What was fishy about the sushi?

1. What was fishy about the sushi? Epi and Lab working together to crack a cluster Julie Borders, MSHP Emerging and Acute Infectious Disease Branch Foodborne Illness Surveillance Texas Department of State Health Services

2. Program objectives: • Explain why “PFGE” and MLVA tests are important in identifying foodborne illness clusters. • Name a tool used by epidemiologists when conducting a foodborne illness investigation. • Name 3 obstacles to completing foodborne illness investigations.

3. Outline: • Background • Tools used for investigations • Discuss obstacles • 2012 Salmonella Bareilly investigation

4. Background: • Definition of foodborne illness • Agents • Symptoms • Reservoirs • Salmonellosis numbers • Typical scenario • New paradigm

5. Agents commonly transmitted through food : • Clostridium botulinum • Campylobacter jejuni • Escherichia coli,shiga-toxin producing • Listeria monocytogenes • Salmonella, spp. • Shigella, spp. • Typhoid fever (S. Typhi) • Vibrio cholerae – toxin producing • Vibrio, spp. (parahemolyticus, vulnificus, etc.) • Yersinia, spp.

6. Reported cases of Salmonellosis in Texas 1999 - 2011 5

7. Foodborne Illness • ~48 million Americans are victims of foodborne illness every year • 128,000 are hospitalized, and 3,000 die of foodborne diseases.

8. Estimates of burden of foodborne illness acquired in the U.S.1 and Texas 1Scallan E, Hoekstra R, Angulo F, Tauxe R, Widdowson, M, Roy S Jones J, Griffin P Foodborne Illness Acquired in the United States – Major Pathogens. Emerging Infectious Diseases J 2011 Jan;17(1):7-15. 14

9. Surveillance Pyramid 13

10. Surveillance Pyramid

11. Changing paradigms: • Old paradigm – restaurants and church picnics • New paradigm – multi-state outbreaks, failure in food safety network

12. Lab tools: • Serotype • PFGE pattern • MLVA – multiple loci variable number tandem repeat analysis

13. 10

14. PFGE Process http://www.cdc.gov/pulsenet/whatis.htm 11

15. 12

17. DSHS lab 30-day cluster analysis

18. National CODA graph for S. Heidelberg pattern JF6X01.0058 as of 1/23/2012

19. Epi tools – the questionnaires: • Case report • Open ended food history • Hypothesis generating questionnaires • Supplemental questionnaires

21. Obstacles or challenges: • Case finding • Recall bias • Data analysis and information overload • Human resources to investigate and analyze

22. Analysis: • Lab data • Questionnaire data • Compare with a control group • Identify statistically significant differences • Does it make sense?

23. Next step – trace backs and sampling

24. So, what was fishy about the sushi?

25. Cluster Identification

26. Cluster Identification/hypothesis generation

27. Cluster Identification/hypothesis generation

28. Hum - Sushi

29. Cases in Salmonella Bareilly cluster, by state, as of 3/16/12..

30. FDA’s role in the investigation: • Narrow down suspect vehicle • Traceback • Traceforward • Sampling • Work with the firm to recall the product • International Inspection

31. FDA timeline: • 3/1/12 – CDC notified FDA and surveillance team began monitoring • 3/15/12 – FDA CORE Response Team activated - 80% seafood exposure; 55% sushi exposure – got their attention. • 4/2/12 – FDA Incident Management Group mobilized – focused on restaurant clusters, spicy tuna complex because of multiple ingredients

32. Local health departments’ role in the investigation (restaurant clusters): • Initial case reports • Administered questionnaires • Findings: • 11 of 14 cases reported eating sushi • Of those 11, 10 different sushi restaurants were named. • Identified 2 restaurant subclusters • Identified 2 restaurant chains (one different from subclusters)

33. Local health departments’ role in the investigation: • Contact restaurants to obtain • Menus • Invoices • Identify brand names • Common distributors • Orders for comparison study • Maintain good will with businesses

34. The Restaurant Investigation

35. Sushi Order Comparison Results

36. FDA Traceback Challenge • Convergence in recipes?

37. FDA Traceback Targets • Narrowed commonalities to • hot sauce • tuna – fresh & frozen

38. FDA timeline - traceback: • Traceback challenges including: • Cash & carry customers – little documentation • Invoice not clear if fresh or frozen tuna • Invoices not showing correct country of origin • Discrepancies in product descriptions • Lack of labeling

40. FDA timeline – recall & inspection: • 4/13/12 – Moon Marine USA voluntarily issues recall of frozen raw yellowfin tuna product • 4/13/12 to 4/14/12 - FDA issued two Import Alerts for fresh and frozen tuna from Moon Fishery India Pvt Ltd. • 4/19/12 to 4/24/12 - FDA conducted a seafood Hazard Analysis and Critical Control Point inspection.

42. FDA timeline - traceforward: • 4/19/12 to 4/24/12 - FDA identifies where Moon Fishery (India) had sent product. • 4/26/12 - SalmonellaBareilly and SalmonellaNchanga found in unopened packages of yellowfin tuna product imported from Moon Marine USA Corporation. • 5/10/12 - Moon Fishery (India) Pvt. Ltd. recalled its 22-pound boxes of “Tuna Strips”.

43. Conclusions: • Based on epidemiologic data, tracebackand traceforwardefforts, and laboratory results, the source of this outbreak was nakaochiscrape tuna from Moon Fishery (India) Pvt. Ltd. • FDA inspectors identified seafood HACCP deficiencies, including significant sanitation observations of concern.  • Unpurified water used for ice • Hygiene issues

46. As of July 25, 2012: • 425 Salmonella Bareilly infections • 15 SalmonellaNchanga infections • Median age = 30 years (range: <1 to 86 years) • 60% (254/423) female • 17% (55/326) hospitalized • No deaths reported

47. Conclusions: • First multistate outbreak of Salmonella Bareilly and SalmonellaNchanga infections linked to raw scraped tuna product. • First documented outbreak of SalmonellaNchanga infections in United States. • Outbreak was an example of the difficulty in investigating an ingredient driven outbreak. • Collaborative efforts between state and local health departments, FDA, CDC, and laboratories enabled traceback to one producer.

48. Acknowledgements: • CDC PulseNet, DSHS, and Houston laboratories • Local and Texas Regional Health Departments (next slide) • U.S. Centers for Disease Control & Prevention • FDA District Offices • Domestic and International • FDA laboratories • FDA CORE Response Team 2

49. Acknowledgements: • Local and Texas Regional Health Departments • Health Service Regions 3, 6, and 7 • Austin-Travis Co. Health & Human Services • City of Houston Health Department • Dallas Co. Health & Human Services • Denton Co. Health Department • Farmers Branch Health Department • Fort Bend Co. Health Department • Harris Co. Public Health & Environmental Services • Tarrant Co. Public Health Department • Williamson Co. & Cities Public Health Department