Foodborne Disease What's Up

							                     Foodborne Disease
                        What’
                        What’s Up?




                            Michelle Malavet, MSA, HO, REHS
                        Foodborne Disease Surveillance Coordinator
                         NJDHSS – Communicable Disease Service




                     Foodborne Disease
                    Statistics (CDC 1999)

             • 76 million cases/year in USA
             • 325,000 hospitalizations
             • 5,000 deaths
             • Costs estimated at $23 billion
                    (Scharff study $152 billion)


Mead et al., 1999




         Percentage of Foodborne Illness
         Attributable to Various Pathogens

              Bacteria
               30%



         Protozoa
                                                               Viruses
           3%
                                                                67%

Mead et al., 1999




                                                                         1
Top Causes of Foodborne
     Disease - USA
• Norovirus - 66.7%
• Campylobacter – 14.2%
• Salmonella – 9.7%
• Clostridium perfringens – 1.8%
• E.coli – 1.3%
• Staphylococcus – 1.3%




                                   2
Factors Affecting Foodborne
      Disease Trends
 Changes in regulatory approach to
 meat and and poultry safety

  • 1997 USDA Pathogen Reduction/ HACCP systems in
      meat and poultry slaughter and processing plants.
  • Regulatory changes E.coli 0157:H7 and Listeria

 Greater consumer awareness of safe
 poultry handling and cooking methods




Factors in the Emergence
 of Foodborne Diseases
   Changes in agricultural practices
   New methods of food processing,
      especially mass production
     Globalization of food industry
     Changes in consumer behavior
     Changes in consumer susceptibility
     Advances in epidemiology &
      laboratory techniques




                                                          3
New Vehicles of Foodborne
  Disease Transmission




     Produce Outbreaks
      1996-2000 (CDC)
      Vehicle           Agents        Outbreaks   Cases
    Raspberries       Cyclospora        101       2614
      Lettuce       E Coli O157:H7       3         105
                     Cyclospora          1         12
       Basil          Cyclospora         2         400
     Tomatoes         Salmonella          1        86
      Parsley       Shigella Sonnei       1       >400
      Mango           Salmonella          1        78
    Canteloupe        Salmonella          1        43
 Cabbage (Coleslaw) E Coli O157:H7        1        27
   Green Onions       Hepatitis A         1        >40




 Antimicrobial Resistance
 Increased resistance to antibiotics
 seen in E.coli 0157:H7, Shigella,
 Salmonella, Campylobacter
 Antibiotic use on farms
  • Used in absence of illness in animals as
     growth promoter
  • CDC collecting info on resistance through
     NARMS (National Antimicrobial
     Resistance Monitoring System)




                                                          4
     Reportable Foodborne
        Diseases - NJ
Botulism                     STEC (including E. coli
                             O157:H7)
Foodborne intoxications
                             Giardiasis
Hepatitis A
                             Hemolytic Uremic
Foodborne Outbreaks          Syndrome
Amoebiasis                   Listeriosis
Campylobacteriosis           Salmonellosis
Cholera                      Shigellosis
Cryptosporidiosis            Trichinosis
Cyclosporiasis               Typhoid fever
Diarrheal disease (daycare   Vibrio infections other than
attendee/foodhandler)        cholera
                             Yersiniosis




                 Why Investigate?
  Identify possible sources of
    exposure (remove from food supply)
  Identify industry practices that may
    cause foodborne illness and correct
  Identify foodhandlers, healthcare
    workers, daycare attendees and
    workers (prevent spread of disease)




      Changing Patterns of
      Foodborne Outbreaks


 Acute: local               Diffuse: multi-state &
                                       multi-
                             international
 Dose & Attack Rate: high
                             Dose & Attack Rate: low
 Detected: by groups
                             Detected: by lab based
                             surveillance




                                                            5
       Who is responsible for
          investigation?
• Local Health Departments
    – Local point source outbreak
• NJDHSS (CDS and FDSP)
    – Coordinate multi-jurisdictional within NJ
                 multi-
    – NJ Lead in multi-state investigations
                 multi-
    – May be lead agency in multi-state outbreak
                              multi-
• CDC (FDA or USDA)
    – May be the lead in multi-state investigation
                         multi-




Surveillance Tools: Detection
  and Reporting Methods
     PulseNet
     ED Volume
     CDRSS (Communicable Disease
      Reporting and Surveillance System)




         PulseNet Overview
• Nationwide network of laboratories
                pulsed-
    performing pulsed-field gel
    electrophoresis (PFGE)
•   Created after 1993 E. coli O157:H7
    outbreak
•                         fingerprint”
    PFGE is a molecular “fingerprint” that
    helps to identify outbreaks
•   Can identify outbreaks over a wide area
    that might not have been otherwise
    noticed




                                                     6
      How Does PulseNet Work?
                                             disease-
    -PulseNet participants perform PFGE on disease-
    causing bacteria from humans and suspected
    food
    -Once PFGE patterns are generated, they are
    entered into an electronic database
    -The patterns are then uploaded to the national
    database located at CDC
    -CDC performs regular searches, looking for
    clusters of patterns, which are reported to
    epidemiologists for investigation




    Food & Clinical Labs Submit Isolates
     (Salmonella, STEC, Listeria monocytogenes, Shigella)

  Serotyped in Foodborne & Enteric Lab
                 (PHEL)


           PFGE analysis performed


   PFGE patterns submitted to PulseNet




Normalization of Salmonella Berta Gel via Bionumerics




                                                            7
  Annual Reported Cases and Foodborne
Outbreaks of S. Typhimurium US, 1996-2000
                                1996-

20                                                            12000
               Outbreaks
18
               Incidence                                      10000
16

14
                                                              8000
12

10                                                            6000

 8
                                                              4000
 6

 4
                                                              2000
 2

 0                                                            0
        1996     1997      1998         1999       2000




                              CDC, Annual Outbreak Listings




     Linking Sporadic Cases to Outbreaks




 Linking Sporadic Cases to Each Other




                                                                      8
               ED Volume
• Monitor ED volume over time
• Regional epis follow up with
  hospital when volume or
  admissions increase is detected
  (algorithm)
• Clusters of similar disease and
  cases with unusual symptomology
  investigated




                  CDRSS
  Communicable Disease Reporting and
     Surveillance System
  Electronic transfer of lab reports to local
     health departments
  Investigations electronically reported to
     NJDHSS
  Epi links detected from case notes
  Increased number of cases over baseline
     triggers alert to be investigated
  Disease statistics for NJ electronically
     reported to CDC




       What can you do?
 • Promote stool testing for patients with GI
     illness
 • Report via phone any clusters of disease
     with epi links
 • Report via phone increases in disease
     above what you typically see
 • Report via phone individual cases of
     botulism, hepatitis A, food poisonings
     such as scombroid, ciguatera, mushroom
     poisoning
 •   Send isolates to PHEL




                                                 9
 Who do you call to report?

   • Local health department
     where patient resides
   • Regional epidemiologist.
   • NJDHSSS, Communicable
     Disease Service




Foodborne Disease Information

    •   www.state.nj.us/health
    •   www.cdc.gov
    •   www.cfsan.fda.gov
    •   www.foodsafety.gov




    Contacts at NJDHSS

 Communicable Disease Service
              588-
        (609) 588-7500
 Food and Drug Safety Program
               588-
         (609) 588-3123
 After hours emergency hotline:
                392-
          (609) 392- 2020




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