More from the Dec. 9 FDA-USDA traceability hearing. Dr. Tim Jones talks about the variability of state outbreak investigations.


Moderator: What I'd like to do is introduce all of our panel members briefly, and then let them tell you what their role is in outbreak investigations, and you'll hear  directly from them their experiences. And we've asked them to not only identify  the challenges or obstacles, because I think many of us are well familiar with  those, but also when it's possible to suggest changes or improvements to the  systems in which they work. So on our first panel, we have starting from your  left, Dr. Tim Jones, who is the state epidemiologist at the Tennessee Department  of Health and has a very special interest in food safety. He is quite active both  in FoodNet and in the Council to Improve Foodborne Outbreak Response, and Tim has  helped us with past public meetings. So we look forward to his comments.







DR. JONES
: Thank you. I'm going to give a little bit of the sort of local and  state perspective which I really think is the base from which all outbreaks are  investigated and tracebacks are performed. Can we move forward one slide? I guess  just to remind folks, that it's at the local and county health department that  victims or patients are interviewed. I mean really this is the only place that the  people who are sick are spoken to and where that information is gathered. And if  good information is not collected at that level, you know, we can talk until we're  blue in the face about doing tracebacks, but if we start out on the wrong path or  can't get beyond that first stage, then the best, you know, traceback systems in the world will not ultimately help  things.

And so I think the key there is how variable local and state health  departments are, and I know that that's a source of great frustration for  industry, for regulators. It's a fact of life, and I think that if that level of  variability does not get better, that we will have a difficult time improving the process overall. Can I have the next slide, please? So these first couple of  slides just sort of demonstrate that variability. This is the number of outbreaks investigated in 2006 by state, and you can see that there are states that  investigate 200 outbreaks a year and others that investigate less than 1 per year. 

Obviously food is no safer or more dangerous I don't think per capita anywhere in  the country. This reflects completely resources that are available in competing  priorities. Can I have the next slide, please? It's also not by state. It's also over time, within states, and so I'll pick on myself and say that, you know, in  Tennessee we investigated .2 outbreaks per year until we became a FoodNet state.  Now we do 30 or 40 a year, but there are other states that are doing 100 a year.

 So there are, you know, continued resource attention that can be issues and  focused on amount outbreak investigations. Next slide. And then there's great  variability in how successful those outbreak investigations are, and this again  shows variability among states in just the ability to identify the pathogen, the  germ, that's causing the outbreak.

Now, if you can't even identify the pathogen,  it's going to be virtually impossible to identify the food or its source, and up  until recently, only about a third of all foodborne disease outbreaks even had the  pathogen identified. I'll also note here that I can almost guarantee you that if  you look at graphs like this at the end of the year, that all of the numbers will be much lower just because people in county and state health departments are the  same people that are doing HIV and immunizations and TB and for the last six  months H1N1, and almost nothing else including foodborne disease investigations.

 Can I have the next slide, please? I think, you know, some of this jurisdictional  variability has to do with a sense of independence. All public health law or state  and local laws, not national laws, unlike a lot of people believe so, different  procedures were not -I don't think any states are under obligation to follow national guidelines, and  therefore there are immensely different levels of experience communicating both  with CDC and regulatory agencies and industry.

So I think you will have --I know  that there are some states that have probably never ever talked to industry  representatives directly and will rely almost entirely on CDC for investigations.  And then there are some states at the other end of the extreme that I think  probably feel like CDC just gets in their way and would prefer to do everything  directly. And, really, I think that we need to achieve some level of baseline  consistency in order to be fair to industry and ultimately the people that we  serve.

Next slide, please. This is some what tongue and cheek, but it's from a  physician that works in caring for victims of torture and basically says that no  matter how hard you torture people, ultimately they're going to say whatever you  think you want them to say. And I think the point here is that regulators, I  think, very often are extremely frustrated with epidemiologists at the local and  state level and will ask us over and over and over, you don't understand. We need  the lot code. You don't understand. You've got information. You didn't ask the  right question. to go back and get us detailed Yes, we understand.

We can't make  people give us information that they don't have. We can't make them tell us things  that we don't know. And, yes, sometimes there are local jurisdictions that aren't as persistent as we would  like them to be, but the huge majority of the time, patients just don't know. They can't tell you what kind of tomato it was, you know, which bin they got it out of,  where they necessarily bought their lettuce that particular day. Next slide,  please. So, yes, there are limitations in that sometimes information is not  aggressively pursued, but I think that that's actually a minority of the time.  

Next slide, please. This also is a little bit tongue and cheek, but I think it's  going to be an important baseline for the next couple of days of discussions in  that it's epidemiologists that talk to ill people and that are investigating  outbreaks. And yet these discussions have to do very much with sort of the  regulatory realm, and the entire culture of epidemiology is completely different,  the whole mindset is very, very different from that of regulators.

You know, regulators, I mean they have police powers. Lots of lawyers  involved have to adhere to very strict procedures. I think epidemiologists are  viewed much more as loose cannons that do whatever they feel like and are not  beholden to attorneys, that maybe will share information much more freely than  regulators and that have a very low threshold for doing things and saying things  to the media or to patients probably much sooner than regulators or industry would  like. I don't think that's because epidemiologists are malicious.

They're trying  to do the right thing, the important thing. It's important to remember that when  we are working with them and when regulators in industry are working with them,  that it's a very different mindset. Next slide, please. So, I think it's not all  hopeless. I think probably, number one, that training and resources at the local  and state level have to be more level and consistent than they are.

 I also think  that coordination among jurisdictions, while it's gotten a lot better, could be improved even more. You've heard a little bit about FoodNet  and OutbreakNet. Those are organizations that supply funding and some consistency  of education and resources to local health departments, but we need to involve  more than 10 or 12 states in those programs.

There are some independent  organizations that have begun to put out guidelines for outbreak investigations. I  think those are very important now. Getting states to adhere to them will be  important, and improved communication, and again I think many of these  organizations like OutbreakNet have helped states talk to each other. I think, you  know, there's no consistent questionnaire among 50 states for O157 outbreaks or  for Salmonella outbreaks, and that makes it very frustrating for national groups  and agencies that are trying to get consistent information when all of the states  that are investigating an outbreak haven't even asked the same questions.

So I  guess just to summarize, if the information that's being gathered at the local  level is not good information, tracebacks will get nowhere, and I think there are  examples of that, you know, the tomato and jalapeno fiasco, lots of people spent a  lot of time and energy going down the wrong path because the very initial  information from the county and state level wasn't as good as we might have hoped  it to be. I'll make one last note, just to remind people that, you know, half of  all the money we spend, that consumers spend in this country on food and eating is  spent on eating out. I don't think there's anyone from the restaurant industry  that's going to be here talking in the next two days, and if Mom and Pop  restaurants can't tell you what produce they mixed or where they got it from, the  best traceback systems in the world aren't going to go anywhere.

And, finally,  I'll just say that we're spending a whole lot of time talking about outbreaks. Outbreaks are the only chance we really have to identify a food, but 97 percent of  all of the foodborne disease that we investigate is not associated with recognized outbreaks, and if we don't do a better job at that,  we're going to be focusing only on a very small handful of the thousands of  outbreaks that we investigate every year which are local contamination, not  associated with externally or nationall contaminated food.