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Progress and challenges in decreasing foodborne illnesses in the United States

Progress and challenges in decreasing foodborne illnesses in the United States. Patricia M. Griffin, M.D. Chief, Enteric Diseases Epidemiology Branch Division of Foodborne, Bacterial and Mycotic Diseases National Center for Zoonotic, Vectorborne and Enteric Diseases

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Progress and challenges in decreasing foodborne illnesses in the United States

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  1. Progress and challenges in decreasing foodborne illnesses in the United States Patricia M. Griffin, M.D. Chief, Enteric Diseases Epidemiology Branch Division of Foodborne, Bacterial and Mycotic Diseases National Center for Zoonotic, Vectorborne and Enteric Diseases April 12, 2008 Who’s Minding the Store? Seattle, Washington

  2. Foodborne illnesses United States • Estimates for 1997 • 76 million ill • 300,000 hospitalized • 5,000 deaths • Healthy People 2010 targets: 50% reduction (from 1997 to 2010) in • E. coli O157 • Campylobacter • Salmonella • Listeria Mead et al., EID 5:707-25, 1999

  3. Bacteria Bacillus cereus Brucella Campylobacter Clostridium botulinum Clostridium perfringens E. coli O157 E. coli, non-O157 Shiga toxin-producing E. coli, other diarrheagenic Listeria monocytogenes Mycobacterium bovis Salmonella Typhi Salmonella non-typhoidal Shigella Staphylococcus Streptococcus Vibrio cholerae, toxigenic Vibrio vulnificus Bacteria (continued) Vibrio, other Yersinia enterocolitica Yersinia pseudotuberculosis Parasites Cryptosporidium Cyclospora Giardia Toxoplasma Trichinella Trypanosoma cruzii Virus Caliciviruses Rotavirus Astrovirus Hepatitis A Hepatitis E Prions Fungus Aflatoxin-producing Major known foodborne pathogens, 2008

  4. Bacteria Bacillus cereus Brucella Campylobacter Clostridium botulinum Clostridium perfringens E. coli O157 E. coli, non-O157 Shiga toxin-producing E. coli, other diarrheagenic Listeria monocytogenes Mycobacterium bovis Salmonella Typhi Salmonella non-typhoidal Shigella Staphylococcus Streptococcus Vibrio cholerae, toxigenic Vibrio vulnificus Bacteria (continued) Vibrio, other Yersinia enterocolitica Yersinia pseudotuberculosis Parasites Cryptosporidium Cyclospora Giardia Toxoplasma Trichinella Trypanosoma cruzii Virus Caliciviruses Rotavirus Astrovirus Hepatitis A Hepatitis E Prions Fungus Aflatoxin-producing Major known foodborne pathogens, 2008 * Green = recognized as foodborne in past 30 years

  5. Bacteria Bacillus cereus Brucella Campylobacter* Clostridium botulinum Clostridium perfringens E. coli O157* E. coli, non-O157 Shiga toxin-producing* E. coli, other diarrheagenic* Listeria monocytogenes* Mycobacterium bovis Salmonella Typhi Salmonella non-typhoidal Shigella Staphylococcus Streptococcus Vibrio cholerae, toxigenic* Vibrio vulnificus* Bacteria (continued) Vibrio, other* Yersinia enterocolitica* Yersinia pseudotuberculosis* Parasites Cryptosporidium* Cyclospora* Giardia* Toxoplasma* Trichinella Trypanosoma cruzii* Virus Caliciviruses* Rotavirus* Astrovirus* Hepatitis A Hepatitis E* Prions* Fungus Aflatoxin* Major identified foodborne pathogens, 2008 Yellow = “Home” of organism is the animal kingdom

  6. Topics • National networks • National surveillance • FoodNet • Overview • E. coli O157 • Campylobacter • Salmonella • PulseNet • OutbreakNet • Overview • Some recent outbreaks • Example: Salmonella outbreak • Attribution project • Progress and challenges

  7. Topics • National networks • National surveillance • FoodNet • Overview • E. coli O157 • Campylobacter • Salmonella • PulseNet • OutbreakNet • Overview • Some recent outbreaks • Example: Salmonella outbreak • Attribution project • Progress and challenges

  8. FoodNet Sites, 2008 Population 45.5 million (15% of U.S. population)

  9. FoodNet • Although all 50 states conduct surveillance for foodborne pathogens, • methods and data quality vary • Need accurate counts of illnesses to measure trends • FoodNet sites have extra resources • to get reports from clinical labs when ill people submit a specimen (usually stool) for testing, and • to submit those reports to CDC • FoodNet measures trends in common foodborne pathogens • Issues an annual “report card” (MMWR April 11, 2008)

  10. Surveillance data • Surveillance data is the “tip of the iceberg”

  11. Pyramid of Surveillance Reported to health department Pathogen isolated Lab tests for pathogen Specimen obtained Person seeks care Person becomes ill Population exposed

  12. Reported to health department Active surveillance Pathogen isolated Clinical lab survey Lab tests for pathogen } Specimen obtained Population survey Person seeks care Person becomes ill Population exposed Pyramid of Surveillance

  13. Topics • National networks • National surveillance • FoodNet • Overview • E. coli O157 • Campylobacter • Salmonella • PulseNet • OutbreakNet • Overview • Some recent outbreaks • Example: Salmonella outbreak • Attribution project • Progress and challenges

  14. E. coli O157 ingested 3 - 4 days 80% 1 - 2 days 92% 8% 5 - 6 days resolution HUS Sequence of events in E. coli O157 infection non-bloody diarrhea, abdominal cramps bloody diarrhea Mead. Lancet 1998

  15. Hemolytic uremic syndrome (HUS) • Kidney failure, anemia, blood clotting problems • Affects persons of all ages • most common in <5 years old and elderly • ~5% die

  16. 0.90 E. coli O157 infections, incidence by year, FoodNet, 1996-2007 Healthy People 2010 Objective: 1.0 illness/100,000 persons Incidence per 100,000 population 1.20 National objective

  17. Percent ofUSDAground beef samples that yielded E. coli O157:H7, 2000-2007 Outbreak investigation resulted in recall of 18 million pounds ground beef % positive Source: www.fsis.usda.gov

  18. 0.90 E. coli O157 infections, incidence by year, FoodNet, 1996-2007 Healthy People 2010 Objective: 1.0 illness/100,000 persons Incidence per 100,000 population 1.20 National objective

  19. Topics • National networks • National surveillance • FoodNet • Overview • E. coli O157 • Campylobacter • Salmonella • PulseNet • OutbreakNet • Overview • Some recent outbreaks • Example: Salmonella outbreak • Attribution project • Progress and challenges

  20. Campylobacter • Common cause of foodborne illness • diarrhea • paralysis is rare complication • Most illnesses from chicken • that is undercooked, or • that contaminates other foods

  21. Incidence per 100,000 population Campylobacter infections, incidence by year, FoodNet, 1996-2007 Healthy People 2010 Objective: 12.30 illnesses/100,000 persons 12.78 National objective

  22. Topics • National networks • National surveillance • FoodNet • Overview • E. coli O157 • Campylobacter • Salmonella • PulseNet • OutbreakNet • Overview • Some recent outbreaks • Example: Salmonella outbreak • Attribution project • Progress and challenges

  23. Salmonella • Common cause of foodborne illness • diarrhea • severe illness in vulnerable populations • Carried by all food animals • Foodborne illness mainly from • foods of animal origin • vegetables contaminated with fecal matter from animals

  24. Incidence per 100,000 population Salmonella infections, incidence by year , FoodNet, 1996-2007 Healthy People 2010 Objective: 6.8 illnesses/100,000 persons 14.92 National objective

  25. Percent change in the incidence of bacterial infections in 2007compared with the previous 3 years (2004-2006), FoodNet 100 Percent change estimate 95% confidence interval 80 Increase 60 40 20 Percent change No change 0 -20 -40 Decrease -60 -80 -100 Campylobacter Listeria Salmonella Shigella STEC*O157 Vibrio Yersinia • Graph Interpretation • No significant change = The 95% confidence interval is both above and below the “no change” line • Significant increase = The estimate and the entire 95% confidence interval are ABOVE the “no change” line • Significant decrease = The estimate and the entire 95% confidence interval are BELOW the “no change” line

  26. Topics • National networks • National surveillance • FoodNet • Overview • E. coli O157 • Campylobacter • Salmonella • PulseNet • OutbreakNet • Overview • Some recent outbreaks • Example: Salmonella outbreak • Attribution project • Progress and challenges

  27. PulseNet USA • National network of >75 public health and regulatory laboratories • Perform molecular typing of foodborne disease-causing bacteria • current method is pulsed-field gel electrophoresis (PFGE) • create DNA “fingerprints” • Share DNA “fingerprints” electronically • DNA “fingerprints” are sent to database at CDC • Reviewed daily at CDC • available on-demand to participants

  28. PulseNet searches for clusters • State health departments submit patterns electronically • CDC and State labs search for similar patterns in past 2-4 months • compare patterns visually • When cluster identified, PulseNet contacts epidemiologists Cluster of indistinguishable patterns

  29. Topics • National networks • National surveillance • FoodNet • Overview • E. coli O157 • Campylobacter • Salmonella • PulseNet • OutbreakNet • Overview • Some recent outbreaks • Example: Salmonella outbreak • Attribution project • Progress and challenges

  30. CDC OutbreakNet 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 • Mission • Ensure rapid, coordinated detection & response to multi-state enteric disease outbreaks • Promotes comprehensive outbreak surveillance

  31. CDC OutbreakNet Team (continued) • Works in partnership with PulseNet • Involves collaborations between CDC and • State and local health departments • U.S. Department of Agriculture (USDA) Food Safety and Inspection Service (FSIS) • U.S. Food and Drug Administration (FDA)

  32. Outbreaks • Outbreaks that we find and solve are the “tip of the iceberg” • We investigate outbreaks • To take immediate action to protect people • To learn how to prevent similar occurrences

  33. Topics • National networks • National surveillance • FoodNet • Overview • E. coli O157 • Campylobacter • Salmonella • PulseNet • OutbreakNet • Overview • Some recent outbreaks • Example: Salmonella outbreak • Attribution project • Progress and challenges

  34. Lettuce at Mexican-style fast food chain Snack food with vegetable coating

  35. Topics • National networks • National surveillance • FoodNet • Overview • E. coli O157 • Campylobacter • Salmonella • PulseNet • OutbreakNet • Overview • Some recent outbreaks • Example: Salmonella outbreak • Attribution project • Progress and challenges

  36. Increase in Salmonella Tennessee illnesses • August to December 2006 • gradual increase in ill persons over expected number • December 2006 • epidemiologists interviewed some ill persons • found no common exposures

  37. States where patients with the outbreak strain of Salmonella Tennessee lived (as of December 1, 2006) PulseNet found more than the expected number of this strain of Salmonella

  38. States where patients with the outbreak strain of Salmonella Tennessee lived (as of December 1, 2006) PulseNet found more than the expected number of this strain of Salmonella Most states had only 1-2 ill persons

  39. Illnesses continued to increase • January 2007 • interviewed 31 ill persons with long questionnaire • consumed peanut butter and turkey more often than general population • Interviewed 6 people with open-ended questions • suspected a brand of peanut butter • February 2007 • designed questionnaire focusing on peanut butter (brand, quantity) • interviewed ill and well persons • peanut butter statistically linked to illness • only Brands A and B

  40. Actions • February 13, 2007 • notified Food and Drug Administration (FDA) • found that brands A and B produced at same plant • distributed to 50 states and ~70 countries • Next day • plant ceased all production • Voluntary recall of all products

  41. Peanut butter testing after recall • 35 jars (opened and unopened) yielded outbreak strain

  42. Investigation of plant • Two environmental samples yielded outbreak strain • Leaky roof and faulty sprinkler in summer • timing coincided with start of outbreak • moisture in processing plants favors growth of Salmonella

  43. Dec Jan Jun Jul Sep Oct Nov Mar Apr May Aug Feb Persons with Salmonella Tennessee infection, by onset week, August 2006 – July 2007 (N=532) Product Recall: February 14, 2007 Contaminated jars produced July 2006 – January 2007 Number of Cases 2006 2007 Week illness began

  44. 1 – 9 None 10 – 19 ≥ 20 Persons with Salmonella Tennessee infection, by state, August 2006 – July 2007(N=714 persons ill)

  45. Summary of peanut butter outbreak • Diffuse national outbreak • Detected by routine Salmonella surveillance, enhanced by PulseNet subtyping • Required intensive multi-state investigation • First U.S. outbreak linked to peanut butter • Product recall based on epidemiologic findings • Contamination at plant over many months Points out the importance of controlling contamination in processed ready-to-eat foods

  46. Topics • National networks • National surveillance • FoodNet • Overview • E. coli O157 • Campylobacter • Salmonella • PulseNet • OutbreakNet • Overview • Some recent outbreaks • Example: Salmonella outbreak • Attribution project • Progress and challenges

  47. Attribution project • How much foodborne illness is from each food commodity, e.g., beef, eggs, vegetables? • Using outbreak data to make estimates • Preliminary data indicates that more illnesses due to known pathogens are acquired by consuming vegetables than any other commodity • leafy greens an important concern

  48. Spinach 3% Broccoli 1% Fresh herbs 8% Cabbage 22% Lettuce 66% Outbreaks caused by leafy greens,1973–2006 (N=219) Herman, Lynch, CDC, unpublished

  49. Proportion of outbreaks due to consumpton of leafy greens, 1981–2005 % of outbreaks Denominator is outbreaks with known food vehicle Source: USDA/Economic Research Service. Data last updated Feb. 15, 2007.http://www.ers.usda.gov/Data/FoodConsumption/FoodAvailSpreadsheets.htm

  50. Topics • National networks • National surveillance • FoodNet • Overview • E. coli O157 • Campylobacter • Salmonella • PulseNet • OutbreakNet • Overview • Some recent outbreaks • Example: Salmonella outbreak • Attribution project • Progress and challenges

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