# Presentation: 431265

## From Laboratory Detection to Interaction with Epidemiology Programs

- Dave Boxrud
- Minnesota Department of Health
- May 15, 2008

## Case 1

| Exposure | Exposure | Exposure |
| --- | --- | --- |
| Doctor | Doctor | Doctor |
| Transport | Transport | Transport |
| Culture | Culture | Culture |
| Transport | Transport | Transport |
| Serotype | Serotype | Serotype |
| PFGE | PFGE | PFGE |
| Report | Report | Report |
| Interview | Interview | Interview |

- Outbreak Detection

- Case 2

- Case 3

## Cluster investigation

| Exposure | Exposure | Exposure |
| --- | --- | --- |
| Doctor | Doctor | Doctor |
| Transport | Transport | Transport |
| Culture | Culture | Culture |
| Transport | Transport | Transport |
| Serotype | Serotype | Serotype |
| PFGE | PFGE | PFGE |
| Report | Report | Report |
| Interview | Interview | Interview |

- Outbreak Detection

## Activities Done In Real–Time :

-   Isolate acquisition
-   Subtype analysis
-   Subtype reporting
-   Case interviewing
-   Cluster investigation

## Activities Done In Real–Time :

-   Isolate acquisition
-   Subtype analysis
-   Subtype reporting
-   Case interviewing
-   Cluster investigation

## a Submission of clinical materials required. Submit isolates or, if an isolate is not available, submit material containing the infectious agent in the following order of preference: a patient specimen; nucleic acid; or other laboratory material.  Call the MDH Public Health Laboratory at 651-201-4953 for instructions.

- a Submission of clinical materials required. Submit isolates or, if an isolate is not available, submit material containing the infectious agent in the following order of preference: a patient specimen; nucleic acid; or other laboratory material.  Call the MDH Public Health Laboratory at 651-201-4953 for instructions.

## Activities Done In Real–Time :

-   Isolate acquisition
-   Subtype analysis
-   Subtype reporting
-   Case interviewing
-   Cluster investigation

## PFGE in Minnesota

-     _**PN Real-Time**_
*E. coli* 0157:H7
*Listeria monocytogenes*
*Salmonella *
*Shigella sonnei*
*N. meningitidis groups B, C, and Y*

-    _**Batch**_
- MRSA
- Invasive GAS
*B. pertussis*
- Others

## PFGE Flowchart

- Sequential Testing

## PFGE Flowchart

- Biochemicals + TSBA

- Enterics

- Serotyping

- Hours - days

-   PFGE

- Isolate received

- Concurrent

- 1 day

- 1 day

## PFGE Reporting

- Local database
- National database
- Document cluster
- LIMS

## Daily Report

-    Automatic printout of any serotype/PFGE info added into LIMS
- Previous days
- Moving time frame
- Historical perspective
- National clusters

## Daily Report

**SPEC****	****LNAME****	****FNAME****	****     CITY****	****       AGE ****	****       AGENT        ****	****  SUBTYPE           DATE**
**01774****	****	****Larsen****	****William****	****Bloomington           37****	****Campylobacter jejuni****	****       Fla9****	****      11-mar-03**
**01770****	****	****Simon****	****Pauline****	****Minneapolis            72****	****Campylobacter jejuni****	****       Fla72****	****      10-mar-03**
**01778****	****	****Hilgren****	****Sven****	****Rosemount              6****	****Escherichia coli****	****       MN31****	****      10-mar-03**
**01773****	****	****Hilgren****	****Cody****	****Rosemount****	****            5****	****Escherichia coli****	****       MN31****	****      12-mar-03**
**01765****	****	****Bergstrom****	****Theresa****	****Rosemount****	****          31****	****Escherichia coli****	****       MN31****	****      11-mar-03**
**01768****	****	****Roberts ****	****Maryln****	****Bemidgi****	****          76****	****Escherichia coli****	****       MN1****	****      11-mar-03**
**01777****	****	****Desowitz****	****Robert****	****St. Cloud****	****          47****	****Salmonella saintpaul****	****              ****	****      14-mar-03**
**01776****	****	****Beers****	****Trevor****	****Minneapolis****	****            3****	****Salmonella typhimurium****	****       TM43****	****      10-mar-03**
**01769****	****	****Sampson****	****Elsa****	****St. Paul****	****          53****	****Salmonella typhimurium****	****       TM2B****	****      11-mar-03**
**01774****	****	****Brady****	****Harold****	****Bloomington         16****	****Shigella flexneri 3a****	****    ****	****      13-mar-03**
**01767****	****	****Crandon****	****Louise****	****Chisago****	****          24****	****Shigella sonnei****	****       SS1****	****      10-mar-03**
**01764****	****	****Petrovich****	****Helen****	****Edina                      67****	****Shigella sonnei****	****       SS44****	****      09-mar-03**

- Names are fictitious

**Page 1**

## Daily 30 Line Listing

_**SPEC**_**	**_**LNAME**_**	**_**FNAME**_**	****     **_**CITY**_**	****       **_**AGE **_**	****     **_**AGENT **_**                       **_**SUBTYPE**_**       **_**DATE**_
**01778****	****	****Hilgren****	****Sven****	****     Rosemount              6                Escherichia coli                        MN31             10-mar-03**
**01773****	****	****Hilgren****	****Cody                       Rosemount             5                Escherichia coli                        MN31             12-mar-03**
**01765****	****	****Bergstrom****	****Theresa****	****      Rosemount             31              Escherichia coli                        MN31             11-mar-03**
**01762****	****	****Hilgren****	****Elizabeth****	****      Rosemount             24              Escherichia coli                        MN31             10-mar-03**
**01760****	****	****Edlestein****	****Michael****	****      Invr Grove Hts        7                Escherichia coli                        MN31              08-mar-03**
**01758****	****	****Langley****	****Joel                         Rosemount             6                Escherichia coli                        MN31              06-mar-03**
**01743****	****	****Sigurson****	****Marie                       Rosemount             8                Escherichia coli                        MN31              06-mar-03**
**01768****	****	****Roberts****	****Maryln****	****      Bemidgi                   76              Escherichia coli                        MN1               11-mar-03**
**01777****	****	****Desowitz****	****Robert****	****      St. Cloud                47               Salmonella saintpaul                                       14-mar-03**
**01776****	****	****Beers****	****Trevor****	****       Minneapolis           3                Salmonella typhimurium         TM43               10-mar-03**
**01762****	****	****Horlath****	****Brett****	****       Minneapolis           5                Salmonella typhimurium         TM43               10-mar-03**
**01747****	****	****Peterson****	****Mary****	****       Minneapolis           9                Salmonella typhimurium         TM43               29-feb-03**
**01769****	****	****Sampson****	****Elsa****	****      St. Paul                    53              Salmonella typhimurium         TM2B              11-mar-03**
**01771****	****	****Yang****	****Xiong                      Duluth                      47             Salmonella typhimurium          TM2B              29-feb-03**

**Names are fictitious**

**Page 1**

## Daily Analysis

**AGENT                                    SUBTYPE              MAR-03         FEB-03       JAN-03         CY-03          CY-02          CY-01**
**Campylobacter jejuni****	****       Fla09****	****	****1                  2                  1                  9                  0                   0**
**Campylobacter jejuni****	****        Fla72****	****	****0                  1                  0****	****                 1****	****                3****	****               0**
**Campylobacter jejuni****	****        All isolates****	****14                35                36                85****	****                770               674**
**Escherichia coli O157:H7****	****        MN31****	****	****7                  1                  0                  8                  1                   2**
**Escherichia coli O157:H7****	****        MN1****	****	****1                   0                 1                  2                   8                  12**
**Escherichia coli O157:H7****	****        All isolates****	****8****	****4                 5                  17                158              168**
**Salmonella saintpaul****	****        All isolates****	****1****	****0                 0                  3                   5                   2**
**Salmonella typhimurium         TM43****	****	****2****	****1                  0                  3                  78                 0****	**
**Salmonella typhimurium****	****        TM2b****	****	****1****	****2                  1                  4                  54                 0**
**Salmonella typhimurium****	****        All isolates****	****17****	****25                16                197              205               160**
**Shigella flexneri 3a****	****        All isolates****	****2****	****0                  4                  6                  2                   2**
**Shigella sonnei****	****        SS1****	****	****1****	****1                  0                  2                  5                   134**
**Shigella sonnei****	****        SS44****	****	****1****	****0                  0                  1                  11                  0**

**15-MAR-2003**
**Page 1**

## Daily National Report

**	**_**AGENT**_**                                      **_**ALERT DATE**_**      **_**STATE**_**     **_**SUBTYPE**_**              **_**EPI ASSOCIATION**_

**Clusters are fictitious**

**Page 1**

**SALMONELLA NEWPORT             01-MAR-03              VA           NEW132                  RESTAURANT**
**ESCHERICHIA COLI O157:H7       25-FEB-03                MI           MN41                       SPROUTS**
**SALMONELLA MUENCHEN          23-FEB-03                NE           NE96046-3                     ?**
**SHIGELLA SONNEI                          12-FEB-03                WA         SS1                            DAYCARE**
**SALMONELA MONTEVIDEO         05-FEB-03                TX          SMON11                  PEANUTS**
**SALMONELLA AGONA                    08-JAN-03                CO          SAG8                       TOMATOES**

## Activities Done In Real–Time :

-   Isolate acquisition
-   Subtype analysis
-   Subtype reporting
-   Case interviewing
-   Cluster investigation

## Epidemiology in Minnesota

- Foodborne illness hotline
- Centralized epidemiology
- Real-time comprehensive interviews
- Dynamic cluster investigation
- Student workers

## A

- D

- C

- B

- OR

- _AD_

- CB

- =

- Measure of Association

- exposed

- not exposed

- case

## Enteric Disease Interview

- 11 pages, 15-40 minutes
- Large # of organisms
- Demographics
- Symptoms/treatment
- Exposures
- 7 day restaurant history
- 5 day meal history
- 7 day food consumption history

## Team Diarrhea and the Vector Squad

## Salmonella I 4,5,12:i:- Outbreak – Banquet Pot Pies

- Nationwide cluster identified June 6, 2007
- CC started in September-chicken, breaded chicken products, and eggs

## Dynamic Cluster Investigation-Pot Pies

- 10/3
- night

## October 4, 4 PM – 3 pot pie eaters, email CDC and other states
October 4 – Other states report consumption of PP
October 8 – ConAgra stopped pot pie line 
October 9 - USDA-FSIS and CDC posted advisories
ConAgra recalled Banquet pot pies on Oct 11
Salmonella positive pot pies in several states
Currently 401 cases in 41 states

- October 4 – Other states report consumption of PP
- October 8 – ConAgra stopped pot pie line
- October 9 - USDA-FSIS and CDC posted advisories
- ConAgra recalled Banquet pot pies on Oct 11
*Salmonella* positive pot pies in several states
- Currently 401 cases in 41 states

*Salmonella* I 4,5,12:i:- Outbreak – Banquet Pot Pies

## Distribution of cases by state, 2007 (n=401)

- Distribution of cases by state, 2007 (n=401)

**GA**
**3**

**0**

**1-9**

**10-19**

**≥****20**

**IN**
**5**

**AR**
**4**

**WY**
**3**

**OK**
**2**

**ME**
**2**

**FL**
**2**

**AK**
**5**

**WV**
**2**

**ND**
**1**

**IA**
**5**

**AZ**
**1**

**MN**
**7**

**TN**
**6**

**MT**
**6**

**MI**
**6**

**KS**
**6**

**TX**
**5**

**NC**
**5**

**OR**
**9**

**NV**
**7**

**WI**
**27**

**PA**
**25**

**OH**
**21**

**MO**
**22**

**CA**
**35**

**WA**
**35**

**SC**
**1**

**NM**
**0**

**SD**
**0**

**NE**
**0**

**MS**
**0**

**AL**
**0**

**GA**
**0**

**MD**
**15**

**CT**
**11**

**VT**
**2**

**NJ**
**8**

**DE**
**6**

**MA**
**8**

**NH**
**0**

**HA**
**0**

**Notes:**
This map shows the distribution of all 398 reported cases in 2007 by state.  

States colored white reported no cases.
States colored light blue reported 1-9 cases.
States colored dark blue reported 10 to 19 cases.
States colored red reported greater than 20 cases. 

## Laboratory/Epidemiology Partnership

- Team approach
- Funding collaboration
- Education
- Daily report
- Physical proximity

## MN OBS 2000-2005

- Analyzed MN FDB enteric OBs
- Reported OBs (n=10)
- Pathogen-Specific Surveillance OBs (n=28)
- Millions of lbs of product recalled
- 10 multi-state outbreaks
- Frozen steaks, ground beef, alfalfa sprouts, ice cream, frozen stuffed chicken...

## Controlling Underlying Problems

- Steaks tenderized by injection

- Product labeling issues

- Retail ice cream blended with raw egg product

## Barriers Identified for Foodborne Disease Surveillance

## Slide 30

## Barriers Identified for Foodborne Disease Surveillance

- Money
- Isolate submission
- Out of state reference labs
- Physical proximity
- Different interview strategies
- Non-centralized epidemiology
- Administrative support
- Experience

## Summary

- Real-time pathogen specific surveillance enhances ability to detect FBD OBs
- Laboratory-epi communication and collaboration vital