NC nurses important in tracing salmonella outbreak

ASHEVILLE, N.C. (AP) -- It was April 14, and it looked like Susan Creede and the other two nurses in the Buncombe County Health Department's Division of Communicable Disease Control would be working overtime. Again.

Creede and fellow nurses Ellis Vaughan and Kelly McDonald along with their supervisor Sue Ellen Morrison were busy in March, trying to track down a small outbreak of salmonella that sickened at least 12 people.

The bacterial infection isn't unusual. Last year, about 30 people in the county reported getting the common type of salmonella. But this didn't look like it. The symptoms, which normally include diarrhea, fever and abdominal cramps, had been pretty severe.

In extreme cases of salmonella poisoning, people have to take antibiotics or be hospitalized. Some actually die from the disease. In 2005, an Australian girl was left with brain damage after a salmonella infection sent her into a coma.

Luckily, none of the local cases had been that bad, but some had been food service workers, and in a city that depends on the reputation of its restaurants, that can be a problem.

On April 14, after health care workers thought the disease had flared itself out in the county, they realized it was back and spreading.

Creede spoke with the Citizen-Times after it was learned that she and co-workers played a crucial role in nailing down the source of the outbreak that eventually infected at least 46 people, hospitalizing seven. Local businesses also took a hit. It would have been worse except for the investigative work of the communicable disease nurses and their intuitive understanding of residents' eating habits, local public health officials said.

Health officials declined to give identities of those sickened, citing federal health privacy laws. They also declined to say where they worked, including restaurants.

Harris also kept news of the first cases quiet. In March, when the cases rose to five, the official number for an outbreak, she decided not to make an announcement. Later in April, though, when a second wave of salmonella hit Buncombe, she and other health officials turned to the media for help getting the word out to the public.

At the beginning of that second wave, from April 14-20, 10 more people were reported to have contracted the illness.

The nurses kicked into high gear, looking for how it was spreading through food, person-to-person contact or cross-contamination on items such as cutting boards.

They were armed with about five pages of forms from the state with questions they were supposed to ask infected people.

The bacteria is transferred from fecal matter to people's mouths. It can be transferred from foods, diapers and even light switches.

Questions concerned meats, vegetables, fluids, places, people and were "very thorough," said Creede. Still, she thought something was missing.

"With salmonella, we typically think of chicken and eggs," she said. But that wasn't what people said they had been eating.

One problem was that the salmonella they were dealing with had a 30-day incubation period, as opposed to normal salmonella infections, in which people display symptoms in just a day or two. That made it tough for most to remember what they had done or eaten a month ago.

"So, we had people look at debit card bills, credit card bills, calendars. People also have a lot of information on their phones," Creede said.

One thing Creede and other nurses began to notice was how young, healthy and nutrition-conscious many of the people were.

She had similar food preferences, and thought about the types of food she eats. One of her favorite sandwiches, she noted, is made with pineapples, green peppers and cheddar cheese on tempeh, a meat substitute made from a kind of fermented bean patty.

While made of beans, the food is not considered produce because of the way it is changed through fermentation and the growing of a fungal culture. As a raw protein, there is the possibility for bacteria to grow despite the use of vinegar in making it.

"We all did interviews and pretty quickly, we had three reports of that product," she said. "We thought that was very unusual. It's not a common product, not a product that is even listed in our investigation."

On April 23, county health workers notified their state colleagues about the possible link.

Unbeknown to them, five days earlier, on April 18, N.C. Department of Agriculture inspectors made a random visit to the makers of Smiling Hara Tempeh at a commercial kitchen they share with other businesses in Candler.

On April 26, a sample inspectors took during the visit showed the possible presence of salmonella in the tempeh.

While more tests were needed to confirm that salmonella was present, Smiling Hara owners told some 30 vendors, including stores and restaurants, mostly in Asheville, to stop using it.

Smiling Hara Executive Manager Chad Oliphant said the six people the business employs were upset about even the possibility of the bacteria being present. "Our customer base is not just consumers, but families, friends and our community, and it has been heartbreaking, devastating," Oliphant said.

The next day, April 27, lab work showed that the salmonella was a rare type, paratyphi B. That type has two strains, one of which can be more severe. Locally, directions went out for mandatory 30-day periods away from jobs for workers in high-risk categories, such as food service, daycare and health care. Antibiotics were also issued in all cases.

On April 30, the cases were up to 34. Tests came back that day showing salmonella was in fact present in Smiling Hara's tempeh. More lab work was being done to see if the salmonella matched the paratyphi B strain from the outbreak.

The company stopped all production, destroyed any product it had and voluntarily recalled all tempeh made between Jan. 11 and April 11 with best-by dates of July 11 through Oct. 25.

Cases climbed to 46 by May 4, with seven people hospitalized.

Different lab work also brought a mix of news the strain of paratyphi B was not the severe kind, lessening the need for antibiotics and job separations. Also, it was confirmed the salmonella in the tempeh was paratyphi B, meaning it likely was a main source.

That in some ways is less important now, said Harris, because person-to-person contact appears to have become a main avenue of transmission

Smiling Hara personnel say they are now looking at the products they use to make the tempeh since no employees were sick and transmission to the final product in that way is unlikely. Ingredients are simple: either soy beans, black beans or black-eyed peas along with distilled vinegar and a culture.

While the outbreak is troublesome, what was learned, in part from the nurses' work, may boost public health measures around the state.

For one, tempeh may be added to the list of foods about which communicable disease questions are asked, Harris said. Public health personnel might also have to be educated about food popular around Asheville but less known in other parts of the state and Southeast.

"Last Thursday, I was at a health directors' conference in Raleigh and I mentioned tempeh and about two-thirds of them said, `What is that?"' she said.

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