The Los Angeles County Health Services Department was slow in alerting Los Angeles-area doctors to the outbreak of a deadly disease linked to contaminated Mexican-style cheese, according an internal audit made public Wednesday.
The audit, conducted by two outside medical consultants, found that local physicians should have been advised to check for listeriosis in patients as early as mid-May, because of an unusual number of such cases, particularly in pregnant Latino women and their newborn infants, that were being reported at County-USC Medical Center.
"It is particularly important that physicians in the community be kept aware of developments in communicable disease surveillance," the consultants wrote.
The findings supported a complaint voiced last month by the Los Angeles County Medical Assn. that the health department was lax in not utilizing the association's computerized network to notify doctors quickly about the outbreak.
Health officials did not link the bacteria, Listeria monocytogenes, to cheeses manufactured by Jalisco Mexican Products Inc. until June 12. The following day, officials announced the link at a press conference, Jalisco shut down its Artesia cheese processing plant and the company issued a voluntary nationwide recall of its products.
The audit also found:
- The mandatory recall of Jalisco products revealed a complicated jurisdictional decision-making process between county, state and federal agencies. The consultants said the state apparently has primary jurisdiction for recalls but urged the county to take an active role in streamlining the recall process.
- The department had difficulty contacting listeriosis patients at the outset and lacked bilingual interviewers to administer questionnaires to Spanish-speaking patients.
- The acute communicable disease unit suffered from chronic understaffing and underfunding. The audit noted that at the time of the listeriosis outbreak, the county also was hit by outbreaks of hepatitis A and salmonellosis.
- The unit followed "sound" epidemiological procedures in tracking down the contaminated cheese.
- The consultants, addressing the fact that health officials took off the first weekend after the recall, said the decision to do so was "appropriate," because a first-day response rate showed that 97% of the food outlets surveyed took the products off their shelves. However, the inspectors checked only a small sample of outlets in making their estimate.
"There were, however, delays and confusion in the recall procedure which can be attributed to spotty supervision of the recall procedures at Jalisco and unavailability of essential records of brand types sold," the audit concluded.
The two epidemiologists who conducted the audit were Dr. Walter F. Schlech, assistant professor of microbiology and preventive medicine at Dalhousie University in Halifax, Nova Scotia, and Dr. Alexander D. Langmuir, a medical consultant to the World Health Organization and various local and state health departments.
Health Services Director Robert C. Gates, in a letter to the Board of Supervisors accompanying the audit, said the consultants turned up a number of areas where the agency could have improved its handling of the listeriosis crisis, and he called for a comprehensive notification system that would let the public know within 24 hours of an outbreak being verified.
"Although the epidemiological process itself appeared to have been conducted in an appropriate and effective manner, there are a number of related functions and activities that should be upgraded to improve the overall management of disease outbreaks in the future," Gates wrote the supervisors.
He said the audit turned up a reluctance on the part of the acute communicable disease staff to notify upper management of outbreaks for fear that misstatements could be made by premature release of the information to the news media.
"I believe it is not appropriate to let such a concern preclude timely and complete disclosure to management, particularly since withholding of such information inhibits the decision-making process as to resource allocations and external communications," Gates said.
The audit was begun after the Board of Supervisors expressed concern that too much time might have passed between the time health officials learned of the listeriosis outbreak and the time they linked the bacteria to cheeses made by Jalisco Mexican Products.
Supervisor Kenneth Hahn said he was not satisfied with the warning system, noting that the public was not informed of the contamination until June 13, yet the first cases were detected in early May.
The death toll from listeriosis reached 55 in California Wednesday, when two more cases were reported in Los Angeles County. One of the victims was a 59-year-old non-Latino woman who suffered a chronic illness and the other was a fetus carried by a 36-year-old Latino woman, according to county health department spokeswoman Toby Milligan.
Many of the deaths and illnesses have occurred in pregnant Latino women and their newborn infants, because the cheeses are sold widely in Latino neighborhoods. It is not known, however, how many of the deaths were connected to Jalisco cheese.
Schlech and Langmuir said hospitals could have improved the manner in which they reported listeriosis cases. They noted that one privately run hospital in the county initially refused to take part in the health department's survey of listeriosis cases, despite a written request.
Meanwhile, Gates produced an updated chronology on how the listeriosis outbreak was handled by his department. In it he said an open package of Jalisco cheese was sent May 28, not to the Centers for Disease Control in Atlanta, as he reported to county supervisors last month, but to a state laboratory in Berkeley for analysis. Gates said this was following Centers for Disease Control procedures. On May 30, the package of cheese was forwarded to Atlanta.