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Responding to a Multi-State Foodborne Disease Outbreak

Responding to a Multi-State Foodborne Disease Outbreak. Objectives. Understand the approach used by public health partners in multi-state foodborne disease outbreak investigations. Identify opportunities for collaboration.

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Responding to a Multi-State Foodborne Disease Outbreak

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  1. Responding to a Multi-StateFoodborne Disease Outbreak This is an outbreak scenario, not a real outbreak

  2. Objectives • Understand the approach used by public health partners in multi-state foodborne disease outbreak investigations. • Identify opportunities for collaboration. • Explore the type and value of information that industry has that can assist, inform and expedite investigations.

  3. Overview Scenario with four parts • Short slide presentation for each section followed by discussion. • Limited time for discussion for each part. 1:00 – 1:10 10m Introductions 1:10 – 1:15 5m Part 1 (Detection) 1:15 – 1:25 10m Discussion 1:25 – 1:35 10m Part 2 (Acceleration) 1:35 – 1:55 20m Discussion 1:55 – 2:00 5m Part 3 (Resolution/Deceleration) 2:00 – 2:15 15m Discussion 2:15 – 2:20 5m Part 4 (Resolution/Deceleration continues) 2:20 – 2:35 15m Discussion 2:35 – 2:45 10m Questions & Answers from audience

  4. Salmonella • Most common bacterial cause of foodborne disease in the United States • ~ 1 million illnesses and 370 deaths annually* • >2,500 serotypes • Typhimurium one of most common * Scallan E, Hoekstra RM, Angulo FJ, Tauxe RV, Widdowson M-A, Roy SL, et al. Foodborne illness acquired in the United States—major pathogens. Emerg Infect Dis. 2011 Jan

  5. Part 1 (Detection) 1:10 – 1:25 This is an outbreak scenario, not a real outbreak

  6. Outbreak Detection May 19, 2012: CDC PulseNet identifies a cluster of SalmonellaTyphimurium infections 17 PFGE-matched patients from 13 states PFGE pattern relatively common Average of 83 cases reported annually to PulseNet between 2006 and 2011 PFGE-matched ground beef sample from Canada (April, 2012 collection date) This is an outbreak scenario, not a real outbreak

  7. 1-Apr 19-May 1-May 7-Apr 7-May 14-Apr 21-Apr Infections with the Outbreak Strain of Salmonella by Date of Upload to PulseNet, April 1 to May 19, 2012 (n=17) • Case Patient Demographic/Clinical Info • Mean age = 27 years • Age range: 2 to 65 years • < 5 years = 12% • 6 to 17 years = 30% • 18 to 50 years = 53% • 50+ years =6% • Female = 59% • 9 hospitalized (53%) • No deaths 7 This is an outbreak scenario, not a real outbreak

  8. States Where Persons Infected with the Outbreak Strain of Salmonella Live by State, April 1 to May 19, 2012(n=17) NH 1 MA 1 NJ 1 PA 3 OH 3 IN 2 CO 1 KY 4 CA 2 This is an outbreak scenario, not a real outbreak

  9. Outbreak Pattern – Historical Data from PulseNet 2006 2009 78 2007 2010 2008 2011 This is an outbreak scenario, not a real outbreak

  10. Panel Discussion – I (until 1:25) • Perspectives and next steps as of May 19, 2012? • Public Health Agencies • Federal • State and local • Laboratory • Do you need other DNA fingerprinting approaches (e.g.MLVA)? • Do regulatory Agencies need to be informed • If so, which one(s)? • Does industry need to be informed • If so, which one(s)? • Does the public need to be informed • If so, how? • What is the “case” definition? This is an outbreak scenario, not a real outbreak

  11. Part 2 (Acceleration)1:25 – 1:55 This is an outbreak scenario, not a real outbreak

  12. Case Definition SalmonellaTyphimuriuminfectionsreported to PulseNetwith a matching PFGE pattern with an isolate collection date on or after April 1, 2012 This is an outbreak scenario, not a real outbreak

  13. Next Steps: Hypothesis Generation CDC requested states to interview PFGE-matched patients with “standard elements” questionnaire ~300 elements including: Ground beef Unpasteurized milk and dairy Leafy greens (spinach, lettuce), sprouts Tomatoes Animal contact Shopping & eating locations Travel history “Clusters” of cases at restaurants, events, or grocery stores CDC Enterics Diseases laboratory requests isolates for MLVA testing Information sharing with regulatory partners This is an outbreak scenario, not a real outbreak

  14. Summary Clinical & Demographic Information as of June 9, 2012 56 cases in 14 states 28 hospitalizations (50%), no reported deaths Reports from 3 patient isolates indicate this is a multi-drug resistant strain of Salmonella Isolates are resistant to multiple antibiotics Slight female predominance (65%) Unusual age distribution Skewed toward 15-49 (56% of cases) This is an outbreak scenario, not a real outbreak

  15. Info comes in as States complete interviews A total of 25 questionnaires received from 8 states Cases report eating: (92% 23/25) eggs, tomatoes, (88% 22/25) leafy greens, chicken, (84% 16/25) ground beef, salads, apples, (76% 19/25) milk, (60% 15/25) cheese, (56% 14/25) strawberries. No other food eaten in unusual frequency No cases in Canada No history of travel to common event Over next two weeks... This is an outbreak scenario, not a real outbreak

  16. Over next two weeks... (Continued) Cases shop in many different grocery stores No two cases at the same location Two unrelated cases report eating at same location of a fast food Restaurant in Columbus, OH Meal dates for both cases was April 21 One became ill on April 23 and one on April 24 Two cases are residents at a nursing home in Pittsburgh, PA One became ill on May 5 and one on May 7 16 This is an outbreak scenario, not a real outbreak

  17. States Where Persons Infected with the Outbreak Strain of Salmonella Live by State, April 1 to June 9, 2012(n=56) NH 1 MA 1 NJ 1 PA 12 OH 11 IN 3 IL 6 WV 2 CO 3 KY 7 CA 5 TN 4 This is an outbreak scenario, not a real outbreak

  18. Infections with the Outbreak Strain of Salmonella by Upload Date to PulseNet, April 1 to June 9, 2012 (n=56) New Reports PulseNet identifies cluster (May 19) 1-Apr 9-Jun 1-May 7-Apr 7-May 27-May 21-May 14-May 14-Apr 21-Apr This is an outbreak scenario, not a real outbreak

  19. Infections with the Outbreak Strain of Salmonella by Illness Onset Date, April 1 to June 9, 2012 (n=38) Illnesses occurring after May 8 might not yet be reported due to the time it takes between when a person becomes ill and when the illness is reported PulseNeta identifies cluster (May 19) 1-Apr 9-Jun 1-May 7-Apr 7-May 27-May 21-May 14-May 14-Apr 21-Apr 19 This is an outbreak scenario, not a real outbreak

  20. Case Food Consumption Information as of June 9 (n=38) 71% of cases report eating any ground beef No common grocery store or type of ground beef Preliminary USDA FSIS investigation not finding ground beef source convergence No known link between PFGE-matched ground beef sample from Canada and US cases Still no cases reported by Canada This is an outbreak scenario, not a real outbreak

  21. Case Food Consumption Information as of June 9 (n=38) (continued) Other exposures reported by >50% of cases in the week before getting sick Fresh Tomatoes: 92% (35 of 38) 94% (33/35) report eating “red, round” 11% (4/35) report eating “roma” 9% (3/35) report eating “cherry or grape tomatoes” 6% (2/35) report eating ‘vine-ripe’, sold on the vine 6% (2/35) did not know the type of tomato None report “tomatoes grown at home” 91% (32/35) report eating a “fresh tomato outside the home” Lettuce: 79% (30 of 38) No single type of lettuce predominates Iceberg lettuce = 9 of 30 (30%) Romaine lettuce = 4 of 30 (13%) prepackaged “bagged” lettuce = 11 of 30 (37%) reporting Of 8 who knew Brand, no single one predominates Apples: 71% (27 of 38) no single type predominates Strawberries: 63% (24 of 38) Chicken: 57% (22 of 38) no single type predominates 21 This is an outbreak scenario, not a real outbreak

  22. Lab Information as of June 9 MLVA results available for 19 patients 89% had same pattern (Pattern A), rare pattern 11% other patterns Canadian ground beef isolate: Does not match pattern A by MLVA Is not antibiotic resistant This is an outbreak scenario, not a real outbreak

  23. Discussion – II (until 1:55) • Perspectives and next steps as of June 13, 2012 • Is this an outbreak? • What is the primary hypothesis (what is the likely cause of this outbreak)? • What should the public health agencies be doing? • Federal, State and local • Laboratory - should MLVA be used in the case definition? • What information do you want to know about the “clusters” of cases? • Should an analytic epidemiologic (case control) study need to be done now? • Does the public need to be informed • If so, how? • Does industry need to be informed/contacted? • If so, how? • What are the next steps? This is an outbreak scenario, not a real outbreak

  24. Part 3: Resolution/Deceleration1:55 – 2:15 This is an outbreak scenario, not a real outbreak

  25. Re-Interviews of “cluster” cases & preliminary supplier information: June 14 Two cases who report eating at same location of a Fast Food Restaurant in Columbus, OH Meal dates for both cases was April 21 One reported eating burger with lettuce, tomato, mayo, ketchup and fries and a diet soda (illness onset on April 23) One reported eating a “BLT Cobb Salad” with ranch dressing and a diet soda (illness onset on April 25) No food handlers reported ill upon health department inspection No major violations noted Restaurant location supplied by Sysco via “Distributor A” out of Columbus, OH 25 This is an outbreak scenario, not a real outbreak

  26. Re-Interviews of “cluster” cases & preliminary supplier information: June 14 2 nursing home residents in Pittsburgh, PA One case who is a strict vegetarian ate most, but not all meals in the week before they got ill at the nursing home (illness onset May 5) One case ate all meals in the week before they got ill at the nursing home (illness onset May 7) Case has advanced Alzheimer's and can’t report a meal history No food handlers reported ill upon health department inspection No major violations noted Supplied by Sysco via “Distributor B” out of Pittsburgh, PA 26 This is an outbreak scenario, not a real outbreak

  27. Case-Control Study: Initiated June 14 Include all cases since April 1 PFGE matched and MLVA “A series” or PFGE matched and MLVA pending 3 controls (“healthy persons”) per case Matched by age, sex, and state of residence Selected by reverse directory lookup Structured targeted questionnaire focusing on items commonly consumed by cases Ground beef, tomatoes, lettuce, cheese, lettuce, and strawberries This is an outbreak scenario, not a real outbreak

  28. On June 15 • CA Department of Health reports 3 unrelated cases in San Diego residents who ate at two different locations of a Mexican-style restaurant called “LosBuenos” • “LosBuenos” not part of national or regional chain with only 2 locations in San Diego area • 2 cases ate at Location A on April 18 • One had a chicken burrito, with lettuce, tomatoes, and sour cream, beans, rice and a beer. • One had a taco salad and a diet soda. • 1 case ate at Location B on April 19 • Had a chiles rellenos with beans, rice, and a margarita. • CO Department of Health reports 2 of cases in CO residents who attended the same conference in San Diego • Both cases ate in a number of restaurants including several different “Mexican-style” ones • The paid cash for meals and did not save the receipts This is an outbreak scenario, not a real outbreak

  29. June 16 – LosBuenos Information • No food handlers reported ill upon inspection at either locations • No major violations noted • Salsa made fresh in house and provided at no cost to all customers on arrival • Salsa recipe: fresh tomatoes; onions; canned green chilies; canned jalapeno peppers; garlic; salt; and lime juice • Fresh produce provided by “San Diego Fresh Cuts, Inc” This is an outbreak scenario, not a real outbreak

  30. Preliminary Case-Control StudyResults, as of June 16 Unmatched Matched ExposureCasesControlsOR(p-value)mOR(p-value) Fresh tomato 42/45 (93%) 104/141 (73%) 5.0 (0.02) 6.1 (0.01) Fresh tomato outside the home38/42 (91%) 36/104 (35%) 17.6 (>0.001) 16.8 (>0.001) Ground Beef 34/42 (81%) 110/141 (78%) 1.2 (0.68) 1.9 (0.48) Lettuce 37/45 (82%) 105/141 (75%) 1.6 (0.14) 1.4 (0.23) “Bagged Lettuce” 25/45 (56%) 58/90 (64%) 1.3 (0.59) 1.4 (0.48) Cheese 38/45 (84%) 120/141 (85%) 1.0 (0.90) 1.2 (0.65) Apples 23/37 (62%) 70/140 (50%) 1.6 (0.19) 1.3 (0.35) Strawberries 23/40 (45%) 57/142 (40%) 1.2 (0.35) 1.6 (0.17) No other food item was statistically associated with illness This is an outbreak scenario, not a real outbreak

  31. Discussion – III (until 2:15)What are next steps? • What is the most likely cause of this outbreak? • Has a product been “implicated”? • Do you want to traceback any food item(s)? • Which one(s) and why or why not? • If so, how would you identify production lots and fields? • What is the role of industry? • Does the public needs to know now (June 17)? • What are the next steps? This is an outbreak scenario, not a real outbreak

  32. Part 4: Resolution/Deceleration2:15 – 2:35 This is an outbreak scenario, not a real outbreak

  33. Distributor Information from Identified Clusters for fresh produce items • Review of “Distributor A” invoices for the two weeks before cases ate finds the Columbus fast food store location received: • Romaine as well as iceberg lettuce • Red, round tomatoes (no other type) • No fresh cilantro • No fresh hot peppers • Review of “Distributor B” invoices for the two weeks before cases became ill finds the nursing home received • Only romaine lettuce (no iceberg) • Red, round tomatoes (no other type) • No fresh cilantro • No fresh hot peppers • Review of “San Diego Fresh Cuts“ invoices for the two weeks before cases ate finds LosBuenos received • Only iceberg lettuce (no romaine) • Both red, round and “salsa buena“ tomatoes • Fresh cilantro • No fresh hot peppers This is an outbreak scenario, not a real outbreak

  34. Traceback Activities • FDA works with CA, OH, and PA to traceback red, round tomatoes from: • Fast food location in Columbus, OH (Sysco/Distributor A) • The nursing home in Pittsburgh, PA (Sysco/Distributor B) • Both LosBuenos locations in San Diego, CA (Fresh Cuts, Inc.) This is an outbreak scenario, not a real outbreak

  35. Tomato Traceback Information • Sysco/Distributor A delivered red, round tomatoes to the Columbus fast food store location on: • April 5 (3 boxes), April 10 (5 boxes), April 16 (4 boxes), April 20 (5 boxes) • Sysco/Distributor B delivered red, round tomatoes to the nursing home on: • April 16 (3 box), April 23 (3 boxes), May 3 (2 boxes) • “San Diego Fresh Cuts, Inc” delivered red, round tomatoes to LosBuenos: • April 6 (2 boxes), April 10 (3 boxes), April 14 (2 boxes), April 17 (2 boxes), April 19 (2 boxes) This is an outbreak scenario, not a real outbreak

  36. Simplified Tomato Traceback Fast Food Columbus, OH Sysco/Distributor A Columbus, OH Sysco DC Nashville, TN Nursing Home Pittsburgh, PA Sysco/Distributor B Pittsburgh, PA Farm A (April 15 Harvest Date) Pelicano Island, MX Grower X Pelicano Island, MX LosBuenos (Location 1) San Diego, CA Fresh Cuts San Diego, CA LosBuenos (Location 2) San Diego, CA This is an outbreak scenario, not a real outbreak

  37. Traceback Summary of Farm A Red, Round Tomatoes Harvested on April 15 • “San Diego Fresh Cuts” purchased 15 cases of Farm A tomatoes on April 16 • LosBuenos purchased 10 cases of Farm A  tomatoes from “Fresh Cuts” on April 17 • The Sysco Nashville DC received 100 cases of Farm A red, round tomatoes on April 18 • The Wendy’s in Columbus, OH received 5 boxes of Farm A tomatoes on April 20 • The nursing home in Pittsburgh, PA received 2 boxes of Farm A on May 3 • The April 18 shipment of Farm A tomatoes had been repacked by the Nashville DC This is an outbreak scenario, not a real outbreak

  38. States Where Persons Infected with the Outbreak Strain of Salmonella Live by State, April 1 to June 18, 2012(n=59) NH 1 MA 1 NJ 1 PA 14 OH 11 IN 3 IL 6 WV 2 CO 3 KY 7 CA 5 TN 6 • 59 cases in 11 states • 29 hospitalizations (49%), • 2 reported deaths • One associated with the nursing home in PA • One a KY resident This is an outbreak scenario, not a real outbreak

  39. Infections with the Outbreak Strain of Salmonella by Illness Onset Date, April 1 to June 18, 2012 (n=59) Illnesses occurring after May 17 might not yet be reported due to the time it takes between when a person becomes ill and when the illness is reported PulseNetidentifies cluster (May 19) 1-Apr 18-June 1-May 1-June 7-Apr 7-May 21-May 14-May 27-May 14-Apr 21-Apr 39 This is an outbreak scenario, not a real outbreak

  40. Discussion – IV (until 2:35) Next Steps? • Was this an outbreak? • What is the most likely cause of this outbreak? • Should there be a recall now (June 18)? • Why or why not? • Do you trace forward any food items? • If so, what? • Does the public need to know? • Why or why not? • Does the fact that this is a multidrug resistant strain matter? • Does the fact that two people with the outbreak strain died matter? • Should a root cause analysis be done? This is an outbreak scenario, not a real outbreak

  41. Wrap up(Until 2:45) This is an outbreak scenario, not a real outbreak Questions and Answers?

  42. Some Concluding Thoughts It is critical that public health, regulatory, and industry partners work together as hypotheses emerge and are tested. Importance of traceability in identifying the source in fresh produce outbreaks. Helping identify what the source is not likely to be. Speed, Accuracy and Collaboration arebeneficial to all involved. 42 This is an outbreak scenario, not a real outbreak

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