PulseNet Asleep At The Wheel
Jim Prevor’s Perishable Pundit, October 12, 2006
The LA Times did a really interesting piece that traces the origin of the spinach recall. You can read it here. Two things stand out:
First, they actually were thinking about the produce industry:
During the first major conference call about the outbreak, public health officials from the CDC and afflicted states laid out their evidence to the Food and Drug Administration that spinach was the source of the deadly bacterium.
But no one had discovered a smoking gun: a bag of the leafy green vegetable from a patient’s refrigerator from which microbiologists had actually grown the correct strain of E. coli.
Jeffrey Davis in Wisconsin reminded his fellow health officials of the strawberry scare of 1996. In that case, hundreds of people in nine states and Toronto were sickened by an outbreak of cyclospora, a parasite that causes intense diarrhea, weight loss and fatigue.
Epidemiologists in Houston, where more than 100 had fallen ill, fingered California strawberries. The real culprit, it later turned out, was raspberries from Guatemala. But by the time scientists realized their mistake, Golden State growers had lost between $20 million and $40 million.
“The strawberry industry has never forgiven us,” Braden said.
The stakes were high.
If they waited to warn the public until they were absolutely certain that spinach was the culprit, more people could get sick and die. But if they went public and were wrong, an innocent industry could be devastated.
Second, the team that runs PulseNet, which we dealt with here and is our nation’s major mechanism for tracking foodborne illness, whether caused by terrorism or error, TAKES OFF FOR THE WEEKEND:
Wisconsin public health officials knew they had a serious problem. They also had a responsibility to alert health officials in other states in case the outbreak was larger than they knew
So on Friday, Sept. 8, microbiologist Linda Machmueller sat at her computer in the Wisconsin State Laboratory of Hygiene in Madison and posted a terse message on PulseNet, a federal Web board run by the Centers for Disease Control and Prevention that allows scientists around the country to communicate about possible disease outbreaks.
“Wisconsin has a cluster of 8 E. coli O157:H7,” she typed, including seven local cases and one from Illinois. They all appeared to “match the pattern” for a strain of the organism that the U.S. Department of Agriculture had isolated earlier in hamburger patties from Texas. The microbiologist attached a copy of the deadly organism’s DNA fingerprint.
She had no idea what would happen next. “You never know when you post these things if it’s going to amount to anything,” she said.
The Wisconsin posting landed on PulseNet at 5:14 p.m. EDT, after everyone at the Web board’s Atlanta headquarters had gone home for the weekend. So it wasn’t until Monday, Sept. 11, that database manager Molly Joyner read the brief note, checked the DNA fingerprint and began trying to figure out what was going on.
PulseNet, as Wisconsin’s Davis puts it, is a little “like a dating service for bacteria.” It allows public health labs throughout the country to compare the organisms they’re seeing with those being found in other states.
The bacterium isolated in the Wisconsin outbreaks was not a highly unusual strain. Two or three cases a week are commonly posted on PulseNet.
But by the end of the day on Sept. 11, Joyner had discovered that nine states had posted single matching E. coli samples to PulseNet in the weeks leading up to the Wisconsin cluster, although it was unclear if they were connected. And Minnesota e-mailed that afternoon with yet another match.
This was clearly a national outbreak.
It boggles the mind. Talk about irresponsible and stupid — foodborne illness doesn’t just happen on week days. The failure to monitor the bulletin board means that a crisis that could have been caught Friday night wasn’t dealt with until Monday.
That delay may have killed people. And if a terrorist properly times an attack on the food supply on Friday evening, what happens? Do we give him a weekend head start?
This has to be rectified. Now.