactly. I think the best hunch is that we know there are certain parts of the world, including our own west coast of the U.S., Hawaii and California, where there are--have been impressively high rates of quinoline-resistant gonorrhea now for several years. Other parts of the world where quinoline resistance is seen included Eastern Asia and Southeast Asia. I think the best speculation is that travel has led individuals to be exposed and acquire infection in places where resistance is higher, and that that is then brought back to communities where we believe that within sexual networks, resistant gonorrhea, once acquired in a place where prevalence is higher, may be more easily transmitted. I don't--we don't actually have any national data on travel behavior by gay men versus other groups, so that's, if you will, a hypothesis. But it's the most plausible one, I think, at this point in time. I guess one other thing that may be worth pointing out is that gay men who practice receptive anal intercourse may have anal-rectal infection, which may be less likely to become symptomatic and to be detected as readily as urethral gonorrhea. And so there is also, once again, hypothetically speaking, the possibility that there may be a longer carriage of infection among gay men, which might promote the persistence of a resistant strain, once acquired.
JENNIFER MORCONE: Great. Next question, please.
OPERATOR: The next question is from Rob Stein with the "Washington Post."
Your line is now open.
QUESTION: Yeah, hi. Thanks very much. Yeah, I had a similar question along the same lines. I just was hoping you could just elaborate a little bit more on why you think this is happening. Is it because gay men are having less-safe sex, and as a result, are being infected with gonorrhea in general more often, and that's leading to an increase in resistant gonorrhea? If you could just sort of elaborate on what might be behind all this, and what the implications are, that would be great.
DR. JOHN DOUGLAS: Yeah. I don't have a lot to add, Robert, for what I just said.
I do think that the data that we've mentioned nationally, as well as the data that Dr. Mayer cited from the Fenway Clinic, which has been seen in other clinics around the country, do suggest that there is an increase in risky behavior. And I think the travel and the networking is probably the biggest reason why, of that gonorrhea which is going on, a bigger chunk of it in gay men is the resistant gonorrhea. I don't think that we have any reason to believe that resistant gonorrhea is a better marker of risky behavior than just gonorrhea overall.
DR. KENNETH MAYER: Yeah, if I could only add one comment to what Dr. Douglas just said--I think there's also sort of a cohort effect that's going on, that once the resistant gonorrhea is introduced into the--into a gay community, people are tending to have partners within that subset of individuals. So that it allows for amplification if there is a critical mass of people who are having multiple partners, and resistant gonorrhea is transmitted into that community. As Dr. Douglas said, there may be a reservoir of asymptomatic, particularly rectal, gonorrhea that may be highly infectious, readily transmissible, and not routinely detected. One of the CDC's guidelines is for sexually active men who have sex with men to have regular STD screening at least twice a year at this juncture. And I think more adherence to that on the part of providers might help curtail the epidemic.
JENNIFER MORCONE: Great. Next question, please? Go ahead, we'll take the next question. MCI, are you there? We are ready for the next question.
OPERATOR: I apologize. Bob Royer from the "Bay Area Post," your line is now open.
QUESTION: Yeah. Yeah, two question areas. One, first, has to do with methodology, in that, is it possible that some of these samples and isolates that you're getting are from the same individual at different points in time, and so it's sort of contained within a core group of people who are practicing, you know, unsafe sex? And then secondly, could you talk about the cost differentials between the quinolones and the recommended therapy now, and resistance. Does this impact resistance of physicians to use the alternatives?
DR. JOHN DOUGLAS: Sure, Bob. Thank you. Regarding the methodology, the 30 cities involved in the Gonococcal Isolate Surveillance Project are, first of all, based in STD clinics. The approach is to sample the first, approximately, 25 men identified with urethral gonorrhea each month who were seen in the clinic. There is no attempt to exclude individuals who come in more than one time. So the question about whether or not individuals could be multiply represented is absolutely possible. And the question about whether or not this, in fact, then might represent a core phenomenon, I think, is highly plausible, although the surveillance system itself doesn't really address that. The second question, I think, had to do with relative cost impact of needing to use other therapies?
I'm seeing nods by my colleagues here, so let me go on that tangent. Costs are going to vary, locale to locale, based on purchasing specifications. In general, most locales that we've been interacting with tell us the purchase of oral quinolone antibiotics is in fact substantially cheaper than the use of the intramuscular alternatives. The other issue, of course, is the administrative cost of having to give an injection, which not only includes the generally minimal cost of the needle and the syringe and this kind of thing, but the actual administrative cost of having to give it. And frankly, the issue that there are a number of places that are set up to prescribe or even hand-deliver oral therapy who are less well set up to give intramuscular therapy. So we've got a barrier in terms of places actually not being able to administer treatment. A colleague of mine, actually, who has helped do this analysis, Dr. Stu Berman, is here, and I'll ask him to comment, as well.
DR. STU BERMAN: Just going back to that other question that was raised, a very important issue about, are you getting just the same bug that's being sampled over and over again in the same network, doesn't appear to be the case. With the little bit of work that has been done in trying to type the bug – its characteristics, its looks -- we're not seeing the same bug over and over again out of a couple of cities, suggesting it's being sampled, you know, in different places, in different times and different kinds of networks.
DR. JOHN DOUGLAS: Thanks, Dr. Berman.
JENNIFER MORCONE: Great. Next question, please?
OPERATOR: The next question is from Miriam Falco with CNN. Your line is now open.
QUESTION: Good morning--or good afternoon, I guess. I have a pretty basic question. This is the first telebriefing we've had from the CDC on the MMWR in a while, which shows how important you think this report is. My question, though, is, what's the most important public health message you're trying to get out, and who is it targeted against? 'Cause you're giving information that's very useful for doctors, in terms of knowing and recognizing the antibiotic resistance, but you're also, it seems to me, trying to reach out to the MSM community. But I'm trying to figure out, what exactly is the most important thing you're trying to get out?
DR. JOHN DOUGLAS: I think you're correct that the message is two-pronged, and you're also correct that the primary target are health departments and individual physicians who deal with individuals with gonorrhea.
I would say in regard to the health departments and the doctors, the key messages here are number one, treatment among those men who are identified as having sex with other men now needs to change. These national and local data are such that fluoroquinolones just aren't going to cut it. Secondly, the message for individual doctors is you need to ask people about who they're having sex with. And, so taking a sexual history among men with gonorrhea, which has always been important for lots of different reasons, now becomes more important than ever. Individual doctors also need to be reminded that travel histories matter, and that people and/or whose partners have been in places, geographic regions, where resistant gonorrhea has been seen, ought to be treated separately. Finally, doctors, again, the individual physician, needs to be alert to the possibility of treatment failure, so that if a patient is treated and these symptoms don't go away, there is some possibility that the doctor could be dealing with a resistant case. And so, the network of doctors across the country really is in some ways sort of one of the first lines we have of understanding when a new problem is emerging. Beyond that, you're also correct that we are concerned about these various evidences pointed out earlier about rising rates of risk behavior and now the sexually transmitted infectious sequelae, syphilis, gonorrhea, overall, and possibly HIV infection. And whether or not this is core group stuff, as was indicated earlier, or core group plus a periphery. They both have concerns at the public health level for the broader gay community. So, that is a group we are interested in hearing and appreciating this message.
JENNIFER MORCONE: Thank you. We have about five more minutes, and we’ll continue taking questions until time runs out. And next question, please?
OPERATOR: The next question is from Nick Mulcahy with the International Medical News Group. Your line is now open.
QUESTION: Yeah. Hi, Dr. Douglas. My question is about women. If you get your data from the GISP site program, where are you getting--which was all men, and then the subgroup is men who have sex with men--where is your data coming from about women?
DR. JOHN DOUGLAS: It's really an excellent question. And at this point, the surveillance system, as you said, is completely male focused. It's completely male-focused, because that was the most effective way to operationalize a system that would give us the broadest geographic reach possible. It being a lot easier to upfront identify whether a man's got gonorrhea and whether or not you can then put him through the surveillance program. There are no biologic reasons to believe that the strains which are present in women would be different than the strains in heterosexual men. However, we are now exploring some options for trying to include women in certain clinical sites to confirm that supposition that we really shouldn't be seeing a difference. So, bottom line, no active surveillance of women, no reason to expect it would be different than heterosexual men. We are in the process of working on strategies to try to expand that appraisal.
JENNIFER MORCONE: Great. Next question, please.
OPERATOR: The next question is from Frankie Edozien for “The New York Post.”
Your line is now open.
QUESTION: Thank you very much, Dr. Douglas. I wondered if you could perhaps give me a better breakdown of the sample that you took in New York. Exactly how many people were tested and how many people were found to have the drug resistant strain?
DR. JOHN DOUGLAS: I'm going to ask Dr. Berman, who worked directly with New York City to provide you that information.
DR. STU BERMAN: You know, in some ways, the data come into different forms than our other sort of routine data. You know, it’s in the MMWR we cited. They have a report of all of their isolates that they've tested. And as reported in the MMWR, it's a little over 3% of a bit over 600 isolates that were tested. But it really doesn't quite tell you what's going on in people, because those isolates don't have a clinical history with them. And so, to have a better sense of what was really going on, New York City went through the charts in about six of their STD clinics and to understand how many isolates came from the same person, and what the characteristics of the individual people were. From those clinics and from those data, as we have in the MMWR, and as Dr. Mayer was citing, among those individuals that you have an understanding of what the sexual behavior was, looks like it was 14 positives of 112 MSM, men who have sex with men, for a prevalence of about 12.5%. Among those men who said they had sex with women, there was a prevalence of three positive, three resistant case isolates among 83 that were tested for prevalence of about 1.6%. And among 42 women that they have information on, one isolate was positive among the 42. So those were the data. And that was how it was looked at in a way to get a sense of really what the risks are and what was going on.
DR. JOHN DOUGLAS: Thanks, Dr. Berman.
JENNIFER MORCONE: Great, Dr. Berman, could you just tell everyone on the phone the spelling of your name and your title, please?
DR. STU BERMAN: Yeah. Stuart Berman. B-e-r-m-a-n. I’m chief of the epidemiology and surveillance branch in the division of STD prevention.
JENNIFER MORCONE: Great, great. I think we have time for one more short question.
OPERATOR: The next question from Roni Rabin from “Newsday.” Your line is now open.
QUESTION: Couple things. I want—I would really like more information from what you have on the HIV increases in terms of demographics. What kind of racial breakdown? Where are we seeing the big problems? Young, old, white, black, Hispanic? And I also just wanted to get back to the issue of women. I was surprised to say that you would not think there would be strains in women if they aren't in heterosexual men. But we know that there’s a lot of bisexuality going on, and I would think that would put certain women at a high risk.
DR. JOHN DOUGLAS: Roni, let me say that I’m gonna ask our communications office to get you some specific data on the demographics of the HIV, since I don't have that in front of me right now. Your point about the bisexual bridging, if you will, to the female population is really an excellent one.
We do have some local data, such as the kind Dr. Berman just cited from New York City, that suggests that the level of resistance in women looks very close to that in heterosexual men. But that's not to say that in certain pockets, where bridging behavior may be more common, we may not be seeing higher rates in women. That's frankly one of the reasons why we're going to be trying to expand that surveillance in females.
JENNIFER MORCONE: Thank you very much. And thank you. If the media on the call would just stand by, I'm gonna turn the call back to MCI. We're gonna ask our gonorrhea folks to step out if they'd like to.
They can stay if they'd like. And we're going to open a new set of press questions, a new queue, shortly. Brad, you can go ahead and open the other speaker lines.
OPERATOR: Thank you and I would like now to introduce Dr. John Douglas, Dr. Robert Tauxe, Dr. Elsa Murano and Dr. David Goldman. And thank you, you may begin.
JENNIFER MORCONE: Great, thank you. We're just going to need a moment here. Okay. Is everybody there? We're ready to begin here in this room. If you could mute the other speaker lines for now. Dr. Tauxe will begin with introductory comments. And next we'll hear from Ms. Janice Oliver, Deputy Director for the Center for Food Safety and Applied Nutrition from FDA. And lastly, we'll hear from Dr. Elsa Murano, the Under Secretary for Food Safety from USDA. Thank you everyone, for your patience. Dr. Tauxe.
DR. ROBERT TAUXE: Thank you very much and good afternoon, everybody. Foodborne infections are an important public health problem in the United States. Back in 1999, we published estimates that 76 million Americans become ill each year. 323,000 are hospitalized. And 5,000 die. Actually, since 1996, we have tracked the frequency of infections that are typically transmitted through contaminated foods using FoodNet. FoodNet is a collaborative surveillance network that's conducted by CDC, with sentinel sites and health departments in nine states, and with our other federal partners, the USDA and the FDA. Today we are releasing the preliminary results of FoodNet surveillance for 2003. These results show three things. First of all, the continuation of sustained declines in some infections, particularly in salmonella, in campylobacter and in Yersinia infections. Second, it shows a more recent decline, largely occurring between 2002 and then 2003 in the E. Coli 0157:H7 infections. We have not observed a significant decline in the other bacterial infections that are being tracked. The decline in the E. Coli 0157 infections is very promising. Although it is too soon to know if it will be a sustained decrease, we have seen much year-to-year variation in this organism's infection patterns in the past. But the decline we observed between the beginning of our surveillance in 2003 was statistically significant for the first time. This means that we are seeing decreases in some important foodborne infections. Our prevention efforts that are manifold throughout the industry and the regulatory authorities, many levels, need to be continued and expanded. We--in order to meet our goals for protecting the health of all Americans.
JENNIFER MORCONE: Great. Thank you, Dr. Tauxe. Ms. Oliver, you can go right ahead.
MS. JANICE OLIVER: Yes, thank you. The FoodNet data published today show that we're making good progress against foodborne bacterial illnesses, and FDA is committed to the continuing progress against conventional threats to food safety. We’re also are committed to continuing our support of this important endeavor. And the FoodNet data shows for a decrease in the major bacterial foodborne pathogens also showing a real progress towards meeting our Healthy People 2010 goal. But while the numbers show a significant decrease, FDA recognizes the need for further reduction to stem foodborne illness even more and we're committed to that effort. Thank you.
JENNIFER MORCONE: Dr. Murano?
DR. ELSA MURANO: Yes.
JENNIFER MORCONE: Please go ahead.
DR. ELSA MURANO: Thank you. Reductions in these foodborne illnesses that have just been announced by the Centers for Disease Control and Prevention certainly show the Bush Administration's aggressive science-based policies that are helping us combat deadly bacteria in meat, poultry and egg products, specifically to USDA's jurisdiction and that these policies are--have been very effective. We have ourselves reported results in the last several months on the prevalence of some of these specific organisms in regulatory samples that we collect at the Food Safety and Inspection Service, and those have also shown significant decreases. We have also seen a decline in the product recalls in the FSIS regulated products--meat, poultry and egg products-- from 2002 to 2003. And I will stress that we believe strongly that a lot of these declines, especially in particular, the E. Coli 157:H7 illnesses over the last year have been the direct result of our policies to control the specific pathogen. We have most prominently mandated that all flour and ground beef establishments reassess their HACCP plans. And these reassessments led most establishments to implement an intervention strategy at the grinding step or to require their suppliers to do so. And following these reassessments, we conducted at FSIS the first comprehensive science-based audits of these HACCP plans to make sure that they were scientifically valid. And this was carried out by our expanded scientifically trained force of HACCP experts and epidemiologists. And finally, the creation of our new training program for our inspectors called the Food Safety Regulatory Essentials, has tremendously improved training of our inspectors in these science-based regulations. So the CDC data certainly provides us with a good start, a benchmark, and although we certainly see progress, we know that breaking the cycle of foodborne illness which we have succeeded to a certain extent in doing, we will not relent and continue to aggressively seek science-based measures to control this.
JENNIFER MORCONE: Great. Thank you very much. At this point, we can open it up for questions for any of our speakers.
OPERATOR: And again, just as a reminder, for questions it is star and 1 on your touchtone phone. And you will be asked to record your name prior to asking your question. And then I will announce you. But again, star and 1 on your touchtone phone. And one moment for the first question. Our first question is from Sally Schuff with Feedstuffs. Your line is now open.
QUESTION: Thank you. My question is for Dr. Murano. Dr. Murano, this is Sally Schuff at Feedstuffs. I was wondering if you could comment on how the FSIS policies have been supported by industry efforts, and if you believe that there has been a joint effort that has contributed to the reduction of E. Coli.
DR. ELSA MURANO: Thank you, Sally. Well, certainly, as we mandated these reassessments of the HACCP plans, these are the food safety programs that these plants have to operate under, industry certainly put forth an effort to be sure to make their reassessments be significant reassessments, not simply do it because we were ordering them to do it, but actually put a lot of work and thought into these which was certainly what we found to be true during our audit. So I think the beef industry certainly in their holding of an E. Coli summit which they did last year, I believe, certainly pledged that they would do everything that they could to minimize or prevent outbreaks and certainly on the heels on the ConAgra recall that took place back in the summer of '02, they certainly understood the importance of doing everything that they could. So we certainly give them credit. Obviously the policy that we put into place which they followed are what guided their efforts to be sure.
JENNIFER MORCONE: Thank you very much. Next question, please.
OPERATOR: Our next question is from Elizabeth Weise from "USA Today." Your line is now open.
QUESTION: Hello. I have two questions. First off, I'm looking at the numbers, and especially the report talks about the ways in which these infections are disproportionately dangerous for babies and young children. Is it fair? Can we work those numbers out? You're looking at them--let's see--122.7 babies under a year per 100,000 persons for salmonella. Can you give percentages? Is it fair to presume those percentages when we know that this is only 14% of the U.S. population? I'm just looking for a number that's going to and little more meaningful to the reader.
DR. ROBERT TAUXE: Uh, this is Rob Tauxe. I’m sorry, so you're asking the question of what percent of salmonella infections are in infants aged less than a year. I think--
QUESTION: Break them down, infants, children 1 through 4 and people over the age of 5.
DR. ROBERT TAUXE: I think that would--certainly that can be calculated. I don't think it can be calculated just from these numbers. If that's something perhaps we could provide to you separately.
QUESTION: That would be great.
JENNIFER MORCONE: We’ll follow up after the call, Elizabeth.
QUESTION: Okay, and the other question I had is, I see that there is a certain type of salmonella, for example, that appears to be increasing. What are some of the emerging pathogens that you're seeing, ones which haven't been as much of an issue in the past but seem to be showing up with greater frequency?
DR. ROBERT TAUXE: Yes. Among the most common sorts of salmonella, that one type, javiana, we’ve flagged as a type that's increasing, particularly in Southern--Southeastern parts of the United States, there have been increases in the past in some of the vibrio infections as well. And vibrio one of the infections that has not decreased since 1996. And it's certainly possible that other infections that currently are not under surveillance may become more common and we may be adding those to FoodNet in the future.
JENNIFER MORCONE: Next question, please.
OPERATOR: The next question is from Marilyn Marchione with “The Milwaukee Journal.” Your line is now open.
QUESTION: Hi, thanks very much. Dr. Tauxe, whenever there has been an increase in foodborne infections, there’s always epidemiology and studies to try to figure out why. Do we have any data on why the decrease is occurring besides guesses, and what about the role of consumer behavior? Haven't we had a lot of high-profile deaths and recalls? Don't you think consumers are changing their behavior?
DR. ROBERT TAUXE: Yes. Thank you very much, Marilyn. I think that the whole issue of preventing foodborne diseases is multifactorial-- there certainly are efforts underway at several different levels starting at, right at the food production, through the food chain and to the final consumer. And you’re right, there have been efforts to educate the consumer, there have been efforts to improve the safety of processing all along the way and more and more efforts that are focused on what happens in the actual farm or field. The evidence that we have suggests that decreases of --may be related to several things. And it is true that more people use thermometers when they cook their meat, more people probably are washing their hands as they prepare food than used to be the case, but those differences have not been, have not been huge. One piece of evidence that we find very important is that the efforts to actually track the levels of contamination in meat and poultry have indicated over time a decrease in the frequency of contamination and most recently even an increase in the contamination with E. Coli 0157. I think that that is sort of a primary measure of the kinds--of the frequency of contamination and of what’s happening to the foods as a result of the changes in industry and the changes in regulation by USDA and FDA.
JENNIFER MORCONE: Next question, please.
OPERATOR: And the next question is from Lance Gay with the Scripps Howard News Service. Your line is now open.
QUESTION: Thank you, Doctor. She just answered one of my questions. But I was--emerging disease issue, there was appearance of 022 in, I believe Texas and Ontario in 2002. Is that of concern and what about other dangerous E. Coli?
Could you speak to--thank you.
DR. ROBERT TAUXE: Yes, indeed. There are other E. Coli as you say, other than 0157 which can cause important illness although are not as frequent as 0157. We have begun to look at those in greater details and have been working with out state Public Health Department to look at the frequency with which some of these other E. Coli may be coming up. And beginning a couple of years ago we began in FoodNet we began tracking some of the other E. Coli as well when they're identified. We don't have that information going back to 1996, so we're not able to say anything about trends. But we are quite concerned and involved in the issue of the other E. Coli when they're identified.
JENNIFER MORCONE: Great. We'll take the next question, please.
OPERATOR: And I'm showing no further questions at this time. But if anyone does have a question, it is star and 1 on your touchtone phone. And please stand by for questions. We do have a question from Carol Sugarman. Please state your company name. Your line is open.
QUESTION: Yes, this is Carole Sugarman from “Food Chemical News.” I'm wondering, do you have any information on fluctuations in pathogens as they relate to various food products?
JENNIFER MORCONE: Are you asking any of our speakers?
QUESTION: I guess any of them. Whether any of the information released today would indicate fluctuations based on food products.
DR. ROBERT TAUXE: I'll take a first answer, but I welcome Ms. Oliver or Dr. Murano as well. What we're measuring in FoodNet is really the number of people who become ill, not the levels of contamination in food. So we don't have information that easily translates to one specific food or another. I think contamination levels within food is something that is tracked to different degrees for different foods by regulatory partners and by industry themselves.
JENNIFER MORCONE: Great. Thank you, Dr. Tauxe. If there are other questions that you’d like to address to us unrelated to the FoodNet data, please feel free to call the press office. 404-639-3286 and we’ll try to help you as best we can. I see that we have one more question. We'll take that last question and then I'll ask our speakers if they wish to add any additional comments they might like to share on this call.
OPERATOR: And the final question is from Marilyn Marchione with “The Milwaukee Journal.” Your line is now open.
QUESTION: Dr. Tauxe, I'm wondering if I can follow up on your comment that levels of contamination in meat and poultry have declined over time. Could you quantify for us roughly what kind of decrease you see?
DR. ROBERT TAUXE: Well, perhaps Dr. Murano would have those numbers immediately available.
DR. ELSA MURANO: Certainly. Certainly. Let me see--we have--of course, we collect regulatory samples that are done as part of our microbial verification to make sure that food safety programs that are in place at these meat and poultry plants are effectively controlling these pathogens. So these are not samples that are taken that are distributed throughout the United States evenly, but they are a measure of trends, we believe, and certainly the fact that the downward trends are matching what CDC is reporting here in terms of illnesses speaks to these trends. They have certainly been valid. With E. Coli 157:H7, for example, in the year 2000, the percent of contamination in products was .86%. And in 2003, which are our latest numbers, it declined to .3%. If you look at it--just compare 2003 back to 2002, just a one year decline, which is basically what CDC is reporting with illnesses from 2002 to 2003, having declined, the presence of E. Coli 157, we have seen also a dramatic decline with .78% positive in 2002, compared to the .3% positive in 2003 that I mentioned a moment ago. When you look at other organisms such as salmonella, which as CDC has reported, there has been a decrease. When you look at a lot of those stereotypes, the salmonella for example, which is typically associated with meat and poultry and other stereotypes like new pork, when you look at those and the regulatory samples which we collect--which again are not distributed throughout the country but they do give us a measure of trend--5.3% of samples were positive for salmonella in general in the year 2000, compared to 3.8% in 2003. So these decreases in the regulatory sample data actually are decreases that we have seen reported by CDC on the illnesses. So it does give us somewhat of a measure. I will add one last thing, which is that we are getting ready to begin what we're calling our baseline studies in the next couple--three months which will seek to do a broad nationwide prevalence study for specific pathogens so that we'll be able to know what is the general prevalence of these pathogens in various areas of the country and how these are maybe affected by season and some other factors.
JENNIFER MORCONE: Thank you very much, Dr. Murano. There is a lot in the report, and I'll ask Dr. Tauxe if there is anything else he'd like to emphasize.
DR. ROBERT TAUXE: Well, let me just say, thank you to you all for your time. I think that FoodNet itself is--has been an innovation in surveillance, an important collaboration among USDA, FDA and CDC and our partners in the state Public Health departments. And it's one of several important improvements in surveillance that we have made in public health, including PulseNet, which improves our ability to identify outbreaks, the ability to do collaborative investigations and tracebacks is better. And those teach us--continue to teach us how to improve our prevention measures. We feel very encouraged by the results released today that shows we are making some progress now with some of our most important foodborne diseases. As I've said before, I think it's too early to--certainly too early to declare victory. And while the decline in E. Coli 0157 infections is promising, this is basically one year change between 2002 and 2003, and more observations, more time is needed to know whether this is going to be sustained. That said, I think the overall trends for these important infections suggest that the efforts by industry, the efforts by individuals, and certainly the efforts in the regulatory arena, seem to have us headed in the right direction.
JENNIFER MORCONE: Wonderful. Thank you, Dr. Tauxe. Thank you, everyone who has called in today. If there are questions related to the STD report, please call 404-639-8895. They'd be happy to help you on resistant gonorrhea. If there is additional questions on the FoodNet data been please feel free to call the main press office here, 404-639-3286. We very much appreciate all of your participation. Thank you.
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