Changing Landscape of Foodborne Disease Arthur P. Liang, M.D., M. P. H. Senior Advisor for Food Safety Division of Foodborne Waterborne & Environmental Diseases Centers for Disease Control & Prevention
CDC & States: The vital link CDC provides the vital link between illness in people & the food safety systems of government agencies & food producers.
Disclosures • Findings & conclusions in this presentation are those of the author and do not necessarily represent the views of the Centers for Disease Control & Prevention • Thank you to HPP for invitation • Speaker reserves the right to say something stupid, wrong or incredibly obvious
Executive Summary • Genomics & Information Technology: Accelerating pace of change • Disease & Food surveillance finding a needle in a haystack • Food safety bar is being raised for ALL More Class 1 Recalls(?)
Listeria Outbreaks & Incidence, 1983-2013 Incidence No. outbreaks (per million pop) Early Listeria Initiative Era Pre-PulseNet PulseNet 2.9 Outbreaks per year 0.3 2.3 5.5 Median cases per 69 11 outbreak
Listeria Outbreaks & Incidence, 1983-2014 Incidence No. outbreaks (per million pop) Early Listeria Initiative WGS Era Pre-PulseNet PulseNet 2.9 8 Outbreaks per year 0.3 2.3 5.5 4.5 Median cases per 69 11 outbreak
Listeriosis Outbreaks & Incidence*, 1983-2015 No. outbreaks Incidence (per million pop) WGS 7.5 4 *2015 incidence rate preliminary data from FoodNet
The bacteria and viruses that cause the most illnesses, hospitalizations, and deaths in the United States are: • Salmonella • Norovirus (Norwalk Virus) • Campylobacter • E. Coli • Listeria • Clostridium perfringens https://www.foodsafety.gov/poisoning/causes/bacteriaviruses/
Accelerating pace of change … • 1854 Era of Classical Epidemiology & Microbiology 1920’s serotyping, 1940’s phage typing • 1998 PulseNet Era • 2014 Genome Sequencing Era John Snow (1813-1858)
Era of Classical Epidemiology & Microbiology How do we know it’s food? Outbreak investigation “church picnic ” or “sore thumb” • Large number of cases in one jurisdiction − Detected by affected group − Local investigation − Local food handling error (s) − Local solution
Outbreak Detected by patients / their doctor On January 12 A pediatric gastroenterologist notified the Washington State Dept of Health (WA DoH) of increase in emergency dept visits for bloody diarrhea & the hospitalization of 3 children with hemolytic uremic syndrome. January 15 No single exposure source from initial interviews Emergency Room & lab alerted for case finding
January 18 • 37 cases identified. 27 ate at same fast food chain A • Cases named 13 different store locations of restaurant chain A Chain has 66 restaurants in the Washington State. All received the same hamburger from the same distribution warehouse. “Controls” = No diarrhea in 2 wks, friend of a case, matched by neighborhood & age
Compare exposures of ill & well persons Case - Control Study Calculate Relative Risk or Odds Ratio Ate Chain A Did not eat Total hamburger hamburger Sick 27 (73%) 10 37 Well 0 (0%) 16 16 matched odds ratio (mOR) = undefined; 95% confidence limit = 3.5 to ∞ Relative Risk = 1 No Association Relative Risk < 1 Negative Association Relative Risk > 1 Positive Association
“Local” food handling error: Cook oking ing Temperatures peratures for r hamburger burger 1992 FDA – 140 o F (60 o C) Washington State 155 o F (68 o C) Cooking temperatures at implicated restaurants ±60 o C, probably less 50 gm frozen hamburger patties, cooked 1 minute on each size, regardless of whether meat was still red or not
“Local” Intervention Janua nuary y 18 WA DoH Advisory: Outbreak likely linked to Restaurant Chain A hamburgers
January nuary 18, , 1993: 93: Voluntary luntary Recall call Restaurant Chain A Press Release: “…measures to ensure menu items prepared in accordance with an advisory issued by the WA DoH .” Recall: ~250,000 hamburger patties
E. Coli i 0157 7 outbre reak ak linked nked to fast st-food ood chain in hamburg burgers, ers, Pacif ific ic Northwest thwest 1993 93 * US & primary culture-confirmed cases = 333 80 *cases by date of exposure who ate Chain A hamburger on a single day 70 60 Improved # of cases cooking temps 50 first 40 report Public 30 alert 20 10 0 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 1 2 3 4 5 6 7 8 January
Cases of E. coli by Date of Illness Onset October 5-18, 1999 N=11
Compare exposures of ill & well persons Case - Control Study Calculate Relative Risk or Odds Ratio Apple No apple Total cider cider Sick 10 (73%) 1 11 Well 0 (0%) 24 24 matched odds ratio (mOR) = undefined; unmatched P-value < 0.00001) Relative Risk > 1 Positive Association
“Local” Intervention October 12, 1999 • OSDH ordered Orchard A to • discontinue unpasteurized apple cider production • recalled the apple cider
Environmental Results Inspection of orchard & juice production site: no violations found − No dropped apples − Washed & brushed apples − Preservative added − Warning labels
PulseNet Era: circa 1996 - present In 1995, the Hubble Space Telescope found distant galaxies and star clusters never seen before. Pulsed- field gel electrophoresis (PFGE) makes “invisible” outbreaks visible
PulseNet, since 1996 • DNA “fingerprints” shared electronically • Kept in national database at CDC
PulseNet Era: circa 1996 - present • Small numbers of cases in many jurisdictions • Detected by lab-based subtype surveillance • Multistate / Country Multi-disciplinary investigation • More challenging to investigate • Higher stakes? • Identifying “new” foods/ingredients
Outbreak Detection by Lab March 1 March 2 NY State notified CDC of 4 cases PulseNet identifies additional 7 Salmonella with cases in 6 states with an indistinguishable PFGE patterns indistinguishable PFGE pattern
Multi-state / National investigation March 2 • First multi-state conference call • Common exposures in early interviews: • Chicken • Seafood • Fresh produce • Japanese restaurant • FDA notified & joins call March 2 • Hypothesis generating questionnaire deployed
Outbreak Detection/Hypothesis Generation March 1 Cluster Identified March 2 Investigation Initiated March 8 Exposure information points to seafood, specifically sushi 7/8 report seafood, 5/8 report sushi
Restaurant-exposure Clusters March 8 2 unrelated ill persons in TX ate the same Japanese restaurant March 13 Second cluster of unrelated ill persons at same Japanese restaurant in WI March 16 3 rd cluster of unrelated ill persons ate sushi from same grocery store in WI March 22 4th cluster of unrelated ill persons at sushi same restaurant in CT March 22 5th cluster of unrelated ill persons ate sushi same restaurant in MD = res estaur urant ant clus uster
Epi i Ana naly lysis sis of of me meal l rec eceipts eipts March 29-April 9 • Compare ill patrons to well patrons from the several restaurants with illness clusters Case-Meals Other Customers “Spicy Tuna” 84% 37% (range:29 - 53%) Well Patron Groups Orders from diners who ate at one of the cluster restaurants Orders placed during the same meal (lunch or dinner) Close to the date when the ill person ate at the restaurant
FDA A Traceb eback ack April il 11 Seafood Importer/Supplier A Seafood Processor A. April 13-14 FDA issued two Import Alerts for fresh & frozen tuna from Seafood Processor A. Seafood Importer/Supplier A recalls raw yellowfin tuna scrape
Higher epidemiologic “standard of proof” Multi-disciplinary Evidence to implicate food Three major pillars Epidemiology – interviews & loyalty cards, case-control, observed vs 1) expected Data from interviews of ill persons, distribution of cases in person/place/time, results of analytic epidemiologic studies, the history of pathogen & past outbreaks Traceback – lot codes, industry consultation 2) of a suspected vehicle linked with ill persons to identify a common point where contamination may have occurred & an assessment of the production facility at that common point Laboratory – clinical, “DNA fingerprint,” food, environmental, 3) results from testing of a cases, suspected vehicle or the production facility where contamination may have occurred
Multistate Outbreak of S Bareilly & S Nchanga Infections Associated with a Raw Scraped Ground Tuna Product, 2012
PulseNet increased the number of multistate foodborne outbreaks reported to CDC: 1973-2010 PulseNet begins
10 new food vehicles identified in multistate outbreaks, 2006 - 2009 Bagged spinach, 2006 1. Carrot juice, 2006 2. Peanut butter, 2007 & 2009 3. Broccoli powder on a snack food, 2007 4. Pot pies, 2007 5. Canned chili sauce, 2007 6. Jalapeño & Serrano peppers, 2008 7. White pepper, 2009 8. Raw cookie dough, 2009 9. Black & red pepper, 2009-10 10. National Foodborne Outbreak Surveillance System
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