Responding to outbreaks of illness linked to unpasteurized milk: A needs assessment of state health and agriculture departments.

AIMS: Consumption of unpasteurized milk can result in severe illness or death. In the United States, the number of people who regularly consume unpasteurized milk is relatively low, but outbreaks resulting from unpasteurized milk outnumber outbreaks linked to pasteurized milk. The sale of unpasteurized milk for human consumption through interstate commerce is prohibited at the federal level, but laws among states vary considerably with respect to the sale of unpasteurized milk. Each state has a different perspective on responding to and preventing outbreaks of illness linked to consuming unpasteurized milk. METHODS AND RESULTS: We conducted a needs assessment of state health and agriculture departments to gather information on state-level strategies to prevent illnesses linked to consuming unpasteurized milk, characterize challenges states face, and identify areas where partners can support state efforts to prevent illnesses. We deployed a survey from 6 January 2021 to 1 March 2021, using a snowball sampling strategy and had 158 respondents. Of 115 respondents, 46 (40%) believed that state laws were ineffective in preventing illnesses, and 92 (80%) agreed that consumers continue to find ways to get unpasteurized milk despite laws restricting sale. Respondents from 19 states were aware of future legislative or regulatory efforts surrounding unpasteurized milk in their state, with 14 (74%) indicating these efforts would expand consumer access. The most common outbreak prevention strategies respondents mentioned included sharing knowledge and experiences with other public health and agriculture officials, providing information to inform legislative efforts, and communicating to the public about outbreaks. Most respondents (41/50, 91%) were interested in pursuing further efforts to prevent unpasteurized milk-associated illnesses in their state. CONCLUSIONS: The results from this needs assessment can be used to inform future strategies for preventing illness outbreaks associated with unpasteurized milk consumption.

Effect of Ground Beef Irradiation on Annual Nontyphoidal Salmonella and Escherichia coli O157 Burden and Direct Healthcare Costs in the United States: A Simulation Study.

Over 20% of E. coli O157 illnesses and over 5% of Salmonella illnesses are estimated to be attributable to beef consumption in the United States. Irradiating ground beef is one possible method to reduce disease burden. We simulated the effect of ground beef irradiation on illnesses, hospitalizations, deaths, and direct healthcare costs from ground beef-associated E. coli O157 and Salmonella illnesses in the United States. To estimate the fraction of illnesses, hospitalizations, deaths, and direct healthcare costs preventable by ground beef irradiation, we multiplied the disease burden attributable to ground beef; the estimated percentage of ground beef sold that is not currently irradiated; the percentage of unirradiated ground beef that would be irradiated; and the percentage reduction in risk of illness after irradiation. We multiplied this fraction by estimates of burden and direct healthcare costs to calculate the numbers or amounts averted. Model inputs were obtained from the literature and expert opinion. We used Monte Carlo simulation to incorporate uncertainty in inputs into model estimates. Simulation outcomes were summarized with means and 95% uncertainty intervals (UI). Irradiating 50% of the currently unirradiated ground beef supply would avert 3,285 (95% UI: 624-9,977) E. coli O157 illnesses, 135 (95% UI: 24-397) hospitalizations, 197 (95% UI: 34-631) hemolytic uremic syndrome cases, 2 (95% UI: 0-16) deaths, and $2,972,656 (95% UI: $254,708-$14,496,916) in direct healthcare costs annually. For Salmonella, irradiation would avert 20,308 (95% UI: 9,858-38,903) illnesses, 400 (95% UI: 158-834) hospitalizations, 6 (95% UI: 0-18) deaths, and $7,318,632 (95% UI: $1,436,141-$26,439,493) in direct healthcare costs. Increasing ground beef irradiation could reduce E. coli O157 and Salmonella burden in the United States. Additional studies should assess whether targeted irradiation of higher-risk ground beef products could prevent similar numbers of illnesses with less total product irradiated.

Appliances Used by Consumers to Prepare Frozen Stuffed Chicken Products - United States, May-July 2022.

Frozen stuffed breaded raw chicken products have repeatedly been implicated in Salmonella outbreaks (1). These products are partially cooked to set the breading, often making them appear cooked (2). Despite their appearance, these products need to be cooked to an internal temperature of 165°F (74°C) to ensure that they are safe to eat. Producers began implementing labeling changes in 2006 to more clearly identify these products as raw; many warn against using microwave ovens (microwaves) to prepare them and provide validated cooking instructions solely for conventional ovens (ovens) (3,4). However, outbreaks continued to occur after implementation of these labeling changes (4). To describe the demographic characteristics of persons who prepare frozen stuffed chicken products and which appliances they use to prepare them, data from a May-July 2022 representative panel survey were analyzed. Although most (82.7%) respondents used an oven as one of their cooking methods, more than one half (54.0%) of respondents also used another appliance, including 29.0% who used a microwave. Oven use was lower among respondents with household income <$25,000 (68.9%), and who lived in mobile homes or other portable types of homes (66.5%). Among respondents who reported using microwaves to cook these products, 8% reported using a microwave with ≤750 W of power, which might be insufficient to thoroughly cook such products (1,5,6). Economic and other factors might influence some groups' access to recommended cooking appliances. Companies could consider implementing additional interventions that rely less on labeling and consumer preparation practices and focus on controlling or reducing levels of Salmonella in these products, such as selling them fully cooked, or monitoring and testing Salmonella levels, to ensure safety. These findings highlight challenges consumers might face in preparing frozen stuffed chicken products safely and can guide strategies for regulatory authorities and industry to prevent outbreaks and illnesses associated with them.

A Qualitative Content Analysis of Responses to CDC's Foodborne Outbreak Messages on Facebook.

The Centers for Disease Control and Prevention (CDC) coordinates investigations of multistate foodborne outbreaks. To better inform future communication efforts with the public during these outbreaks, we conducted a qualitative content analysis of comments on multistate foodborne outbreak Facebook posts distributed on the CDC's Facebook page September to December 2018. The CDC created 27 Facebook posts for nine multistate foodborne outbreaks (one to eight posts per outbreak), and 2,612 comments were analyzed. The CDC used two Web tools to deliver outbreak information: food safety alerts (FSAs) and investigation notices (INs). Qualitative analyses were conducted separately for Facebook posts resulting from FSAs and INs. Using an inductive coding approach, we identified nine categories of comments: information sharing (e.g., tagging others), actions (e.g., discarding contaminated food), convictions and beliefs (e.g., food-related preconceived notions), questions (e.g., clarifying outbreak location), emotional responses (e.g., worry), blame (e.g., responsibility for outbreak), food specific (e.g., repackaging ground beef and losing identifying information), promoting another cause (e.g., vaccine hesitancy), and unrelated. No differences were found between FSAs and INs. Facebook users helped further disseminate important outbreak information but identified barriers that prevented them from taking recommended actions. Real-time evaluation of social media during outbreaks provides opportunities to refine messaging and improve communication.

A Qualitative Evaluation of the Centers for Disease Control and Prevention Risk Communication Methods during Multistate Foodborne Outbreaks.

Many efforts across the farm-to-fork continuum aim to reduce foodborne disease and outbreaks. Real-time risk communication is an important component of the Centers for Disease Control and Prevention (CDC) efforts, especially during outbreaks. To inform risk communication with the public during multistate foodborne outbreaks, we conducted a series of focus groups of adults in the Washington, D.C., metropolitan area to understand attitudes, perceptions, behaviors, and how people receive information around foodborne disease outbreaks. Results from these focus groups provided insight on factors that might influence consumer perception and behavior during an outbreak. Perceived outbreak proximity and personal consumption of an outbreak vehicle were identified as also reported hearing about multiple outbreaks per year some drivers of perceived risk to an outbreak. Participants through a variety of sources and following recommended actions during an outbreak, implying some existing penetration of current risk messages for multistate foodborne outbreaks. Findings from these focus groups are a first step in increasing understanding of how CDC messages affect the consumers' ability to access and act upon reliable information to protect their health during outbreaks and serve as a baseline for further evaluation efforts of CDC risk communication strategy for multistate foodborne outbreaks.

Investigations of Possible Multistate Outbreaks of Salmonella, Shiga Toxin-Producing Escherichia coli, and Listeria monocytogenes Infections - United States, 2016.

PROBLEM/CONDITION: Salmonella, Shiga toxin-producing Escherichia coli (STEC), and Listeria monocytogenes are the leading causes of multistate foodborne disease outbreaks in the United States. Responding to multistate outbreaks quickly and effectively and applying lessons learned about outbreak sources, modes of transmission, and risk factors for infection can prevent additional outbreak-associated illnesses and save lives. This report summarizes the investigations of multistate outbreaks and possible outbreaks of Salmonella, STEC, and L. monocytogenes infections coordinated by CDC during the 2016 reporting period. PERIOD COVERED: 2016. An investigation was considered to have occurred in 2016 if it began during 2016 and ended on or before March 31, 2017, or if it began before January 1, 2016, and ended during March 31, 2016-March 31, 2017. DESCRIPTION OF SYSTEM: CDC maintains a database of investigations of possible multistate foodborne and animal-contact outbreaks caused by Salmonella, STEC, and L. monocytogenes. Data were collected by local, state, and federal investigators during the detection, investigation and response, and control phases of the outbreak investigations. Additional data sources used for this report included PulseNet, the national molecular subtyping network based on isolates uploaded by local, state, and federal laboratories, and the Foodborne Disease Outbreak Surveillance System (FDOSS), which collects information from state, local, and territorial health departments and federal agencies about single-state and multistate foodborne disease outbreaks in the United States. Multistate outbreaks reported to FDOSS were linked using a unique outbreak identifier to obtain food category information when a confirmed or suspected food source was identified. Food categories were determined and assigned in FDOSS according to a classification scheme developed by CDC, the Food and Drug Administration (FDA), and the U.S. Department of Agriculture Food Safety and Inspection Service (FSIS) in the Interagency Food Safety Analytics Collaboration. A possible multistate outbreak was determined by expert judgment to be an outbreak if supporting data (e.g., temporal, geographic, demographic, dietary, travel, or food history) suggested a common source. A solved outbreak was an outbreak for which a specific kind of food or animal was implicated (i.e., confirmed or suspected) as the source. Outbreak-level variables included number of illnesses, hospitalizations, cases of hemolytic uremic syndrome (HUS), and deaths; the number of states with illnesses; date of isolation for the earliest and last cases; demographic data describing patients associated with a possible outbreak (e.g., age, sex, and state of residence); the types of data collected (i.e., epidemiologic, traceback, or laboratory); the outbreak source, mode of transmission, and exposure location; the name or brand of the source; whether the source was suspected or confirmed; whether a food was imported into the United States; the types of regulatory agencies involved; whether regulatory action was taken (and what type of action); whether an outbreak was publicly announced by CDC via website posting; beginning and end date of the investigation; and general comments about the investigation. The number of illnesses, hospitalizations, cases of HUS, and deaths were characterized by transmission mode, pathogen, outcome (i.e., unsolved, solved with suspected source, or solved with confirmed source), source, and food or animal category. RESULTS: During the 2016 reporting period, 230 possible multistate outbreaks were detected and 174 were investigated. A median of 24 possible outbreaks was under investigation per week, and investigations were open for a median of 37 days. Of these 174 possible outbreaks investigated, 56 were excluded from this analysis because they occurred in a single state, were linked to international travel, or were pseudo-outbreaks (e.g., a group of similar isolates resulting from laboratory media contamination rather than infection in patients). Of the remaining 118 possible multistate outbreaks, 50 were determined to be outbreaks and 39 were solved (18 with a confirmed food source, 10 with a suspected food source, 10 with a confirmed animal source, and one with a suspected animal source). Sprouts were the most commonly implicated food category in solved multistate foodborne outbreaks (five). Chicken was the source of the most foodborne outbreak-related illnesses (134). Three outbreaks involved novel food-pathogen pairs: flour and STEC, frozen vegetables and L. monocytogenes, and bagged salad and L. monocytogenes. Eleven outbreaks were attributed to contact with animals (10 attributed to contact with backyard poultry and one to small turtles). Thirteen of 18 multistate foodborne disease outbreaks with confirmed sources resulted in product action, including 10 outbreaks with recalls, two with market withdrawals, and one with an FSIS public health alert. Twenty outbreaks, including 11 foodborne and nine animal-contact outbreaks, were announced to the public by CDC via its website, Facebook, and Twitter. These announcements resulted in approximately 910,000 webpage views, 55,000 likes, 66,000 shares, and 5,800 retweets. INTERPRETATION: During the 2016 reporting period, investigations of possible multistate outbreaks occurred frequently, were resource intensive, and required a median of 37 days of investigation. Fewer than half (42%) of the 118 possible outbreaks investigated were determined to have sufficient data to meet the definition of a multistate outbreak. Moreover, of the 50 outbreaks with sufficient data, approximately three fourths were solved. PUBLIC HEALTH ACTION: Close collaboration among CDC, FDA, FSIS and state and local health and agriculture partners is central to successful outbreak investigations. Identification of novel outbreak sources and trends in sources provides insights into gaps in food safety and safe handling of animals, which helps focus prevention strategies. Summarizing investigations of possible multistate outbreaks can provide insights into the investigative process, improve future investigations, and help prevent illnesses. Although identifying and investigating possible multistate outbreaks require substantial resources and investment in public health infrastructure, they are important in determining outbreak sources and implementing prevention and control measures.

Incorporating the Six Core Elements of Health Care Transition Into a Medicaid Managed Care Plan: Lessons Learned From a Pilot Project.

This pediatric-to-adult health care transition pilot project describes the process and results of incorporating the "Six Core Elements of Health Care Transition (2.0)" into a Medicaid managed care plan with a group of 35 18-23 year olds who have chronic mental health, developmental, and complex medical conditions. The pilot project demonstrated an effective approach for customizing and delivering recommended transition services. At the start of the 18-month project, the Medicaid plan was at the basic level (1) of transition implementation of the Six Core Elements with no transition policy, member transition readiness assessment results, health care transition plans of care, updated medical summaries, transfer package for the adult-focused provider, and assurance of transfer completion and consumer feedback. At the conclusion of the pilot project, the plan scored at level 3 on each core element. The primary reason for not scoring at the highest level (4) was because the transition elements have not been incorporated into services for all enrollees within the plan. Future efforts in managed care will benefit from starting the transition process much earlier (ages 12-14), expanding the role of nurse care managers and participating pediatric and adult-focused clinicians in transition, and offering payment incentives to clinicians to implement the Six Core Elements of Health Care Transition.