ST. PAUL -- Three days before Christmas, a call to Minnesota's food-borne illness hotline set off bells: A nursing home had three residents sickened by salmonella.
Salmonella cases had been bubbling up in Minnesota for a month, longer in other states. Here was a potential cluster. Minnesota's food-borne illness team sprang into action. State workers pored over the nursing home's menus, looking for clues. Another case popped up at a different nursing home, then two at a school. More menus were compared.
Within three weeks, Minnesota identified King Nut peanut butter as the culprit, and Peanut Corp. of America as the producer. It was the first big break in a case that has sickened more than 677 nationwide, might have led to nine deaths and has caused one of the largest food recalls in U.S. history, affecting more than 3,000 products.
Without the Minnesota break — and the presence of a cluster of cases from a confined population such as the nursing home's — the outbreak "could have dragged on for who knows how long," says Tom Safranek, state epidemiologist in Nebraska.
Minnesota's prowess in investigating food-borne illness outbreaks — in contrast to less successful efforts by other states — exposes weaknesses in the nation's ability to quickly track and contain outbreaks, food safety specialists say.
That's because the national system for identifying food-borne illnesses relies on the efforts of hundreds of local, regional and state health departments, all with differing capabilities, budgets, priorities and procedures. If an outbreak starts in a region ill-prepared to investigate cases, it may not be stopped as quickly as if it had started elsewhere, food safety officials say.
"People die who don't need to die. It happens all the time in food-borne illness outbreaks," says Michael Osterholm, director of the Center for Infectious Disease Research & Policy at the University of Minnesota, who testified last year before Congress on the issue. "If each state was as effective as Minnesota, more of these could be detected."
Minnesota's fast work has protected the public from contaminated food before. Last year, its team was among the first to blame hot peppers — not tomatoes, the initial suspect — for the largest salmonella outbreak in a decade. In 2007, the team found pot pies to be the source of another salmonella outbreak. In both cases, Minnesota took less than a month to find what turned out to be a confirmed culprit when people had been falling ill in other states for months.
When it comes to food-borne illness investigation, "Minnesota is leap years ahead of … most of the rest of the nation," says James Phillips, head of infectious diseases for the Arkansas Department of Health.
Food-borne illness investigations start after someone gets sick, goes to a doctor and submits a stool sample. If that sample comes up positive for potential food-borne illness, such as E.coli or salmonella, state investigators go to work.
In about three-quarters of the states, patient interviews are done by workers in hundreds of local or regional health departments. In other states, work is centralized at the state level.
In Minnesota, things happen that don't always happen elsewhere. Every salmonella or E.coli victim is interviewed by a state health worker. A standardized form, which takes 25 to 30 minutes to fill out, collects data on activities such as what the person ate during the past seven days, where they bought groceries, traveled or came in contact with animals.
"We assume that every potential case is the first of an outbreak we haven't identified yet," says Carlota Medus, Minnesota state epidemiologist.
In other places, officials won't get deep histories until an outbreak is suspected.
"If somebody calls and says, 'I got sick, and I think it was McDonald's,' nothing happens," says Chris LeFevre, environmental director for Ohio's Carroll County Health Department, which investigates food-borne illnesses. "You need at least two people to start an investigation."
Even with three calls in an afternoon, "Good luck solving that mystery," he says.
By law, Minnesota requires that salmonella samples collected by hospital and clinic laboratories be sent to the state lab for further testing to see if they match other cases nationwide. That's not true for 40% of states, says the Association of Public Health Laboratories.
Minnesota's lab turns test results in one or two days, says Kirk Smith, supervisor of the Foodborne Diseases Unit at the Minnesota Department of Health.
Some state labs batch samples, meaning officials wait for several before they run tests. That saves money, but samples can sit for days, says Ali Khan, assistant surgeon general at the Centers for Disease Control and Prevention, which monitor such illnesses.
Every day, Minnesota's lab issues a report to the state's epidemiologists about new cases, and how they match with older and national ones. That gives a quick read on connections, Medus says.
The epidemiologists direct "Team Diarrhea," a team of seven to nine graduate students. They work afternoons, evenings and Sundays — when consumers are more reachable — to interview victims. They work the phones from one large cubicle in the state's health department headquarters. Snippets of conversation bounce around as they build patient histories.
"Did you vomit?"
"Did you have any diarrhea?"
"Wow. That's a lot."
"Where would you have purchased chicken?"
"What else do you put on the turkey sandwich?"
Often, victims are interviewed twice as patterns emerge. In last year's pepper salmonella outbreak, one of Minnesota's first victims didn't recall eating at a restaurant that eventually pointed to peppers until he was asked about it after other victims mentioned it.
Minnesota "has a lot of best practices … to get to people quickly to find out what they ate," the CDC's Khan says.
Investigation delays can have national implications.
Last year, the pepper salmonella outbreak sickened 1,442. Some states took weeks to interview victims and fully test their stool samples, says Osterholm. In Minnesota, that process typically takes days, Medus says.
Texas accounted for more than one-third of reported cases in that outbreak, the CDC says. In Texas, hospital and clinic laboratories aren't required by law to send salmonella samples to the state lab for testing to see if they match other cases nationwide. Instead, Texas only requests that labs send samples to the state lab, and they're not always sent.
As the pepper outbreak spread, Texas officials e-mailed local health departments and asked them to contact labs to make sure samples were sent to the state. That resulted in a surge of cases that the state had been unaware of, says Susan Neill, state lab director.
Nationwide, almost 10% of outbreak cases took more than a month from when the people fell ill to when they were in a national database, the CDC says. "Faster transfer of bacterial strains to public health laboratories and faster subtyping in those laboratories would result in more timely investigation," the CDC wrote in its report on the outbreak.
The outbreak cost the U.S. tomato industry more than $100 million, according to industry estimates. It wasn't until late July that the Food and Drug Administration warned consumers nationwide not to eat fresh jalapeño peppers. Tomatoes may have caused illnesses early in the outbreak, the CDC maintains.
Many outbreaks are missed
Minnesota also has good resources for tracking outbreaks.
It's one of 10 states that won federal contracts to get extra funds to track food-borne diseases and do related studies. That totals about $500,000 a year per state, the CDC says. In Minnesota, some of that pays for workers who help in outbreak probes. The state spends about $1 million a year to look for and investigate food-borne illnesses, Smith says.
But nationwide, nearly 30% of states in fiscal 2008 had smaller health department budgets than in 2007, and most expected more cuts, the Association of State and Territorial Health Officials reported.
In Columbus, Ohio, public health recently lost 60 of 230 positions, says Teresa Long, health commissioner. During last year's salmonella outbreak, workers were diverted from checking restaurants for compliance with FDA warnings to avoid tomatoes to focus on a diarrheal disease outbreak in the city's pools, she says.
In Kansas, a local health worker might be assigned to interview a potential food-borne illness victim while facing a whooping cough outbreak at a school, says Charles Hunt, interim state epidemiologist. "They (local health departments) have to balance out their priorities," Hunt says. As a result, "I'm sure we do miss some outbreaks," he says.
Nationwide, the CDC estimates U.S. consumers suffer 76 million food-borne illnesses a year. Most aren't reported, the CDC says. For every reported illness, dozens go unreported because people don't see doctors, or doctors don't test for them, the agency says.
Even when outbreaks are noticed, they're not always figured out. Of 1,247 food-borne illness outbreaks tracked by the CDC in 2006, investigators pinpointed a specific food and pathogen in only one-third of the cases, says the non-profit Center for Science in the Public Interest, which tracks outbreaks. "This is only a fraction of a fraction of a fraction of cases," says CSPI's food safety director, Caroline Smith DeWaal. She says most states don't have resources to fully investigate.
If cases aren't fully investigated, outbreaks may be missed. Texas, with 22 million people, reported four food-borne outbreaks to the CDC in 2006. Wyoming, population 500,000, also reported four. Minnesota, with less than one-fourth the population of Texas, reported 79.
"Food safety is about the same everywhere," says Tim Jones, epidemiologist for the Tennessee Department of Health, which reported 30 outbreaks in 2006. "Some states don't have the capacity to look for (outbreaks) and don't recognize them," he says.
Osterholm says more money for food-borne illness detection would pay for itself. For one E.coli case in which someone suffers severe kidney damage, medical costs often top $500,000, he says. He says regional "Team Ds" or a national "Team D" could support local health departments.
The CDC's Khan says more "boots on the ground" are needed to interview victims. State labs need more tools, and states need more databases, he says.
"Unless we make it easier for states to investigate these outbreaks, we won't see an improvement in their ability to prevent and contain them," he says.
Contributing: Barbara Hansen in McLean, Va.; Weise reported from San Francisco