Cake Decorating Luster Dust Associated with Toxic Metal Poisonings - Rhode Island and Missouri, 2018-2019.

During 2018-2019, the Rhode Island Department of Health (RIDOH) and the Missouri Department of Health and Senior Services (DHSS) investigated cases of metal poisonings associated with commercially and home-prepared cakes decorated with products referred to as luster dust. Several types of glitters and dusts, broadly known as luster dust,* for use on prepared foods can be purchased online and in craft and bakery supply stores (1). Decorating foods with luster dust and similar products is a current trend, popularized on television programs, instructional videos, blogs, and in magazine articles.† Some luster dusts are specifically produced with edible ingredients that can be safely consumed. Companies that make edible luster dust are required by law to include a list of ingredients on the label (2). Luster dusts that are safe for consumption are typically marked "edible" on the label. Some luster dusts used as cake decorations are not edible or food grade; labeled as "nontoxic" or "for decorative purposes only," these luster dusts are intended to be removed before consumption (3). RIDOH (2018) and Missouri DHSS (2019), investigated heavy metal poisonings associated with commercially and home-prepared cakes decorated with luster dust after receiving reports of children (aged 1-11 years) who became ill after consuming birthday cake. Cases in Rhode Island were associated with copper ingestion, and the case in Missouri was associated with a child's elevated blood lead level. In Rhode Island, luster dust products that had been used in cake frosting were found to contain high levels of multiple metals.§ These events indicate that increased vigilance by public health departments and further guidance to consumers and bakeries are needed to prevent unintentional poisonings. Labeling indicating that a product is nontoxic does not imply that the product is safe for consumption. Explicit labeling indicating that nonedible products are not safe for human consumption is needed to prevent illness from inappropriate use of inedible products on foods. Educating consumers, commercial bakers, and public health professionals about potential hazards of items used in food preparation is essential to preventing illness and unintentional poisoning from toxic metals and other nonedible ingredients.

Whole-Genome Sequencing Detection of Ongoing Listeria Contamination at a Restaurant, Rhode Island, USA, 2014.

In November 2014, the Rhode Island Department of Health investigated a cluster of 3 listeriosis cases. Using whole-genome sequencing to support epidemiologic, laboratory, and environmental investigations, the department identified 1 restaurant as the likely source of the outbreak and also linked the establishment to a listeriosis case that occurred in 2013.

Anaemia prevalence may be reduced among countries that fortify flour.

The effectiveness of flour fortification in reducing anaemia prevalence is equivocal. The goal was to utilise the existing national-level data to assess whether anaemia in non-pregnant women was reduced after countries began fortifying wheat flour, alone or in combination with maize flour, with at least Fe, folic acid, vitamin A or vitamin B12. Nationally representative anaemia data were identified through Demographic and Health Survey reports, the WHO Vitamin and Mineral Nutrition Information System database and other national-level nutrition surveys. Countries with at least two anaemia surveys were considered for inclusion. Within countries, surveys were excluded if altitude was not consistently adjusted for, or if the blood-draw site (e.g. capillary or venous) or Hb quantification method (e.g. HemoCue or Cyanmethaemoglobin) differed. Anaemia prevalence was modelled for countries that had pre- and post-fortification data (n 12) and for countries that never fortified flour (n 20) using logistic regression models that controlled for time effects, human development index (HDI) and endemic malaria. After adjusting for HDI and malaria, each year of fortification was associated with a 2.4% reduction in the odds of anaemia prevalence (PR 0.976, 95% CI 0.975, 0.978). Among countries that never fortified, no reduction in the odds of anaemia prevalence over time was observed (PR 0.999, 95% CI 0.997, 1.002). Among both fortification and non-fortification countries, HDI and malaria were significantly associated with anaemia (P,0.001). Although this type of evidence precludes a definitive conclusion, results suggest that after controlling for time effects, HDI and endemic malaria, anaemia prevalence has decreased significantly in countries that fortify flour with micronutrients, while remaining unchanged in countries that do not.

Potential quantitative effect of a laboratory-based approach to Lyme disease surveillance in high-incidence states.

Historically, public health surveillance for Lyme disease has required clinical follow-up on positive laboratory reports for the purpose of case classification. In areas with sustained high incidence of the disease, this resource-intensive activity yields a limited benefit to public health practice. A range of burden-reducing strategies have been implemented in many states, creating inconsistencies that limit the ability to decipher trends. Laboratory-based surveillance, or surveillance based solely on positive laboratory reports without follow-up for clinical information on positive laboratory reports, emerged as a feasible alternative to improve standardization in already high-incidence areas. To inform expectations of a laboratory-based surveillance model, we conducted a retrospective analysis of Lyme disease data collected during 2012-2018 from 10 high-incidence states. The number of individuals with laboratory evidence of infection ranged from 1302 to 20,994 per state and year. On average, 55% of those were ultimately classified as confirmed or probable cases (range: 29%-86%). Among all individuals with positive laboratory evidence, 18% (range: 2%-37%) were determined to be 'not a case' upon investigation and 23% (range: 2%-52%) were classified as suspect cases due to lack of associated clinical information and thus were not reported to the Centers for Disease Control and Prevention (CDC). The number of reported cases under a laboratory-based approach to surveillance in high-incidence states using recommended two-tier testing algorithms is likely to be, on average, 1.2 times higher (range: 0.6-1.8 times) than what was reported to CDC during 2012-2018. A laboratory-based surveillance approach for high-incidence states will improve standardization and reduce burden on public health systems, allowing public health resources to focus on prevention messaging, exploration of novel prevention strategies and alternative data sources to yield information on the epidemiology of Lyme disease.

A Case Report of Cake Frosting as a Source of Copper Toxicity in a Pediatric Patient.

INTRODUCTION: Copper is an uncommon source of metal toxicity in children that requires a high index of suspicion for diagnosis. CASE REPORT: We describe the unique presentation of a 12-month-old girl who developed acute onset of vomiting and diarrhea after ingestion of a copper-contaminated birthday cake. CONCLUSION: This case highlights the presentation, evaluation, and management of the rare pediatric patient who presents with copper poisoning. This case also illuminates the public health implications of potential metal poisoning when using non-edible decorative products in homemade and commercially prepared baked goods.

Evidence of Failure of Oral Third-Generation Cephalosporin Treatment for Shigella sonnei Infection.

In 2017, state health departments notified the Centers for Disease Control and Prevention about 4 patients with shigellosis who experienced persistent illness after treatment with oral third-generation cephalosporins. Given increasing antibiotic resistance among Shigella, these cases highlight the need to evaluate the efficacy of oral cephalosporins for shigellosis.

Rhode Island Lyme Disease Surveillance Summary 2014-2016.

[Full article available at http://rimed.org/rimedicaljournal-2017-11.asp].

Preventing Foodborne and Enteric Illnesses Among At-Risk Populations in the United States and Rhode Island.

One out of every six people in the United States is estimated to become sick each year from pathogens that can cause foodborne illness. The groups at greatest risk for serious illness, hospitalization, or death include young children, older adults, people with chronic conditions, and pregnant women. Such health disparities must be considered along with those disparities that may exist among racial and ethnic groups and among groups of varying socioeconomic status. We analyzed risk profiles for enteric disease using data from Rhode Island and the nation as a whole, exploring disparities among groups defined by demographic and health characteristics. As expected, disparities in the burden of enteric illnesses are not limited to racial or ethnic differences in disease burden, or in differences otherwise attributable to socioeconomic status. Age is an especially important determinant of risk, as is residential status. Other groups found to be especially vulnerable to foodborne and enteric illnesses in Rhode Island include pregnant women and those with certain health conditions (e.g., cancer, liver disease or immunosuppression). By understanding what groups are at increased risk, providers can more effectively counsel their patients to mitigate risk and effectively treat these conditions. [Full article available at http://rimed.org/rimedicaljournal-2016-11.asp].

Food Allergy Knowledge and Attitudes of Restaurant Managers and Staff: An EHS-Net Study.

Dining outside of the home can be difficult for persons with food allergies who must rely on restaurant staff to properly prepare allergen-free meals. The purpose of this study was to understand and identify factors associated with food allergy knowledge and attitudes among restaurant managers, food workers, and servers. This study was conducted by the Environmental Health Specialists Network (EHS-Net), a collaborative forum of federal, state, and local environmental health specialists working to understand the environmental factors associated with food safety issues. EHS-Net personnel collected data from 278 randomly selected restaurants through interviews with restaurant managers, food workers, and servers. Results indicated that managers, food workers, and servers were generally knowledgeable and had positive attitudes about accommodating customers' food allergies. However, we identified important gaps, such as more than 10% of managers and staff believed that a person with a food allergy can safely consume a small amount of that allergen. Managers and staff also had lower confidence in their restaurant's ability to properly respond to a food allergy emergency. The knowledge and attitudes of all groups were higher at restaurants that had a specific person to answer food allergy questions and requests or a plan for answering questions from food allergic customers. However, food allergy training was not associated with knowledge in any of the groups but was associated with manager and server attitudes. Based on these findings, we encourage restaurants to be proactive by training staff about food allergies and creating plans and procedures to reduce the risk of a customer having a food allergic reaction.

Anaemia prevalence over time in Indonesia: estimates from the 1997, 2000, and 2008 Indonesia Family Life Surveys.

OBJECTIVE: To summarize anaemia prevalence data for children, women, and men using data from the second, third and fourth waves of the Indonesia Family Life Surveys (IFLS), which were conducted in 1997/8, 2000, and 2007/8, respectively. METHODS: Anaemia prevalence was determined for children 0 to 5 years, 5 to 12 years, 12 to 15 years, non-pregnant women at least 15 years, pregnant women at least 15 years, and men at least 15 years, based on haemoglobin adjusted for altitude and smoking status. RESULTS: Compared with 1997/8 estimates, anaemia prevalence estimates were lower in 2007/8 for all groups, with the greatest relative decline occurring in children 5 to 12 years (25.4%). Trend analysis found anaemia significantly declined over the survey years for all groups (χ² p=0.005 for pregnant women, χ² p<0.001 for all other groups). CONCLUSIONS: IFLS anaemia estimates for different population groups decreased between 1997/8 and 2007/8 and were consistent with estimates from Southeast Asia, and with other studies conducted in Indonesia. While the prevalence of anaemia consistently decreased in all groups, anaemia remains a moderate public health problem for children 0 to 5 years, children 5 to 12 years, and non-pregnant and pregnant women.

Health disparities around the world: perspectives from the 2012 Principles and Practice of Cancer Prevention and Control course at the National Cancer Institute.

INTRODUCTION: The National Cancer Institute Principles and Practice of Cancer Prevention and Control course is a 4-week course encompassing a variety of cancer prevention and control topics that is open to attendees from medical, academic, government, and related institutions around the world. Themes related to the challenges health disparities present to cancer prevention efforts and potential solutions to these issues emerged from facilitated group discussions among the 2012 course participants. MATERIALS AND METHODS: Small-group discussion sessions with participants (n = 85 from 33 different countries) and facilitators (n = 9) were held once per week throughout the 4-week course. Facilitators prepared open-ended questions related to course topics. Participants provided responses reflecting their opinions of topics on the basis of experiences in their countries. A thematic analysis was conducted to explore themes emerging from the discussion groups. RESULTS: The varied influences of health disparities on cancer prevention efforts among > 30 countries represented prominent themes across discussion groups. Participants discussed the interplay of individual characteristics, including knowledge and culture, interpersonal relationships such as family structure and gender roles, community and organizational factors such as unequal access to health care and access to treatment, and national-level factors including policy and government structure. CONCLUSION: The ideas and solutions presented here are from a geographically and professionally diverse group of individuals. The collective discussion highlighted the pervasiveness of health disparities across all areas represented by course participants and suggested that disparities are the largest impediment to achieving cancer prevention goals.