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A Review of Foodborne Illness & an Outbreak Investigation that Lead to a Product Recall. Rashid A. Chotani, MD, MPH Assistant Professor & Director Global Infectious Disease Surveillance & Alert System (GIDSAS) Center for International Emergence, Disaster & Refugee Studies

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A Review of Foodborne Illness & an Outbreak Investigation that Lead to a Product Recall

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A review of foodborne illness an outbreak investigation that lead to a product recall l.jpg

A Review of Foodborne Illness & an Outbreak Investigation that Lead to a Product Recall

Rashid A. Chotani, MD, MPH

Assistant Professor & Director

Global Infectious Disease Surveillance & Alert System (GIDSAS)

Center for International Emergence, Disaster & Refugee Studies

Johns Hopkins Schools od Medicine & Public Health

Phone: 410-614-8330

E-mail: rchotani@jhsph.edu


Significance l.jpg

Significance

  • Foodborne illness is one of the largest preventable public health problem in the world

  • In the US it causes an estimated 9,000 deaths/yr (CDC)

  • 6.5 to 81 mil cases of diarrheal disease/yr

  • Most of the infections go undiagnosed & unreported

Rashid A. Chotani, MD, MPH

GIDSAS-JHU


Sequelae l.jpg

Sequelae

  • Guillain-Barre Syndrome (C. jejuni)

  • Renal Disease (E. coli O157:H7 and other Shiga-like toxin producing bacteria)

Rashid A. Chotani, MD, MPH

GIDSAS-JHU


Contributing factors l.jpg

Contributing Factors

  • Poor foodhandler hygiene (inadequate handwashing, open wounds, etc.)

  • Inadequate cooking of raw products or holding temperatures

  • Cross contamination (equipment/work surface/hands)

  • Improper cooking

  • Food obtained from an unsafe source

  • Inadequate washing of fresh produce

  • Others

Rashid A. Chotani, MD, MPH

GIDSAS-JHU


Events and potential contamination sources during produce processing l.jpg

Events and potential contamination sources during produce processing

Event Contamination sources

Production and harvest

Growing, picking, bundling Irrigation water, manure, lack offield sanitation

Initial processing

Washing, waxing, sorting, boxing Wash water, handling

Distribution

Trucking Ice, dirty trucks

Final processing

Slicing, squeezing, shredding, peeling Wash water, handling, cross-contamination


Enteric host defense l.jpg

Enteric Host Defense

  • Saliva

  • Gastric Acid

  • Intestinal motility

  • Enteric flora

  • Shedding & replication of epithelium

  • Mucus layer

  • Immune system

  • Proteolytic enzymes

Rashid A. Chotani, MD, MPH

GIDSAS-JHU


Changing patterns of foodborne diseases l.jpg

Changing Patterns of Foodborne Diseases

  • Newly identified pathogens, routes & vehicles (e.g. increasing frequency of outbreaks associated with consumption of raw fruits and vegetables)

  • Increasing complexity of of foodborne disease outbreaks

    Old Outbreak ScenarioNew Outbreak Scenario

    acute: local diffuse: multi-state & inter

    dose & attack rate: high dose & attack rate : low

    detected : by groups detected : by lab-basedsurveillance

Rashid A. Chotani, MD, MPH

GIDSAS-JHU


Factors in the emergence of foodborne diseases l.jpg

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

  • Epidemiology & laboratory

Rashid A. Chotani, MD, MPH

GIDSAS-JHU


Foodnet l.jpg

FoodNet

Rashid A. Chotani, MD, MPH

GIDSAS-JHU


The foodborne disease activity surveillance network l.jpg

The Foodborne Disease Activity Surveillance Network

  • Established in 1995 in 5 states - Minnesota, Oregon, Georgia, California, and Connecticut; MD & NY joined the program in 1997

  • Foodborne disease component of Emerging Infections Program (EIP)

  • Collaborative project

    • CDC

    • EIP states

    • USDA

    • FDA

  • Active surveillance system

Rashid A. Chotani, MD, MPH

GIDSAS-JHU


Foodnet goal l.jpg

FoodNet Goal

  • Determine & monitor the burden of foodborne diseases

  • Determine the proportion of foodborne diseases attributable to specific foods

  • Develop a network to respond to new & emerging foodborne diseases

Rashid A. Chotani, MD, MPH

GIDSAS-JHU


Foodnet components l.jpg

FoodNet Components

  • Active lab-based surveillance

  • Surveys of clinical labs

  • Survey of physicians

  • Survey of the population

  • Case-Control studies

Rashid A. Chotani, MD, MPH

GIDSAS-JHU


Classification l.jpg

Classification


Definition l.jpg

Definition

  • Poisoning: results from eating foods containing poisons (chemicals or toxins)

  • Infections: result from eating food containing pathogenic microorganisms

  • Toxin: a poison produced by a living organism

  • Intoxication: disease caused by consumption of food containing toxins

Rashid A. Chotani, MD, MPH

GIDSAS-JHU


Epidemiologic triad l.jpg

Epidemiologic Triad

Agent

Host

Environment

Rashid A. Chotani, MD, MPH

GIDSAS-JHU


Mechanisms of foodborne agents l.jpg

Mechanisms of foodborne Agents

  • Preformed toxin in food = rapid onset of nausea, vomiting, and cramps e.g. S. aureus and Bacillus cereus emetic syndrome

  • Direct tissue invasion = inflammatory diarrhea (often fever &/or bloody stool) e.g. Salmonella, Shigella, Campylobacter, Vibrio parahaemolyticus, Yersinia, andEntamoeba histolytica

Rashid A. Chotani, MD, MPH

GIDSAS-JHU


Mechanisms of foodborne agents20 l.jpg

Mechanisms of foodborne Agents

  • Enterotoxin producing in the gut =noninflammatory (watery) diarrhea e.g. Clostridium perfringens,Bacillus cereus diarrhea syndrome, Vibrio cholerae, and Enterotoxigenic E. coli

  • Neurotoxin producing = e.g. Clostridium botulinum; mushroom, shellfish, ciguatera fish and puffer fish poisioning

Rashid A. Chotani, MD, MPH

GIDSAS-JHU


Etiologic agents of foodborne disease l.jpg

Etiologic Agents of foodborne Disease

1.Bacteria

S. aureus, B. cereus, C. perfringens, C. botulinum, E. coli, Salmonella, Shigella, Streptococcus, Brucella, Listeria monocytogenes, Yersinia sp. Campylobacter sp. Vibrio sp., others

2. Parasites

Protozoa

Giardia, Cryptosporidium, Entameoba histolytica, Toxoplasma gondii, Cylospora, others

Helminths

Trichinella spiralis, Tapeworms (e.g. taenisis, cysticercosis), others.

Rashid A. Chotani, MD, MPH

GIDSAS-JHU


Etiologic agents of foodborne disease22 l.jpg

Etiologic Agents of foodborne Disease

3.Virus

Hepatitis A, Norwalk virus & Norwalk like viruses, others

4. Intoxicants & Chemical Poisons

a) Poisonous plant tissue (jimson weed, rhubarb leaves)

b) Poisonous animal tissues (puffer fish, blow fish, moray eels)

c) Mycotoxins and poisonous fungi (ergot alkaloids, trichothecenes, zearalenone, alfatoxins, poisonous mushrooms)

d) Dinoflagellate toxins (ciguatera fish poisoning, shell fish poisoning

f) Chemicals (pesticides, heavy metals, MSG, drugs, nitrates)

g) Others

Rashid A. Chotani, MD, MPH

GIDSAS-JHU


Bacteria l.jpg

Bacteria

  • Single cell organisms

  • Multiply by single division; can multiply in foods

  • Most common cause of foodborne outbreak

  • Some can produce resistant strains

  • Some may produce toxins in food or gut

Rashid A. Chotani, MD, MPH

GIDSAS-JHU


Parasites l.jpg

Parasites

  • Live on another organism (host)

  • Transmitted through food & water

  • Do not multiply outside host

  • Some require favourable environment to become infectious (e.g. Cyclospora)

Rashid A. Chotani, MD, MPH

GIDSAS-JHU


Viruses l.jpg

Viruses

  • Obliterate intracellular organisms

  • Require host cell to multiply

  • Do not produce toxins or multiply in food

  • Reservoirs are humans

Rashid A. Chotani, MD, MPH

GIDSAS-JHU


Foodborne disease case investigation l.jpg

Foodborne disease Case Investigation

I.Sources of case report

II. Goals of foodborne illness case investigation

III. Information collection

Demographics

Illness information

Exposure information

Miscellaneous information

IV. Interventions & public health actions

Rashid A. Chotani, MD, MPH

GIDSAS-JHU


Source l.jpg

Source

  • Public

  • Laboratory reports

  • Healthcare providers

  • Health departments

  • Other state departments

Rashid A. Chotani, MD, MPH

GIDSAS-JHU


Slide28 l.jpg

Goal

  • Prevent transmission

  • Early detection

  • Understanding outbreak disease epidemiology

  • Evaluate food safety programs

  • Identify high risk food & processes

Rashid A. Chotani, MD, MPH

GIDSAS-JHU


Information l.jpg

Information

  • Timing is ESSENCE

    • Designate team leader

    • Assign responsibilities

    • Obtain maximum information on first contact

    • Use standardized form

Rashid A. Chotani, MD, MPH

GIDSAS-JHU


Information30 l.jpg

Information

  • Demographic

    • Name, address, phone no., age, occupation, gender

  • Illness

    • Symptoms, onset, duration, have they been to a physician

      • Name, Dx, Lab tests, results, Tx

  • Exposure

    • 72 hour food history

      • What was eaten, who else was there, when was the meal eaten, where was the meal eaten, was there anything unusual

Rashid A. Chotani, MD, MPH

GIDSAS-JHU


Definition31 l.jpg

Definition

  • The occurrence of more cases of disease than expected in a given area or among a specific group of people over a particular period of time

  • Single case is considered an outbreak (inclusive)

    • Anthrax, botulism, brucellosis, cholera, diptheria, encephalitis, measles, plauge, polio, psisticosis, human rabies, rubella, trichinosis, typhoid fever, hepatitis A, H. influenza type b, or meningococcal disease

Rashid A. Chotani, MD, MPH

GIDSAS-JHU


Interpretation of outbreak curves l.jpg

Interpretation of Outbreak Curves

  • Common source transmission:

    • Occur via point, intermittent or a continuous source

  • Propagated transmission:

    • Person-to-person transmission

    • Cases increase gradually and than decrease gradually (uncommon foodborne outbreak)

Rashid A. Chotani, MD, MPH

GIDSAS-JHU


Point source outbreak l.jpg

Point Source Outbreak

10

8

6

Catered event

# of Cases

4

2

0

4/1/01

4/2/01

4/3/01

4/4/01

4/5/01

4/6/01

4/7/01

4/8/01

Days

Rashid A. Chotani, MD, MPH

GIDSAS-JHU


Intermittent source outbreak l.jpg

Intermittent Source Outbreak

10

8

6

# of Cases

4

2

0

4/1/01

4/2/01

4/3/01

4/4/01

4/5/01

4/6/01

4/7/01

4/8/01

4/9/01

4/10/01

Days

Rashid A. Chotani, MD, MPH

GIDSAS-JHU


Continuous source outbreak l.jpg

Continuous Source Outbreak

10

8

6

# of Cases

4

2

0

4/1/01

4/2/01

4/3/01

4/4/01

4/5/01

4/6/01

4/7/01

4/8/01

4/9/01

4/10/01

Days

Rashid A. Chotani, MD, MPH

GIDSAS-JHU


Propagated source outbreak l.jpg

Propagated Source Outbreak

10

8

6

# of Cases

4

2

0

4/1/01

4/2/01

4/3/01

4/4/01

4/5/01

4/6/01

4/7/01

4/8/01

4/9/01

4/10/01

4/11/01

4/12/01

4/13/01

Days

Rashid A. Chotani, MD, MPH

GIDSAS-JHU


Analytical epidemiology measures of association case control study l.jpg

Analytical Epidemiology:Measures of association: Case-Control Study

  • Odds Ratio (OR) = odds of exposure in cases

    odds of exposure in controls

    illwell

    Ate suspectedYESa b

    Food item?NOc d

  • OR = ad/bc

    Done when you CANNOT interview everyone

Rashid A. Chotani, MD, MPH

GIDSAS-JHU


Analytical epidemiology measures of association cohort study l.jpg

Analytical Epidemiology:Measures of association: Cohort Study

  • Relative Risk (RR) = attack rate in exposed

    attack rate in non-exposed

    illwell

    Ate suspectedYESa b

    Food item?NOc d

  • RR = [(a/a+b)x100] / [(c/c+d)x100]

    Done when you CAN interview everyone

Rashid A. Chotani, MD, MPH

GIDSAS-JHU


A foodborne outbreak of gastroenteritis in a teaching hospital l.jpg

A Foodborne Outbreak of Gastroenteritis in a Teaching Hospital

Reference: Chotani et al. SHEA Annual Meeting 1998


Hospital l.jpg

Hospital

  • 940 bed hospital with 4 cafeterias.

  • Cafeteria A, located in the OPD, serves approximately 600 visitors and employees daily.

Rashid A. Chotani, MD, MPH

GIDSAS-JHU


Events l.jpg

Events

  • On 12/9/97 individuals who ate at Cafeteria A reported nausea and projectile vomiting after eating a noon meal.

Rashid A. Chotani, MD, MPH

GIDSAS-JHU


Method case definition l.jpg

Method: case definition

Any person who ate lunch prepared at cafeteria A on December 9, 1997 and developed sudden onset of

  • vomiting or

  • diarrhea or

  • abdominal cramps

    and

    Any of the following symptoms including nausea, fever, body aches, headache, chills or fatigue.

Rashid A. Chotani, MD, MPH

GIDSAS-JHU


Method case finding l.jpg

Method: case finding

We identified all cases who identified

individuals who ate with them.

All non-Ill persons were used as

controls.

  • Additional cases were found when we contacted:

    • Nurse managers

    • Hospital managers

    • Directors of nursing, functional unit directors, JHH vice-presidents

    • Several employee groups were notified via e-mail and asked to identify cases.

Rashid A. Chotani, MD, MPH

GIDSAS-JHU


Methods questionnaires l.jpg

Methods: questionnaires

Standard questionnaires were

used to obtain medical and food

history from

  • Food service workers

  • Ill and non-ill employees

  • Menu reviewed at Cafeteria A.

  • Rashid A. Chotani, MD, MPH

    GIDSAS-JHU


    Control measures and interventions cafeteria a l.jpg

    Control Measures and Interventions: Cafeteria A

    Cafeteria:

    • Kitchen was inspected

    • Leftover foods recovered and cultured

    • Food preparation, kitchen cleaning procedures reviewed

    • Certain food items quarantined

    • Employees were interviewed, inspected for sores, boils, cuts, IV tract marks and sent to occupational health services

    • We obtained nares swabs

    • 3 cafeteria staff members submitted stool samples or rectal swabs

    • All staff (n=17) were questioned daily for symptoms

    Rashid A. Chotani, MD, MPH

    GIDSAS-JHU


    Laboratory l.jpg

    Laboratory

    • Food was processed in standard fashion

      • Blood agar plateR/OBacillus

      • CAN plateR/OStaphylococcus

      • Plates for enteric pathogens

        R/O

        Salmonella, Shigella, Aeromonas, Campylobacter, Yersinia

    • Samples sent to city, state, FDA, and commercial laboratory

    • Sequencing preformed

    • Heavy metal testing

    Rashid A. Chotani, MD, MPH

    GIDSAS-JHU


    Results l.jpg

    Results

    • N = 75 (ill = 40; non-ill = 35)

    • Mean age: 39 years (range 25-56)

    • Sex: 85% female

    Rashid A. Chotani, MD, MPH

    GIDSAS-JHU


    Incubation period jhh employees n 40 l.jpg

    Incubation period: JHH employees (n=40)


    Symptoms l.jpg

    Symptoms


    Results outcomes l.jpg

    Results: outcomes

    • Duration of illness: mean--24 hr. (range <24 - 72 hr.)

    • Bedridden62.5%

    • Sought medical care27.5%

    • Hospitalized 2.5%

    Rashid A. Chotani, MD, MPH

    GIDSAS-JHU


    Results univariate analysis l.jpg

    Results: univariate analysis

    Food itemORCI 95%p-value

    Green beans36.46.93,341.60 <0.0001

    Tortellini5.501.03, 54.500.02

    Corn soup0.230.04, 1.100.03

    Veg soup0.230.04, 1.100.03

    Not associated: bread, breadsticks, chicken salad, broccoli salad, cheese salad, caesar salad, havarti cheese, swiss cheese, beef stew, Thai beef, couscous, honey turkey, chicken fingers, cheese pizza, sausage pizza, chow mein noodles, marinated tomatoes, onions, mixed greens, cucumbers, dressing tomato-bacon/peppercorn, creamy, sunflower seeds, crackers, chips, cookies, yogurt, and fresh fruits

    Rashid A. Chotani, MD, MPH

    GIDSAS-JHU


    Results multivariate analysis l.jpg

    Results: multivariate analysis

    VariableORCI 95%p-value

    Green beans1.84 1.49,2.27 <0.005

    Tortellini1.25 0.98,1.59 NS

    Corn soup0.89 0.69,1.16 NS

    Veg soup0.93 0.71,1.21 NS

    Rashid A. Chotani, MD, MPH

    GIDSAS-JHU


    Results laboratory l.jpg

    Results: laboratory

    • Bacillus sp. recovered from garlic mix (opened/unopened jars), Moroccan beef stew and vegetable soup.

    • Bacillus subtilis was identified based on the library profiles.

    • Heavy metals negative.

    • Patient/employees culture negative.

    Rashid A. Chotani, MD, MPH

    GIDSAS-JHU


    Food preparation l.jpg

    Food preparation

    • Frozen green beans steamed for 10 minutes.

    • Seasoned with salt, pepper, olive oil and garlic mix.

    • Baked in oven for 15 minutes at 375 OF.

    • Stored in warmer at 180 degrees.

    • Placed in pan and sent to serving line (140 degrees); maximum time 4 hours.

    Rashid A. Chotani, MD, MPH

    GIDSAS-JHU


    Summary l.jpg

    Summary

    • 40 persons became ill after eating green beans.

    • We under-estimated magnitude of problem because case ascertainment difficult.

    • The symptoms pointed to a toxin mediated illness.

    • The process of preparing green beans with garlic (in soy oil base) most likely led to the illness.

    • Bacillus was isolated from opened/unopened jars.

    Rashid A. Chotani, MD, MPH

    GIDSAS-JHU


    Conclusions l.jpg

    Conclusions

    • FDA

      • Inspected the manufacturing facility

      • Inspected food supplier

      • Ordered recall of all garlic jars produced by company A

      • Mandated new control protocols

    • Aggressive control measures should be taken to prevent the spread of any outbreak particularly in a hospitals in order to protect not just the patients but the staff.

    • Rarely bacillus subtilis has been associated in food poisoning.

    Rashid A. Chotani, MD, MPH

    GIDSAS-JHU


    Slide57 l.jpg

    Thank you

    Rashid A. Chotani, MD, MPH

    GIDSAS-JHU


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