Anatomy of Multistate 

F

Focus on ProduceA

LCDR Casey Barton Behra

v

Acting Team Lead, Out

Outbreak Response a

n

Division of Foodborne, Waterbo

r

National Center for Emerging Z

o

U.S. Centers for Disease 

F be

bruary 

SAFER • HEALT

Foodborne Out

Associated Outb

vesh DVM, DrPH, DA

break Response Team

nd Prevention Branch

rne and Environmental 

oonotic and Infectious D

Control and Prevention

28 2011 28, 2011

THIER • PEOPLE
Burden of Foo

• Estimated 48 million illne

– 1 out of 6 Americans get a – 128,000 hospitalizations– 3 000 deaths 3,000 deaths

• Certain populations are m

– Children older persons im Children, older persons, im

• Typically causes diarrhea

– Can cause life Can cause life-threatening threatening

• Many sources

– Meat poultry produce ani Meat, poultry, produce, ani

dborne Illnes

esses annually

foodborne illness

more susceptible

mmune-compromise

a and fever

g complications g complications

imal contact imal contact
Number of Salmonello

Commodity Category o

f

1998

-

100110

7080904050607010203040

0

Beef

Dairy

Eggs

Game

Pork

Poultry

G

Po

G

sis Outbreaks 

f Single Implica

-2005

Grains

tanicals

roduce

stacean

Fi

G

Bota

Pro

Crusta

F
Some Recent Large US Multi-State 

2006-20

1

2006 - E. coli O157 and bagged spinac

h

2006 - E. coli O157 and shredded lettu

c

2006 - E. coli O157 and shredded lettu

c

2006 - Botulism and commercial paste

u

2006 - Salmonella and fresh tomatoes2007 - E. coli O157 and frozen pizza2007 - Salmonella and peanut butter 2007 - Salmonella and a vegetarian sn

a

2007 - Salmonella and dry dog food 2007 - Salmonella and microwaveable p and microwaveable

p

2007 - Salmonella and dry puffed brea

k

2007 - E. coli O157 and ground beef2007 - Botulism and canned chili sauc

e

2008 - Salmonella and cantaloupe2008 - E coli .O157 and ground beef O157 and ground beef

2008 - Salmonella and raw produce (p

e

2009 - Salmonella and peanut butter c

o

2009 - Salmonella and imported white 

a

2009 - Salmonella and alfalfa sprouts2009 - E coli .O157 and prepackaged co O157 and prepackaged co2009 - Multidrug resistant Salmonella

a

2009 - E. coli O157 and blade tenderize2009 - Salmonella and salami made wi

t

2010 - E. coli O145 and romaine lettuc

e

2010 - S l ll a

lmonella and lf lf t d alf

alfa sprou

t

s

2010 - Salmonella and frozen meals2010 - Salmonella and shell eggs2010 - Salmonella and alfalfa sprouts

Outbreaks of Foodbo

10 (n=28)

h

ce (restaurant chain A)ce (restaurant chain B)

urized carrot juice

ack food 

pot pies pot pies

kfast cereal 

e

eppers)

ontaining foods

and black peppe

r

ookie dough ookie dough

and ground beef (x2) 

d steaks

th contaminated peppe

r

e
Some Recent Large US Multi-State 

2006-20

1

2006 - E. coli O157 and bagged spinac

h

2006 - E. coli O157 and shredded lettu

c

2006 - E. coli O157 and shredded lettu

c

2006 - Botulism and commercial paste

u

2006 - Salmonella and fresh tomatoes2007 - E. coli O157 and frozen pizza2007 - Salmonella and peanut butter 2007 - Salmonella and a vegetarian sn

a

2007 - Salmonella and dry dog food 2007 - Salmonella and microwaveable p and microwaveable

p

2007 - Salmonella and dry puffed brea

k

2007 - E. coli O157 and ground beef2007 - Botulism and canned chili sauc

e

2008 - Salmonella and cantaloupe2008 - E coli .O157 and ground beef O157 and ground beef

2008 - Salmonella and raw produce (p

e

2009 - Salmonella and peanut butter c

o

2009 - Salmonella and imported white 

a

2009 - Salmonella and alfalfa sprouts2009 - E coli .O157 and prepackaged co O157 and prepackaged co2009 - Multidrug resistant Salmonella

a

2009 - E. coli O157 and blade tenderize2009 - Salmonella and salami made wi

t

2010 - E. coli O145 and romaine lettuc

e

2010 - S l ll a

lmonella and lf lf t d alf

alfa sprou

t

s

2010 - Salmonella and frozen meals2010 - Salmonella and shell eggs2010 - Salmonella and alfalfa sprouts

Outbreaks of Foodbo

10 (n=28)

h

ce (restaurant chain A)ce (restaurant chain B)

urized carrot juice

ack food 

pot pies pot pies

kfast cereal 

e “Pr

Outbre

eppers)

ontaining foods

and black peppe

r

ookie dough

Outbre

ookie dough

and ground beef (x2) 

d steaks

th contaminated peppe

r

e
Challenge: A Bro

a

Can Be Con Can Be Con

10 new food vehicles iden

t

since 2006:

• bagged spinach• carrot juice carrot juice• peanut butter• broccoli powder on a s

n

• dog food• pot pies• canned chili sauce canned chili sauce• hot peppers• white 

p pp e er

• raw cookie dough

Nati

o

ad Range of 

ntaminated

tified in multistate 

nack food

onal Foodborne Outbreak Surveillance System
Challenge: A Bro

a

Can Be Con Can Be Con

10 new food vehicles iden

t

since 2006:

• bagged spinach• carrot juice carrot juice• peanut butter• broccoli powder on a s

n

• dog food• pot pies• canned chili sauce canned chili sauce• hot peppers• white 

p pp e er

• raw cookie dough

Nati

o

ad Range of 

ntaminated

tified in multistate 

nack food

onal Foodborne Outbreak Surveillance System
Produce-associated 

o

• Proportion of all foodbor

n

with produce increasing 

o

– From < 1% to 6% of all out

b

– From < 1% to 12% of outbr

e

• Some produce items pre

d

with particular pathogen with particular pathogen

– Salmonella: Almonds, mel

o

– E. coli O157:H7: leafy gree

n

outbreaks on 

ne outbreaks ass

over last 30 years

breaks

eak associated case

dominantly assoc

ons, sprouts, tomat

n

s
Contaminated Food
What is a foodb

• When 2 or more people g When 2 or more people g

the same contaminated fo

• Illnesses not part of a rec

“sporadic”

borne outbrea

get the same illneget the same illne

ood or drink

cognized outbrea
Who investigates foo

• Multidisciplinary teams Multidisciplinary teams

– Epidemiologists– Microbiologists– Environmental health spec– Regulatory officials and in

• Other professionals adde

proceeds

– Food industry can play imp

odborne outb

cialists or sanitarian

spectors

ed as investigatio

portant role
What agencies

• State and local health dep• St t l t i State regulatory agencies• CDC

– Non-regul t bli h lth latory, public health ag– Focus on problem identification– Usually lead multistate outbreak

• FDA and USDA-FSIS

– Regulatory agencies– F ik d ocus on risk management and

– Trace foods to origin, test foods

restaurants and food processingannounce f d ll oo recalls

s are involved

partments

s

gency

n and source implication

k investigations

source assessment

s, assess food safety m

g facilities, lead farm in
Cycle of Foodborne 

Prev

e

Survei

Applied

Research

Preve

n

Meas

Outbreak Con

e

ntion

llance

Epid

Inve

ntion

ures 
Foodborne Disease O

u

• Goals of investigations

– Immediate control of outb

r

illnesses

– Provide opportunities to i

d

systems

• Outbreak epidemiology 

c

– Globalization, centralizati

o

– Number of possible outbr

e

substantially

• Effective investigations 

k

foodborne disease

– Id tif f d hi l d Identify 

foo

d vehi

cles an

d

outbreaks

utbreak Inves

reak and prevention 

dentify gaps in food 

changing

on, industrialization 

eaks detected has g

key to reducing b

f t hi h l d fac

tors whi

c

h lea

d
Cycle of Foodborne 

Prev

e

Survei

Applied

Research

Preve

n

Meas

Outbreak Con

e

ntion

llance

Epid

Inve

ntion

ures 
Cycle of Foodborne 

P ti St Prevention: Stages 

Survei

Stage 1: Detecting a c

Applied

Stage

1: Detecting

a

c

infections above basel

Research

Preve

n

Meas

Outbreak Con

of I ti 

f an 

Investig

llance

cluster (increase # of

Epid

cluster (increase

# of

line for time period)

Inve

ntion

ures 
National Surveilla

F db oo orne

• Reports to CDC of suspe Reports to CDC of suspe

and local health departm

• Laboratory-based survei based survei

– Serotype results– PulseNet

ance for Bacte

e I f ti n ec ons

ected outbreaks bected outbreaks b

ments 

llance of clinical llance of clinical 
What is P

• National molecular subtyping 

network for foodborne disease network for foodborne diseasesurveillance

• Network of >75 public health &

regulatory laboratories

• Current method is pulsed-field

electrophoresis (PFGE) electrophoresis (PFGE)

– Creates DNA “fingerprints”

• Share DNA Share DNA “fingerprints fingerprints”

electronically 

• DNA “fingerprints” kept in 

dynamic database at CDC

PulseNet?

e

&

d gel 

Cluster of indistipatterns as patterns as “outb

outb
Outbreak Epidem

Pa

• Food distribution localize Food distribution localize• Local outbreaks, large nu• Identified by affected gro Identified by affected gro• Improper food handling i

event

• Local control measures

miology 

 Chan 

ast

ed

umbers ill

oup

n single restaura
Cluster Identific

ation in the P
Outbreak Epidem

Past

• Food distribution localized• Local outbreaks large Local outbreaks, large

numbers ill

• Identified by affected group

• Improper food handling in 

single restaurant or event

• L l tl ocal control measures

miology 

 Chan 

Prese

• Food produ

distrib

• Many affected 

with few 

• PulseNet d

connects disp

• Commun

coordinatio

• Industrial co

• Large-sca

meas
Cluster Identification Toda
Burden of Food

b

Re

ported to He

a

Culture-co

n

Laboratory tes

t

S

pecime

n

Person s

e

Person b

e

Population

borne Disea

alth De

partment

nfirmed case

ts for organism

n obtained

eeks care

ecomes ill

 exposures
Timeline for Reporti

n

Person Eats 

Contaminated Food

1 

Time to co

n

care syst

e

Stool Sample 

Collected

Time to Diag

n

Shipping Time 

Serotyping and “D

Public Health 

Laboratory 

Receives Sample

Serotyping and “D

= 2 to

Typically 2-3 weeks for Salm

o

ng Salmonella 

to 3 days

Pe

ntact with health 

em = 1 to 5 days

nosis = 1 to 3 days

= 0 to 7 days

DNA fingerprinting” DNA fingerprinting”

 10 days

C

onella infections 
Cycle of Foodborne 

Prev

e

Survei

Applied

Research

Preve

n

Meas

Outbreak Con

e

ntion

llance

Epid

Inve

ntion

ures 
ORPB’ O tb k

• Supports national network o

f

ORPB’s 

O

utbrea

k

pp

public health officials who in

v

foodborne, waterborne, and 

o

United States United States

• Collaboration between CDC 

a

– State and local health de

partm

e

• Close partnership with Pulse• Hel

ps ensure

– Rapid, coordinated detection & 

disease outbreaks

– P t h i tb Promo

tes compre

hensive outbr

kR T

f e

pidemiolo

gists an

k

Response 

T

p g

vestigate outbreaks 

other enteric illness

and

ents, , USDA FDA

Net

response to multi-state 

reak ill surveillance
Cycle of Foodborne 

Prevention: Stages

Surveillance

Stage 1: Detecting a cluster of illnesses

Epidem

I

Applied

Research nves

Prevention

Measures 

Outbreak Con

 of an Investig

miologic

ti ti

Stage 2: Gen

Stage 3: Test

stigation Stage 3: Test

Stage 4: Trac

Stage 5: Labo

asse
Generating

• Strategies include Strategies include

– Interviews with structured – Intensive open-ended inter– In-depth interview with peo

refrigerator, pantry

• Some combination of all• Attempt to standardize in• Review interview data for

– Food items, restaurants, st– Collect shopper card numb

Hypothesis

questionnaire 

rviews 

ople in their homes, 

nterviews

r common expos

tores

bers
Looking for e

• Age distribution Age distribution• Gender• Geography

early clues...
Cycle of Foodborne 

Prevention: Stages

Surveillance

Stage 1: Detecting a cluster of illnesses

Epidem

I

Applied

Research nves

Prevention

Measures 

Outbreak Con

 of an Investig

miologic

ti ti

Stage 2: Gen

Stage 3: Test

stigation Stage 3: Test

Stage 4: Trac

Stage 5: Labo

asse
Case-Con

• Study p that compares two

– Cases: persons diagnosed– Controls: similar group of 

• Study medical and lifesty

what risk factors may be 

• Look for statistical and e

with food or other exposu

trol Study

o g p pp roups of peopl

d with illness

people without dise

yle histories to de

associated with 

pidemiologic ass

ure
Cycle of Foodborne 

Prevention: Stages

Surveillance

Stage 1: Detecting a cluster of illnesses

Epidem

I

Applied

Research nves

Prevention

Measures 

Outbreak Con

 of an Investig

miologic

ti ti

Stage 2: Gen

Stage 3: Test

stigation Stage 3: Test

Stage 4: Trac

Stage 5: Labo

asse

(prod
Cycle of Foodborne 

Prev

e

Survei

Applied

Research

Preve

n

Meas

Outbreak Con

e

ntion

llance

Epid

Inve

ntion

ures 
Health Alerts and Consumer A
Preventing Fut

• Outbreak investigations p

foodborne diseases

– New pathogens, new vehic

• Offer opportunities for di

professionals to work tog professionals to work tog

• R i ti th t d Raise questions that need

understand, prevent, redu

ture Outbreak

play key role in p

cles, gaps in food sa

fferent authoritie

gether

d h t b td research to bet

uce contaminatio
Preventing Fut

• Outbreak investigations a Outbreak investigations a

lead to

– Better industry practices– Regulations and enforcem– Consumer understanding

• All should reduce numbe

ture Outbreak

and additional reand additional re

ent by regulatory a

er of foodborne il

Gaps in Multistate Ou

• Need to decrease time to get subt

y

Gaps in Multistate Ou

Met

h

• Limited resources for health depa• Individual illnesses may appear “

s

– Patients not routinely intervie

w

• Cluster and outbreak investigatio

n

– Delays in

• Patient interviews due to 

o

• Lag time from illness to in

t

• Re-interviewing to collect 

p

– Initial 

questionnaires often no

t

– Lack of a standard database f

o

• No electronic transmission of e

x

– Rel

y on hundreds of voluntee

r

studies

utbreak Invest

yping results, enhance 

utbreak Invest

hods

rtments to conduct inte

sporadic”

wed

n

s

other 

priorities

terview, affects recall o

product information

t standardized between 

or states to enter interv

xposure information to CDC

rs to conduct multistate 
Lessons Learned f

I ti nvesg

• Continually assess how w Continually assess how

w

cause and source of out

b

– Apply lessons to future in

v

• Powerful role of investig

a

restaurants or events du

r

– Aided by menus and recip

e

– Makes tracking specific in

g

• Importance of consideri

n

vehicles that may not be considered by ill people considered by ill people

rom Past Out

g

ations

we can better pinwe can better pin

breaks more quic

vestigations

ating clusters in 

ring multistate ou

e

s

gredients easier

ng potential “stea

initially reported 
Lessons Learned f

I ti nvesg

• Importance of working w Importance of working

w

possible to correct and i

d

contamination

• Im

p p ortance of ra

pid trac

e

single product, producer 

rom Past Out

g

ations

ith industry as soith industry as so

dentify potential 

eback that conve

or manufacturer
Imp g rovin Outb

• Improvements in laborato Improvements in laborato

– Make it easier to identify fo– Increased number and sco

• Enhancing capacity and i

approaches at state, loca

– Make outbreak detection, i

faster

• A l t d bilit t id Accelerated ability to ide

people faster

– Tracebacks to start sooner Tracebacks to start sooner

break Respon

ory infrastructure ory infrastructure

oodborne disease o

ope of outbreaks 

implementing sta

al, and federal lev

nvestigation, and c

ntif d i 

tify cases and i

r once food is suspr once food is susp
2010 OutbreakNe

MT ND

WA

ID

NE

OR

SD

WY

CO KS

NE

NV

UT

CA

AZ NM OK

TX

HI

AK

et Sentinel S

Sentinel S

IA

MN

PA 

WI 

MI

IN 

KY

MO

N

TN

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OH

AL

LA

TN

GA

MS

SC

AR

LA

FL
OutbreakNet Sen

• Facilitate collection of exposu

d l h th d i develop hypotheses and imp

• Facilitate collection of specifi

for traceback investigations for traceback investigations

• More rapidly collate and analy

information from multiple sta

• Routinely join epidemiologic • Improve quality and speed of

regult i f t latory agencies for trace

• Share information in real time

Decrease time to ide

contaminat

ntinel Sites ( 

O

ure data to more ra

li t hi l licate vehicles

ic product informat

yze epidemiologic a

ates

and PulseNet data

f product data provi

b k ac

e with regulatory ag

entify how and wher

tion occurred
Final Th

• Produce is increasingly recogn

outbreaks, causing more and la

• We are continually working to i

investigation and response

• Food industry can play an impo

investigations

• New science and detection met New science and detection met

outbreaks are driving our undeconsequences

• Increasing consumer awarenes

safety improvements

houghts

nized as a source of 

arger outbreaks

mprove foodborne 

ortant role in outbre

thods for foodborne thods for foodborne 

rstanding of risks a

ss is driving the dem
Public Hea

Salmonella Outbreak Fu

Peanut Case Shows Peanut Case Shows

Obama Seeks to Im

The White House Blo

R i T bli Reversing a Troubling 

Mar. 14

alth Impact

uels Food-Safe

Holes in Safet

Feb. 7, 2009

Holes in Safet

Feb. 8, 2009

mprove Food S

Mar. 14, 2009

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4, 2009
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