A multistate outbreak of Salmonella Heidelberg infections linked to ground turkey in 2011 sickened 136 people, causing 37 hospitalizations and one death. The Pew Charitable Trusts' analysis of the outbreak found numerous inadequacies in the foodborne illness surveillance system that, if addressed, could help to prevent illnesses and, in some cases, deaths.
Salmonella causes more than 1 million foodborne illnesses every year.1 It is responsible for more hospitalizations and deaths than any other type of bacterium or virus found in food, and its health-related costs to the nation run as much as $11 billion a year.2 Food is estimated to be the source of 90 percent of all salmonella infections, and contaminated poultry is believed to be a main culprit.3,4
A multistate outbreak of Salmonella Heidelberg infections linked to ground turkey in 2011 sickened 136 people, causing 37 hospitalizations and one death. The Pew Charitable Trusts' analysis of the outbreak found numerous inadequacies in the foodborne illness surveillance system that, if addressed, could help to prevent illnesses and, in some cases, deaths.
An examination of the timeline for the outbreak reveals that the U.S. Centers for Disease Control and Prevention (CDC) and the U.S. Department of Agriculture’s Food Safety and Inspection Service (FSIS) did not identify the contaminated food source—ground turkey processed at one of Cargill Meat Solutions Corp.'s plants — until 22 weeks after the first person became ill and 10 weeks after CDC detected the outbreak. Cargill's subsequent recall of approximately 36 million pounds of ground turkey products is one of the nation's biggest poultry recalls.
The 2011 Salmonella Heidelberg outbreak linked to ground turkey deserves special scrutiny because it highlights several opportunities to improve foodborne illness surveillance, detection, and response. Pew's examination of this outbreak focuses on three problems in the system as it currently exists:
1. Infections from salmonella are not given enough attention by the public health system and, as a result:
2. Bacteria isolated from retail meat and poultry samples and uploaded onto PulseNet — a national network of labs that shares information on foodborne bacteria — are not identified with the names of the brand and processing plants that produced the samples, nor by their purchase dates.i This is the case for other foodborne pathogens, not just salmonella. Delays in the resolution of outbreaks may occur because investigators who rely on PulseNet to find matches of bacteria in humans and other sources do not have ready access to this identifying information. In addition, without these data, there is no ability to detect when a plant repeatedly produces contaminated products.
3. Government officials often wait until they are relatively certain of a likely source of an outbreak before notifying a company that it may have produced the contaminated food. Waiting for certainty in the 2011 ground turkey case resulted in an outbreak lasting months when, with earlier food industry input, it might have been resolved much sooner and thereby prevented many illnesses.
Based on its analysis, Pew makes three general recommendations for improving salmonella outbreak detection and response. These recommendations could inform the CDC’s charge under Section 205 of the 2011 FDA Food Safety Modernization Act to evaluate how to "enhance foodborne illness surveillance systems."
1. Federal and state officials should make the detection of and response to salmonella outbreaks a
priority by enhancing the surveillance system for these bacteria so that:
2. The U.S. Food and Drug Administration (FDA) should modify the retail arm of the National Antimicrobial
Resistance Monitoring System (NARMS) so that it can be used to help detect and respond to outbreaks. Specifically, FDA should require that information on the brand, processing plant, and purchase date for meat and poultry retail samples be included when the DNA fingerprint of bacteria isolates are uploaded to PulseNet. Moreover, the DNA fingerprints should be uploaded more quickly.
3. FDA, FSIS, CDC, and state authorities must develop a mechanism that facilitates engagement with food companies in the early stages of an outbreak investigation when information, such as production schedules and distribution patterns, could speed identification of contaminated foods.
Pew's recommendations for surveillance improvements target key points in this outbreak investigation in which existing policies and practices resulted in unnecessary delays and preventable illnesses. While resource constraints could make these recommendations difficult for some states to achieve, in light of the staggering health-related costs of foodborne illnesses, stopping outbreaks as soon as possible will save money and protect the public.
i - The samples are originally collected under the retail arm of the National Antimicrobial Resistance Monitoring System, a national public health surveillance system that tracks antibiotic resistance in foodborne bacteria. The NARMS program was established in 1996 as a partnership between the U.S. Food and Drug Administration, the Centers for Disease Control and Prevention, and the U.S. Department of Agriculture. NARMS monitors antimicrobial susceptibility among enteric bacteria from humans, retail meats, and food animals.
1. Elaine Scallan, Robert M. Hoekstra, Frederick J. Angulo, Robert V. Tauxe, Marc-Alain Widdowson, Sharon L. Roy, Jeffery L. Jones, and Patricia M. Griffin, “Foodborne Illness Acquired in the United States — Major Pathogens,” Emerging Infectious Diseases 17 (2011): 7-15.
2. Robert L. Scharff, “Economic Burden from Health Losses Due to Foodborne Illness in the United States,” Journal of Food Protection 75 (2012): 123-131.
3. Shua J. Chai, Patricia L. White, Sarah L. Lathrop, Suzanne M. Solghan, Carlota Medus, Beth M. McGlinchey, Melissa Tobin-D’Angelo, Ruthanne Marcus, and Barbara E. Mahon, “Salmonella enterica Serotype Enteritidis: Increasing Incidence of Domestically Acquired Infections,” Clinical Infectious Diseases 54 (2012): S497.
4. Michael B. Batz, Sandra Hoffmann, and J. Glenn Morris, Jr., “Ranking the Risks: The 10 Pathogen-Food Combinations With the Greatest Burden on Public Health,” 2011, accessed June 14, 2012, www.folio.iupui.edu/bitstream/handle/10244/1022/72267report.pdf.
5. Scallan et al., “Foodborne Illness Acquired in the United States—Major Pathogens,” 7-15.
6. “Investigation Update: Multistate Outbreak of Human Salmonella Heidelberg Infections Linked to Ground Turkey,” Centers for Disease Control and Prevention, accessed June 14, 2012, www.cdc.gov/Salmonella/heidelberg/111011.
7. Rendi Murphree, Katie Garman, Quyen Phan, Karen Everstine, L. Hannah Gould, and Timothy F. Jones, “Characteristics of Foodborne Disease Outbreak Investigations Conducted by Foodborne Diseases Active Surveillance Network (FoodNet) Sites, 2003-2008,”Clinical Infectious Diseases 54 (2012): S503.
8. “Multistate Foodborne Outbreaks: CDC’s Role,” Centers for Disease Control and Prevention, accessed Nov. 9, 2012, www.cdc.gov/outbreaknet/outbreaks-cdc-role.html.
9. “Multistate Foodborne Outbreak Investigations,” Centers for Disease Control and Prevention, accessed June 14, 2012, www.cdc.gov/outbreaknet/outbreaks.html.
10. Pathogen Reduction; Hazard Analysis and Critical Control Point (HACCP) Systems; Final rule No. 144, 9 C.F.R. 304 (July 25, 1996).
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12. Food Safety and Inspection Service, “Nationwide Raw Ground Turkey Microbiological Survey,” 1996, accessed Oct.
11, 2012, www.fsis.usda.gov/OPHS/baseline/rwgrturk.pdf.
13. Section 205 of the FDA Food Safety Modernization Act; Public Law 111-353, 124 STAT. 3885 (Jan. 4, 2011).
14. Scallan et al., “Foodborne Illness Acquired in the United States—Major Pathogens,” 7-15.
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14, 2012, www.cdc.gov/salmonella/outbreaks.html.
16. Batz et al., “Ranking the Risks: The 10 Pathogen-Food Combinations With the Greatest Burden on Public Health,”
2011.
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2011.
18. Centers for Disease Control and Prevention, “Vital Signs: Incidence and Trends of Infection With Pathogens Transmitted Commonly Through Food — Foodborne Diseases Active Surveillance Network, 10 U.S. Sites, 1996-2010,” Morbidity and Mortality Weekly Report 60 (2011): 749-755, accessed Dec. 12, 2012, http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6022a5.htm.
19. Centers for Diseases Control and Prevention, “Healthy People 2010: Final Review,” 2010, accessed June 16, 2012, www.cdc.gov/nchs/data/hpdata2010/hp2010_final_review.pdf.
20. “Healthy People 2020 Topics & Objectives,” Centers for Disease Control and Prevention, accessed June 18, 2012, http://www.healthypeople.gov/2020/topicsobjectives2020/ overview.aspx?topicid=14.
21. Centers for Disease Control and Prevention, “Vital Signs: Incidence and Trends of Infection With Pathogens Transmitted Commonly Through Food—Foodborne Disease Active Surveillance Network, 10 U.S. Sites, 1996-2010,” 749-755.
22. “Healthy People 2010: Final Review.”
23. “Healthy People 2020 Topics & Objectives.”
24. Council of State and Territorial Epidemiologists, “2010 Food Safety Epidemiology Capacity Assessment,” 2010, accessed June 12, 2012, http://www.cste2.org/webpdfs/fseca.pdf.
25. David Boxrud, Timothy Monson, Tracy Stiles, and John Besser, “The Role, Challenges, and Support of PulseNet Laboratories in Detecting Foodborne Disease Outbreaks,” Public Health Reports 125 (2010): 57-62.
26. Ian Williams, e-mail message, Feb. 15, 2012.
27. This data comes from a survey done by the Association of Public Health Laboratories. Out of 55 PulseNet laboratories,
41 agreed to provide their survey information to Pew.
28. Max Levy, Joe Yerardi, and Dustin Volz, “Flawed State Reporting Leaves Consumers Vulnerable,” News21, accessed June 12, 2012, http://foodsafety.news21.com/2011/response/analysis.
29. A video on how contaminated food is identified during an outbreak can be found at http://www.youtube.com/ watch?v=XKD7eNn8bFs.
30. “Multistate and Nationwide Foodborne Outbreak Investigations: A Step-by-Step Guide.” Centers for Disease Control and Prevention, accessed March 8, 2013, www.cdc.gov/outbreaknet/investigations/investigating.html.
31. “Multistate Outbreak of Listeriosis Linked to Whole Cantaloupes From Jensen Farms, Colorado,” Centers for Disease Control and Prevention, accessed June 14, 2012, www.cdc.gov/listeria/outbreaks/cantaloupes-jensen-farms/ index.html.
32. Chai et al., “Salmonella enterica Serotype Enteritidis: Increasing Incidence of Domestically Acquired Infections,” S497.
33. “Making Food Safer to Eat: Reducing Contamination from the Farm to the Table,” Centers for Disease Control and Prevention, accessed June 14, 2012, http://www.cdc.gov/ vitalsigns/foodsafety/.
34. Scharff, “Economic Burden from Health Losses Due to Foodborne Illness in the United States,” 123-131.
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36. Scharff, “Economic Burden from Health Losses Due to Foodborne Illness in the United States,” 123-131.
In January 2011, President Barack Obama signed the FDA Food Safety Modernization Act (FSMA) into law, signaling the first major update to our nation’s food safety oversight framework since the Great Depression. Despite widespread support for the legislation and its implementation, the Obama administration still has not issued all of the proposed rules under FSMA.
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