ALBUQUERQUE -- There are the pit bulls, chained and unchained. The scary-looking guy with bloodshot eyes. The 37 houses in a row with people who don't want to talk. The trailers in the middle of the desert with only a TV watching over a couple of kids.
The nation's outbreak of salmonella saintpaul has been going on for four months. At least 1,307 have been sickened, and it's not over yet. As state and federal officials zero in on jalapeoos as the cause, the eventual conclusion of the investigation will be based on painstaking detective work.
It has been slow going, patient by patient, involving hundreds of public health workers nationwide. The information they collect not only will add to the understanding of this outbreak, but it also could open a window on the nature of how food-borne illnesses spread in this country.
Spending two days with two of the investigators dispels any television-inspired, wrapped-up-in-an-hour CSI notion of their work.
Elizabeth Russo, 32, and Kanyin Liane Ong, 28, arrived in Albuquerque two weeks ago, one of three CDC teams sent to New Mexico to interview people who have become sick in the past few weeks. Their mission is to gather data to answer a troubling question: Why did the first surveys done of salmonella patients in New Mexico point so strongly to tomatoes when later cases seemed to implicate jalapeoos?
Russo, a doctor, is one of 70 young scientists admitted each year to the Epidemic Intelligence Service (EIS), a pre-eminent training ground for public health staff.
"This is applied public health," says Ian Williams, chief of CDC's Outbreak Net Team, which tracks illnesses nationally. "The way you learn is you go out in the field, and you do it in the trenches."
In this 16th week of the salmonella outbreak, epidemic teams are in New Mexico, Arizona, North Carolina, Missouri and Houston. Each will spend three weeks to two months going from house to house, asking the same questions: "What did you eat? Where did you eat? Do you remember what you bought at the store?"
It's slow, grueling, sometimes frightening work.
One woman's story
On this bright July afternoon, Russo and Ong have interviewed one salmonella victim and are on their way to the home of Margarita Simental on the outskirts of Albuquerque.
Simental fell ill on July 1. The diarrhea quickly got so bad, two or three bouts an hour, that she couldn't sleep. Her husband and three children stayed away, and no one was allowed near the bathroom she was using for fear that they, too, would catch it.
Ong, who specializes in constructing outbreak databases, begins the interview, methodically going through everything the family might have eaten in the week prior. Simental signs a form that will allow the CDC to access their supermarket loyalty card data to get a complete list of everything they'd bought.
There are certainly faster ways to do this work. "You can get 50 people making phone calls, and then it's done," says Williams. "But we were trying to figure out why it affected New Mexico the way it did. We really needed to get into patients' homes."
It makes a difference. With Russo and Ong sitting in her living room as she goes over her credit card bill, Simental remembers that she also went to Wal-Mart that week, another data point to add to their collection.
The CDC also worried people might not know exactly what cilantro was or be able to tell the difference between a serrano and jalapeoo pepper -- all suspect foods. So the team is equipped with a Rubbermaid container filled with fresh tomatoes, peppers and cilantro they picked up at the local supermarket.
The Simental interview takes about an hour. Then comes the hard part: finding "controls" to interview who are similar to Simental but who didn't get sick.
Frustrating search
Each team does exactly the same thing: They start at the "case house," count three houses to the left and start ringing doorbells. But today it doesn't go well. In this upscale development, few people are at home at midafternoon. It takes knocking on 11 doors before they find someone, but she has a cellphone to her ear and says, "I'm on a conference call, sorry, can't help you," and closes the door.
Another four doors and they come to a house where the garage is open and a man is working on a car. Russo and Ong explain that they're working with the New Mexico Public Health Department to try and find the source of the salmonella saintpaul outbreak and ask if he has any time to help them.
He doesn't. "We don't eat vegetables," he says, and declines to be interviewed.
Four more houses, and there's another person home, but she says, "I always eat out," and is too busy to complete the survey.
It isn't until house No. 30 that someone says she'll let them in to talk. But their excitement quickly cools. Their first question is "Has anyone in the household had diarrhea in the past month?" It turns out the couple's son was sick two weeks back. That puts them in the category of "possibly sick," and they can't be used.
Finally, at house No. 37, a very nice middle-aged woman answers the door and says she's been following the outbreak and would be happy to help them out. She doesn't let them inside, so she speaks from the doorway while Russo and Ong go through their survey. She says no on peppers, no on cilantro, but they have tomatoes at almost every meal. She buys the type still on the vine, which the FDA cleared in June.
That is what's so confounding about this outbreak, which has thus far spawned four large studies. "In the first study, 87.5% of the people (who got sick said they) ate tomatoes," Williams says. But as clusters of illnesses started to show up in restaurants around the country, not all could be explained by tomatoes, and a link to salsa seemed to emerge.
But in the second study, which included 150 cases and 300 controls, only half the cases reported eating salsa, only 33% ate Mexican food, and only 33% reported eating jalapeoos.
Dogged investigators
Ideally, Russo and Ong would approach more houses in the neighborhood to get at least three controls for the one person who was sick, but it's now 6:30 p.m. Earlier in the day, they interviewed a case at the other end of town, and they need to find controls there. They head over in their air-conditioned rental car. To stave off hunger, they munch on a bag of chips, "jalapeoo-flavored, naturally," Russo says.
This neighborhood seems friendlier. It's more down at the heels, but there are kids in the street, an ice-cream truck tinkles by, and a group of teens is playing basketball in a cul-de-sac.
One of the first houses they reach is a gold mine, epidemiologically speaking. Noel Youngbeck is happy to help. When Russo asks what her family ate the week of June 12-19, she says, "Excuse me," steps back in the house, then comes out with a sheaf of papers hooked together with three rings.
Youngbeck has been putting together a weekly menu for her family since before her kids were born. She has an exact record of every meal they ate that week. "This is the mother lode," Russo says.
By 7:40, after five more houses, Ong and Russo are back in the car, contemplating where they can grab some food before heading back to their hotel to spend a few hours inputting the data they've gathered.
The next morning dawns bright and hot. The investigators pack up their car for the two-hour drive to Espaoola.
They stop on the way to pick up Carole Kirby, a nurse epidemiologist with the state who speaks Spanish and who has been in contact with their first case of the day, Toby Trujillo, 62, who lives pretty far out into the desert. He and his wife take an hour to interview. Now Russo and Ong need to find controls.
They drive down to the next roadway and stop in front of the third house they come to, which features a large chained gate.
Kirby, who has 30 years experience working in New Mexico, is horrified. This area, she says, "is where all our hepatitis C cases come from. There are a lot of drugs around here."
No one answers the door.
The road leads to a cluster of trailer homes. The first one is empty. No answer at the second. At the third, a skinny man with extremely bloodshot eyes says vaguely that he's "giving the kids a bath" and can't help them.
A few trailers down a pit bull chained in the yard snarls as Russo and Ong walk toward the door. At the next house, there's an unchained pit bull, and Russo makes a unilateral change to the protocol: Houses guarded by unchained pit bulls will be skipped.
Another road, another group of trailers. Here they find two with kids at home, a TV blaring but no adults. They skip those. Finally, at attempt No. 12, an older woman invites them in.
At 1:30, they're done for the morning. It's taken three hours to interview two people.
Now for the analysis
Over the next two weeks, the teams would interview almost 30 cases and 50 controls. It takes that many to begin seeing real trends, Williams says. Otherwise it's just anecdotes.
This week, the three teams meet in Albuquerque to go over the data they've collected and begin to analyze it. CDC officials hope it will help them understand why so many people are still getting sick in New Mexico, including many people who say they don't eat jalapeoos.
"Is this a dual-vehicle outbreak? Maybe it was tomatoes and jalapeoos in New Mexico and jalapeoos in Minnesota," Williams says. "You can sit in your office and speculate all you want, but it takes people out in the field to really get to the bottom of it."
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