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Foodborne Disease Surveillance in the United States. Dubai February 17, 2014 Donald J. Sharp, MD, DTM&H CDC, Atlanta. The findings and conclusions in this presentation are those of the author and do not necessarily represent the views of the Centers for Disease Control and Prevention.

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Foodborne Disease Surveillance in the United States


February 17, 2014

Donald J. Sharp, MD, DTM&H

CDC, Atlanta

The findings and conclusions in this presentation are those of the author and do not necessarily represent the views of the Centers for Disease Control and Prevention

what is surveillance
What is “Surveillance”?
  • The systematic ongoing collection, analysis, interpretation and dissemination of data for public health action
  • Can be “passive” or “active”
purposes of foodborne disease surveillance
Purposes of Foodborne Disease Surveillance
  • Detection of sporadic cases of foodborne illness
    • FoodNet
  • Detection of outbreaks of foodborne illness
    • Local outbreaks
      • Complaints of foodborne illness (common)
      • Lab-based serotyping sometimes finds outbreaks
    • Multistate outbreaks
      • PulseNet: laboratory-based system
      • OutbreakNet: Network of epidemiologists
what is foodnet
What is FoodNet?
  • Foodborne Diseases Active Surveillance Network
  • Established in 1996
  • Collaborative project among
    • CDC
    • United States Department of Agriculture-Food Safety Inspection Service (USDA-FSIS)
    • Food and Drug Administration (FDA)
    • 10 participating state health departments

FoodNet Sites 2014

46 million (~15% of U.S. population)


FoodNet Objectives

  • Determine the burdenof foodborne illness in the United States
  • Monitor trends in the burdenof specific foodborne illness over time
  • Attribute the burden of foodborne illness to specific foods and settings
  • Develop and assess interventions to reduce the burden of foodborne illness
foodnet surveillance
FoodNet Surveillance
  • Active surveillance for laboratory-confirmed infections at >650 clinical laboratories
    • Salmonella, Shigella, Campylobacter, Shiga-toxin producing E. coli, Listeria monocytogenes, Yersinia enterocolitica, Vibrio, Cryptosporidium and Cyclospora
  • Active surveillance for hemolytic uremic syndrome (HUS)
pyramid of surveillance1
Pyramid of surveillance

Lab-confirmed case reported

Lab identifies pathogen

Sample submitted to lab

Doctor requests sample

Person goes to doctor

Person has symptoms

monitoring trends over time
Monitoring Trends Over Time
  • Use negative binomial regression model to account for:
    • Increase in number of participating sites
    • Site-to-site variation in incidence
    • Calculate confidence intervals
  • Measure change in incidence compared to 1996-1998 baseline

FIGURE 1 . Relative rates of laboratory-confirmed infections with Campylobacter, STEC*O157, Listeria, Salmonella, and Vibrio compared with 1996-1998 rates, by year – Foodborne Diseases Active Surveillance Network (FoodNet), United States, 1996-2012†

* Shiga toxin-producing Escherichia coli.

† The position of each line indicates the relative change in the incidence of that pathogen compared with 1996-1998. The actual incidences of

these infections cannot be determined from this graph.

outbreak detection illness complaints
Outbreak Detection: Illness Complaints
  • Data collection content
    • Collect basic demographic information
    • Clinical information
    • Date/time of onset
    • Food history, 3-day or 5-day
    • Restaurants
  • Data collection system
    • Paper-based
    • Electronic, web-based
outbreak detection laboratory based surveillance
Outbreak Detection: Laboratory-based Surveillance
  • Serotyping
  • PulseNet: laboratory information
  • OutbreakNet: epidemiologists

Peter Gerner-Smidt, MD, DMS

Enteric Diseases Laboratory Branch

Centers for Disease Control & Prevention

Atlanta, GA, USA


National Molecular Subtyping Network for Foodborne Disease Surveillance

  • Connects cases of illness nationwide
  • Allows us to find outbreaks we never knew existed
  • Changed our understanding of the epidemiology of Foodborne Disease

Developed: 1996

pulsenet data analysis searching for clusters
PulseNet Data Analysis: Searching for Clusters
  • State health depts submit patterns electronically
  • CDC searches for similar patterns in past 2-4 months
  • CDC compares patterns visually
  • When cluster identified, PulseNet contacts epidemiologists

Cluster of indistinguishable patterns


Outbreaks and Incidence of Reported Cases of Listeriosis, 1978-2008, United States






Number of outbreaks/incidence per million























Multistate outbreak Single state outbreak Incidence

Incidence data from active surveillance systems (FoodNet since 1996)

Outbreaks of confirmed Listeria monocytogenes reported to CDC (eFORS)



Before and After PulseNet

1993 Western States E. coli O157 Outbreak

outbreak detected 1993726 ill, 4 deaths

39 d

2002 Colorado E. coli O157 Outbreak

outbreak detected 2002 44 ill, no deaths

18 d


PulseNet Europe





PulseNet Asia Pacific


Latin America &


PulseNet Middle East

PulseNet Africa

As of October, 2010, 82 member countries from 7 National and Regional PulseNet Networks

outbreaknet cdc s foodborne disease outbreak response team
OutbreakNet: CDC’s Foodborne Disease Outbreak Response Team

Supports a national network of epidemiologists and other public health officials who investigate outbreaks of foodborne, waterborne, and other enteric illnesses in the United States

Collaboration between CDC and

U.S. State and local health departments

U.S. Department of Agriculture (USDA)

U.S. Food and Drug Administration (FDA)

Works in close partnership with PulseNet

The national molecular subtyping network for foodborne disease surveillance

Helps ensure

Rapid, coordinated detection & response to multi-state enteric disease outbreaks

Promotes comprehensive outbreak surveillance

Focal scenario

Large number of cases in one jurisdiction

Detected by affected group

Local investigation

Local food handling error

Local solution

The Spectrum of Foodborne Disease Outbreaks

  • New dispersed scenario
  • Small numbers of cases in many jurisdictions
  • Detected by lab-based subtype surveillance
  • Multistate/Country investigation
  • Industrial contamination event
  • Broad implications

Coordination among multiple states, agencies, and countries is critical

foodborne disease outbreak investigations
Foodborne Disease Outbreak Investigations

Goals of investigations

Immediate control of outbreak and prevention of illnesses

Provide opportunities to identify gaps in food safety systems

Outbreak epidemiology changing

Globalization, centralization, industrialization

Number of possible outbreaks detected has grown substantially

Effective investigations key to reducing burden of foodborne disease

Identify food vehicles and factors which lead to outbreaks


Patient BecomesIll


Case Confirmedas Part ofOutbreak

Inherent Delays in Surveillance

Timeline for Reporting Cases

Patient EatsContaminatedFood

1 – 3 days

Contact with health care system: 1 – 5 days

Diagnosis: 1 – 3 days


Shipping: 0 – 7 days

Serotyping & DNA fingerprinting: 2 – 10 days

Public HealthLab ReceivesSample

flow of pulsenet multistate cluster investigations
Flow of PulseNet Multistate Cluster Investigations

Submission of PFGE patterns by state to CDC PulseNet

Cluster identification by CDC PulseNet

CDC PulseNet Epi Liaison

Epi Investigation

Food Vehicle Identified

Regulatory Activity

enteric clusters by source of report to cdc outbreak response and prevention branch 2013 n 221
Enteric clusters by source of report to CDC Outbreak Response and Prevention Branch, 2013 (n=221)

Most clusters are reported to CDC via PulseNet

Source of Report


Human Specimen Isolates Uploaded to PulseNet USA and Identified Clusters, 1996-2013†

† Data are preliminary and subject to change

* data type information may not be complete for these years


Average weekly number* of clusters CDC Outbreak Response Team followed by month and pathogen, February 1, 2008 – December 31, 2013

* Number per week averaged over a month period

Identifying new vehicles in multistate outbreaks21 new vehicles identified in multistate outbreaks since 2006

bagged spinach

carrot juice

peanut butter

broccoli powder on a snack food

dog food

pot pies/frozen meals

canned hot dog chili sauce

fresh hot chili peppers

black pepper

Tahini sesame paste

raw cookie dough

aquatic water frogs

fresh papaya

frozen mamay fruit pulp


in-shell hazelnuts

  • pine nuts
  • par-cooked, broiled chicken livers
  • scraped tuna
  • cashew cheese
  • sugar cane juice
thank you
Thank You!

Don Sharp