Germs No Match For Montgomery's Nurse Detectives

By Steve Hendrix
Washington Post Staff Writer
Monday, August 18, 2008

Summer in the suburbs. For the innocent, that means cookouts, swimming, fresh produce, maybe a trip to the beach. But sunny fun has its dark side, and that means suspect potato salad, tainted pool water, toxic weeds, maybe a trip to the doctor because of "something I ate."

And when summer sickens, that's a job for Montgomery County's nurse detectives -- CSI: Diarrhea.

"It's a little bit crazy at this time of the year," said Cindy Edwards, a registered nurse and manager of the Silver Spring-based Disease Control team, a unit of Montgomery's Department of Heath and Human Services. "People are outside, they are playing with pets, they are going to picnics, children are at sleepover camps, little kids get sick in the swimming pool. There are a lot of ways for outbreaks to get started."

Edwards's squad is charged with investigating food poisonings, animal bites, waterborne illnesses and other infectious-disease cases that could, potentially, spin into a countywide threat. By questioning patients, keeping tabs on lab results from all over the county and sleuthing out the sources of salmonella, E. coli and other bugs, these five nurses in lab coats are the thin white line between Montgomery's million human residents and countless trillions of dangerous germs.

"We're always just a phone call away from a disaster," said Carol Jordan, who oversees the program as the health department's director of communicable disease and epidemiology.

Jordan's office also manages the county's tuberculosis, HIV and pandemic flu preparedness programs. But for the nurse detectives, the outbreaks tend to be of a smaller scale. Although the nurses won't reveal specifics, here are some cases from the Montgomery archives:

· When three unrelated people in the same Zip code recently had infections, the nurses walked the victims back through their recent eating until they came across a neighborhood restaurant common to them all. It got a visit from county health inspectors. The problems didn't recur.

· An investigator once noticed the same brand of pâté d' foie gras in the refrigerators of two women who had suffered miscarriages, which led to the discovery of an entire batch of the delicacy contaminated with lysteria bacteria and the closing of the plant that manufactured it.

· When a stray kitten turned out to be rabid, the nurses traced more than 700 people who might have played with the cat when it was up for adoption at a veterinarian's office.

· When a youth group visiting Washington saw one child after another fall sick in a Montgomery hotel, investigators sniffed around until a janitor tipped them to the key event: a child had vomited near the group's collected luggage on the day of their arrival.

"You could track it from that point," said Holly Conners, an investigator. She and her colleagues then went into containment mode, advising group leaders on keeping the sick children isolated and directing the hotel on how to clean what was probably a norovirus. "Nobody else got sick. We stopped it there."

Most of the time, an investigation begins when a medical lab alerts the team that the blood or stool sample of an area patient has tested positive for one of 68 listed agents and diseases, including cryptosporidium, salmonella, giardia and hepatitis. The nurses frequently compare the reports they've seen, looking for patterns and any sign of an outbreak.

"Two or three times a day, you see them gathered in the hallway, brainstorming," Jordan said.

Last month, when four lab slips from one part of the county came in showing shigella -- a waterborne agent that causes severe diarrhea and cramps -- the nurses began cross-checking reports and calls they had received individually. That led them to a company picnic that, they would learn, had sickened more than 30 kids. The source of the bacteria was found to be an inflatable water slide, possibly contaminated by a child's dirty diaper.

"Often, we never know where it comes from originally," Edwards said. "Our goal is to identify it and put some measures in place to prevent its spread."

Most of the detective work is done by phone, and a lot of that is leading patients through the tricky process of remembering where they've been and, more difficult, what they have eaten for the past week.

"The food histories can be tough," investigator Sue Wilby said. "The first one I ever did was with a person who was on Weight Watchers and kept a log of every bite she ate. I've never had one that easy since."

Patients also tend to the start the process with some firmly fixed ideas of what made them sick. They are quick to blame restaurants rather than their own kitchens. And they assign themselves powerful diagnostic powers.

"They say, 'I knew that food didn't taste right,' " investigator Celia Adams said. "But taste has nothing to do with it. Tainted food usually tastes perfectly normal."

Every now and then, some serious fieldwork is called for. One of those incidents occurred earlier this summer when six members of a Gaithersburg family ended up in intensive care after eating homemade stew. Edwards and her team found themselves confronted by "the Case of the Backyard Belladonna."

When the adults were taken to Shady Grove Adventist Hospital with nausea and hallucinations, first reports blamed mint leaves from the family's yard, which medical technicians suspected were tainted with organophosphate pesticide. The nurse detectives weren't so sure.

"That didn't quite feel right," Conners said. As the patients lingered in serious condition, the Disease Control team began its own investigation, in consultation with state officials and attending doctors. Finally, with a botanist in tow, Edwards and Jordan talked a family member into giving them a tour of the scene.

"The pan with the stew was still on the stove," Edwards said. "It looked like no one had been there since the night of the dinner."

In the back yard, they found an overgrown garden and, off to one side, some strange, recently cut stalks. Edwards pointed them out to the botanist, Charles Schuster of the Maryland Cooperative Extension service. "That's jimson weed!" he cried.

In the kitchen trash, they found more jimson leaves mixed up with other food scraps from the stew. A state lab in Annapolis rushed an analysis and confirmed that the family, all of whom recovered after several days in intensive care, had been poisoned by a weed that packs powerfully toxic belladonna alkaloids.

"We don't get many of those 'Aha!' moments," Edwards said.

If the nurses' work is more office-bound, it is often more delicate. Much of the investigators' work is done after the physical symptoms are gone. And although the victims might still be contagious, they don't always have patience for prying questions.

"The health department doesn't usually call with good news," Wilby said. "We have to be tactful."

The nurses often have to tell people that, according to the law, their child might have to stay out of child-care for another week or 10 days after the symptoms have passed. If others in the house work in food handling, health care or other sensitive jobs, they, too, might have to miss work, even if they never show sign of illness.

"There's an art to these interviews," Conners said. "You want to get the name of the day-care provider up front."

Jordan remembers a recent case in which nurses were backtracking the movements of a woman who died of meningitis. When they learned she had been on a business trip, they interviewed everybody else at the meeting to see, basically, whether she had any kissing colleagues.

"Sometimes we have to have to be very personal in our questioning," Jordan said. "But it's in their best interest to be honest with us."