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.
In 2011, a multistate foodborne illness outbreakii of infections caused by Salmonella Heidelberg bacteria sickened 136 persons in 34 states. Thirty-seven people were hospitalized, and one person died. However, these numbers represent only those illnesses actually reported to public health authorities. Based on CDC estimates, due to the underdiagnosis of salmonella5 (see Figure 2), this outbreak could have sickened 4,000 people nationally. In addition, the outbreak’s strain of Salmonella Heidelberg was resistant to several commonly prescribed antibiotics.6
Pew staff reviewed and analyzed a series of public documents regarding the 2011 Salmonella Heidelberg outbreak and the health community’s response to it, including detailed timelines produced by CDC. Reports and data collected by the Association of Public Health Laboratories (APHL) and peer-reviewed literature that describes the current system for foodborne disease surveillance in the United States were also evaluated. Pew based its observations, conclusions, and recommendations on its staff’s professional expertise, as well as on detailed correspondence, conversations, and input from many stakeholders involved in public health, the food industry, and its regulation.
Craig Hedberg, Ph.D., Division of Environmental Health Sciences, University of Minnesota School of Public Health, and Ian Williams, Ph.D., chief of the Outbreak Response and Prevention Branch of the National Center for Emerging and Zoonotic Infectious Diseases at CDC, peer-reviewed the report. Hedberg served on Cargill’s expert review panel assembled post-outbreak to review the company’s entire process from live-animal operations through ground turkey production. Williams heads the CDC team that investigates all multi-state outbreaks of foodborne illness. Additional reviewers included staff with the U.S. Food and Drug Administration, U.S. Department of Agriculture’s Food Safety and Inspection Service, CDC, APHL, and Cargill Meat Solutions Corp.
Multistate outbreaks of foodborne illness such as this are only about 1 percent7 of those reported to CDC each year.iii However, because they involve illnesses nationwide and over a single time period, these events tend to attract the attention of consumers, the news media, and policymakers. According to CDC, these outbreaks have been identified more easily in recent years due to improved surveillance of foodborne disease resulting in detection of a cluster of illnesses that previously would have been missed. Additionally, these outbreaks could be occurring more often because of our increasingly centralized food supply, which results in contaminated products being shipped to many states, making people ill across the country.8
A goal in any outbreak investigation is to quickly identify the contaminated food and remove it from the market; the faster this is done, the fewer people will get sick, because contaminated food will remain in stores and pantries until a recall is widely publicized. The timeline for the Salmonella Heidelberg outbreak reveals that, while the first person became ill Feb. 27, 2011, the contaminated food source — ground turkey processed at Cargill Meat Solutions' plant P-963 in Springdale, AR — was not identified until 22 weeks later. On Aug. 3, Cargill undertook one of the biggest poultry recalls—approximately 36 million pounds of ground turkey products. (See Figure 1 for a detailed timeline of the outbreak.)
ii - An outbreak occurs when two or more people get the same illness from the same contaminated food or drink.
iii - The vast majority of outbreaks are restricted to a county or a state and traditionally do not substantially involve CDC, which focuses only on multistate incidents.
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).
11. Contamination with Microorganisms; Process Control Verification Criteria and Testing; Pathogen Reduction Standards; 9 C.F.R. 381.94.
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.
15. “Reports of Selected Salmonella Outbreak Investigations,” Centers for Disease Control and Prevention, accessed June
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.
17. Batz et al., “Ranking the Risks: The 10 Pathogen-Food Combinations With the Greatest Burden on Public Health,”
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.
35. “FDA Warns Consumers Nationwide Not to Eat Certain Types of Raw Red Tomatoes,” U.S. Food and Drug Administration, accessed June 18, 2012, www.fda.gov/ NewsEvents/Newsroom/PressAnnouncements/2008/ ucm116908.htm.
36. Scharff, “Economic Burden from Health Losses Due to Foodborne Illness in the United States,” 123-131.
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