Exploring the association of weather variability on Campylobacter - A systematic review.

BACKGROUND: Previous work has found climate change-induced weather variability is suspected to increase the transmission of enteric pathogens, including Campylobacter, a leading cause of bacterial gastroenteritis. While the relationship between extreme weather events and diarrheal diseases has been documented, the specific impact on Campylobacter infections remains underexplored. OBJECTIVE: To synthesize the peer-reviewed literature exploring the effect of weather variability on Campylobacter infections in humans. METHODS: The review included English language, peer-reviewed articles, published up to September 1, 2022 in PubMed, Embase, GEOBASE, Agriculture and Environmental Science Database, and CABI Global Health exploring the effect of an antecedent weather event on human enteric illness caused by Campylobacter (PROSPERO Protocol # 351884). We extracted study information including data sources, methods, summary measures, and effect sizes. Quality and weight of evidence reported was summarized and bias assessed for each article. RESULTS: After screening 278 articles, 47 articles (34 studies, 13 outbreak reports) were included in the evidence synthesis. Antecedent weather events included precipitation (n = 35), temperature (n = 30), relative humidity (n = 7), sunshine (n = 6), and El Niño and La Niña (n = 3). Reviewed studies demonstrated that increases in precipitation and temperature were correlated with Campylobacter infections under specific conditions, whereas low relative humidity and sunshine were negatively correlated. Articles estimating the effect of animal operations (n = 15) found presence and density of animal operations were significantly associated with infections. However, most of the included articles did not assess confounding by seasonality, presence of animal operations, or describe estimates of risk. DISCUSSION: This review explores what is known about the influence of weather events on Campylobacter and identifies previously underreported negative associations between low relative humidity and sunshine on Campylobacter infections. Future research should explore pathogen-specific estimates of risk, which can be used to influence public health strategies, improve source attribution and causal pathways, and project disease burden due to climate change.

A Prediction Tool to Identify the Causative Agent of Enteric Disease Outbreaks Using Outbreak Surveillance Data.

Information on the causative agent in an enteric disease outbreak can be used to generate hypotheses about the route of transmission and possible vehicles, to guide environmental assessments, and to target outbreak control measures. However, only about 40% of outbreaks reported in the United States include a confirmed etiology. The goal of this project was to identify clinical and demographic characteristics that can be used to predict the causative agent in an enteric disease outbreak and to use these data to develop an online tool for investigators to use during an outbreak when hypothesizing about the causative agent. Using data on enteric disease outbreaks from all transmission routes (animal contact, environmental contamination, foodborne, person-to-person, waterborne, unknown) reported to the U.S. Centers for Disease Control and Prevention, we developed random forest models to predict the etiology of an outbreak based on aggregated clinical and demographic characteristics at both the etiology category (i.e., bacteria, parasites, toxins, viruses) and individual etiology (Clostridium perfringens, Campylobacter, Cryptosporidium, norovirus, Salmonella, Shiga toxin-producing Escherichia coli, and Shigella) levels. The etiology category model had a kappa of 0.85 and an accuracy of 0.92, whereas the etiology-specific model had a kappa of 0.75 and an accuracy of 0.86. The highest sensitivities in the etiology category model were for bacteria and viruses; all categories had high specificities (>0.90). For the etiology-specific model, norovirus and Salmonella had the highest sensitivity and all etiologies had high specificities. When laboratory confirmation is unavailable, information on the clinical signs and symptoms reported by people associated with the outbreak, with other characteristics including case demographics and illness severity, can be used to predict the etiology or etiology category. An online publicly available tool was developed to assist investigators in their enteric disease outbreak investigations.

Collecting a Sexual History During Shigellosis Case Investigations: Nationwide Practices and an Assessment of Data Quality.

Shigellosis is spread through the fecal-oral route, including sexual activity. The Centers for Disease Control and Prevention recommends collecting a sexual history from people diagnosed with shigellosis to enhance the understanding of its epidemiology and outbreak detection and the design of disease prevention messaging, although individual jurisdictions decide if and how this is done. Moreover, enteric disease interviewers typically receive in-depth general interviewing training, but often not sexual history question training. The goal of this project was to inform national practices around sexual history questions asked during shigellosis interviews by collecting information from U.S. state health agencies and evaluating sexual history data from people diagnosed with shigellosis in Colorado. From November 2021 to January 2022, information on sexual history questions asked of persons with reported shigellosis and accompanying training resources were collected from U.S. state health departments. Data completeness and quality of shigellosis sexual history questions from Colorado's notifiable disease database from 2018 to 2022 were also evaluated. Of 48 states, 54% reported routinely asking all adults about their sexual history during shigellosis interviews. Of 44 states, 18% indicated having accompanying training materials for interviewers. In Colorado, the proportion of unknown/missing responses to questions about recent sexual contact with male and female partners was lower for males (3.3% unknown and 3.3% missing) than females (5.4% and 6.2%) and highest among those 66 years and older (6.7% and 10%). Among those reporting new sexual partners, 93.5% indicated how they met. The evaluation of Colorado data demonstrates that routine collection of complete, high-quality, actionable sexual history data from all adults with reported shigellosis is feasible. Nearly half of the responding states indicated not doing so, and few had training resources. We recommend training enteric disease interviewers to routinely ask all adults with reported shigellosis about their sexual history, including new partner meeting location.

The Need for Responsive Workforce Development During the Pandemic and Beyond: A Case Study of the Regional Public Health Training Centers.

CONTEXT: The COVID-19 pandemic underscored the importance of a strong public health infrastructure for protecting and supporting the health of communities. This includes ensuring an adaptive workforce capable of leading through rapidly changing circumstances, communicating effectively, and applying systems thinking to leverage cross-sector partnerships that help promote health equity. The 10 Regional Public Health Training Centers (PHTCs) advance the capacity of the current and future public health workforce through skill development and technical assistance in these and other strategic areas. PROGRAM: This study examines activities through which the Regional PHTCs and their partners supported the public health workforce during the pandemic. Representatives of the 10 Regional PHTCs completed a survey in the spring of 2022. The survey included (1) pulling trends in training usage from 2018-2021 annual performance reports and (2) questions assessing the type, content, and reach of training needs assessments, training and technical assistance, student placements, and PHTC Network collaborative activities that occurred from January 1, 2020, to December 31, 2021. Respondents also reflected on trends in use, challenges, lessons learned, stories of impact, and future PHTC practice. EVALUATION: During the pandemic, the Regional PHTCs engaged in numerous efforts to assess needs, provide training and technical assistance to the practice community, facilitate projects that built student competency to support public health agency efforts, and collaborate as the PHTC Network on national-level initiatives. Across these activities, the Regional PHTCs adjusted their approaches and learned from each other in order to meet regional needs. DISCUSSION: The Regional PHTCs provided student and professional development in foundational public health knowledge and skills within their regions and nationally while being flexible and responsive to the changing needs of the field during the pandemic. Our study highlights opportunities for collaboration and adaptive approaches to public health workforce development in a postpandemic environment.

Preliminary Incidence and Trends of Infections Caused by Pathogens Transmitted Commonly Through Food - Foodborne Diseases Active Surveillance Network, 10 U.S. Sites, 2022.

Each year, infections from major foodborne pathogens are responsible for an estimated 9.4 million illnesses, 56,000 hospitalizations, and 1,350 deaths in the United States (1). To evaluate progress toward prevention of enteric infections in the United States, the Foodborne Diseases Active Surveillance Network (FoodNet) conducts surveillance for laboratory-diagnosed infections caused by eight pathogens transmitted commonly through food at 10 U.S. sites. During 2020-2021, FoodNet detected decreases in many infections that were due to behavioral modifications, public health interventions, and changes in health care-seeking and testing practices during the COVID-19 pandemic. This report presents preliminary estimates of pathogen-specific annual incidences during 2022, compared with average annual incidences during 2016-2018, the reference period for the U.S. Department of Health and Human Services' Healthy People 2030 targets (2). Many pandemic interventions ended by 2022, resulting in a resumption of outbreaks, international travel, and other factors leading to enteric infections. During 2022, annual incidences of illnesses caused by the pathogens Campylobacter, Salmonella, Shigella, and Listeria were similar to average annual incidences during 2016-2018; however, incidences of Shiga toxin-producing Escherichia coli (STEC), Yersinia, Vibrio, and Cyclospora illnesses were higher. Increasing culture-independent diagnostic test (CIDT) usage likely contributed to increased detection by identifying infections that would have remained undetected before widespread CIDT usage. Reducing pathogen contamination during poultry slaughter and processing of leafy greens requires collaboration among food growers and processors, retail stores, restaurants, and regulators.

Improving Foodborne Disease Surveillance and Outbreak Detection and Response Using Peer Networks-The Integrated Food Safety Centers of Excellence.

CONTEXT: Foodborne disease surveillance and outbreak investigations are foundational to the prevention and control of foodborne disease in the United States, where contaminated foods cause an estimated 48 million illnesses, 128 000 hospitalizations, and 3000 deaths each year. Surveillance activities and rapid detection and investigation of foodborne disease outbreaks require a trained and coordinated workforce across epidemiology, environmental health, and laboratory programs. PROGRAM: Under the 2011 Food Safety Modernization Act, the Centers for Disease Control and Prevention (CDC) was called on to establish Integrated Food Safety (IFS) Centers of Excellence (CoEs) at state health departments, which would collaborate with academic partners, to identify, implement, and evaluate model practices in foodborne disease surveillance and outbreak response and to serve as a resource for public health professionals. IMPLEMENTATION: CDC designated 5 IFS CoEs in August 2012 in Colorado, Florida, Minnesota, Oregon, and Tennessee; a sixth IFS CoE in New York was added in August 2014. For the August 2019-July 2024 funding period, 5 IFS CoEs were designated in Colorado, Minnesota, New York, Tennessee, and Washington. Each IFS CoE is based at the state health department that partners with at least one academic institution. EVALUATION: IFS CoEs have built capacity across public health agencies by increasing the number of workforce development opportunities (developing >70 trainings, tools, and resources), supporting outbreak response activities (responding to >50 requests for outbreak technical assistance annually), mentoring students, and responding to emerging issues, such as changing laboratory methods and the COVID-19 pandemic.

Identifying Sepsis From Foodborne Hospitalization: Incidence and Hospitalization Cost by Pathogen.

BACKGROUND: Sepsis causes a major health burden in the United States. To better understand the role of sepsis as a driver of the burden and cost of foodborne illness in the United States, we estimated the frequency and treatment cost of sepsis among US patients hospitalized with 31 pathogens commonly transmitted through food or with unspecified acute gastrointestinal illness (AGI). METHODS: Using data from the National Inpatient Sample from 2012 to 2015, we identified sepsis hospitalizations using 2 approaches-explicit ICD-9-CM codes for sepsis and a coding scheme developed by Angus that identifies sepsis using specific ICD-9-CM diagnosis codes indicating an infection plus organ failure. We examined differences in the frequency and the per-case cost of sepsis across pathogens and AGI and estimated total hospitalization costs using prior estimates of foodborne hospitalizations. RESULTS: Using Explicit Sepsis Codes, sepsis hospitalizations accounted for 4.6% of hospitalizations with a pathogen commonly transmitted through food or unspecified AGI listed as a diagnosis; this was 33.2% using Angus Sepsis Codes. The average per-case cost was $35 891 and $20 018, respectively. Applying the proportions of hospitalizations with sepsis from this study to prior estimates of the number foodborne hospitalizations, the total annual cost was $248 million annually using Explicit Sepsis Codes and $889 million using Angus Sepsis Codes. CONCLUSIONS: Sepsis is a serious complication among patients hospitalized with a foodborne pathogen infection or AGI resulting in a large burden of illness. Hospitalizations that are diagnosed using explicit sepsis codes are more severe and costly, but likely underestimate the burden of foodborne sepsis.

Persisting gastrointestinal symptoms and post-infectious irritable bowel syndrome following SARS-CoV-2 infection: results from the Arizona CoVHORT.

In this study, we aimed to examine the association between gastrointestinal (GI) symptom presence during severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and the prevalence of GI symptoms and the development of post-infectious irritable bowel syndrome (PI-IBS). We used data from a prospective cohort and logistic regression to examine the association between GI symptom status during confirmed SARS-CoV-2 infection and prevalence of persistent GI symptoms at ≥45 days. We also report the incidence of PI-IBS following SARS-CoV-2 infection. Of the 1475 participants in this study, 33.8% (n = 499) had GI symptoms during acute infection. Cases with acute GI symptoms had an odds of persisting GI symptoms 4 times higher than cases without acute GI symptoms (odds ratio (OR) 4.29, 95% confidence interval (CI) 2.45-7.53); symptoms lasted on average 8 months following infection. Of those with persisting GI symptoms, 67% sought care for their symptoms and incident PI-IBS occurred in 3.0% (n = 15) of participants. Those with acute GI symptoms after SARS-CoV-2 infection are likely to have similar persistent symptoms 45 days and greater. These data indicate that attention to a potential increase in related healthcare needs is warranted.

Trends in Outpatient Medical-Care Seeking for Acute Gastroenteritis During the COVID-19 Pandemic, 2020.

The rate of enteric infections reported to public health surveillance decreased during 2020 amid the coronavirus disease 2019 (COVID-19) pandemic. Changes in medical care-seeking behaviors may have impacted the diagnosis of enteric infections contributing to these declines. We examined trends in outpatient medical care-seeking behavior for acute gastroenteritis (AGE) in Colorado during 2020 compared with the that of previous 3 years using electronic health record data from the Colorado Health Observation Regional Data Service (CHORDS). Outpatient medical encounters for AGE were identified using diagnoses codes from the International Classification of Diseases 10th Revision and aggregated by year, quarter, age group, and encounter type. The rate of encounters was calculated by dividing the number of AGE encounters by the corresponding total number of encounters. There were 9064 AGE encounters in 2020 compared with an annual average of 18,784 from 2017 to 2019 (p < 0.01), representing a 52% decrease. The rate of AGE encounters declined after the first quarter of 2020 and remained significantly lower for the rest of the year. Moreover, previously observed trends, including seasonal patterns and the preponderance of pediatric encounters, were no longer evident. Telemedicine modalities accounted for 23% of all AGE encounters in 2020. AGE outpatient encounters in Colorado in 2020 were substantially lower than during the previous 3 years. Decreases remained stable over the second, third, and fourth quarters of 2020 (April-December) and were especially pronounced for children <18 years of age. Changes in medical care-seeking behavior likely contributed to declines in the number of enteric disease cases and outbreaks reported to public health. It is unclear to what extent people were ill with AGE and did not seek medical care because of concerns about the infection risk during a health care visit or to what extent there were reductions in certain exposures and opportunities for disease transmission resulting in less illness.

Using Outbreak Data for Hypothesis Generation: A Vehicle Prediction Tool for Disease Outbreaks Caused by Salmonella and Shiga Toxin-Producing Escherichia coli.

Hypothesis generation about potential food and other exposures is a critical step in an enteric disease outbreak investigation, helping to focus investigation efforts and use of limited resources. Historical outbreak data are an important source of information for hypothesis generation, providing data on common food- and animal-pathogen pairs and other epidemiological trends. We developed a model to predict vehicles for Shiga toxin-producing Escherichia coli and Salmonella outbreaks using demographic and outbreak characteristics from outbreaks in the Centers for Disease Control and Prevention's Foodborne Disease Outbreak Surveillance System (1998-2019) and Animal Contact Outbreak Surveillance System (2009-2019). We evaluated six algorithmic methods for prediction based on their ability to predict multiple class probabilities, selecting the random forest prediction model, which performed best with the lowest Brier score (0.0953) and highest accuracy (0.54). The model performed best for outbreaks transmitted by animal contact and foodborne outbreaks associated with eggs, meat, or vegetables. Expanding the criteria to include the two highest predicted vehicles, 83% of egg outbreaks were predicted correctly, followed by meat (82%), vegetables (74%), poultry (67%), and animal contact (62%). The model performed less well for fruit and poultry vehicles, and it did not predict any dairy outbreaks. The final model was translated into a free, publicly available online tool that can be used by investigators to provide data-driven hypotheses about outbreak vehicles as part of ongoing outbreak investigations. Investigators should use the tool for hypothesis generation along-side other sources, such as food-pathogen pairs, descriptive data, and case exposure assessments. The tool should be implemented in the context of individual outbreaks and with an awareness of its limitations, including the heterogeneity of outbreaks and the possibility of novel food vehicles.

Direct Outpatient Health Care Costs Among Commercially Insured Persons for Common Foodborne Pathogens and Acute Gastroenteritis, 2012-2015.

Foodborne illness is common in the United States with most, but not all, foodborne pathogens causing symptoms of acute gastroenteritis (AGI). Outpatient care is the most frequent type of medical care sought; however, more accurate estimates of outpatient costs are needed to inform food safety policy decision. Using the U.S. MarketScan Commercial Claims and Encounters database, we quantified the per-visit cost of outpatient visits with any AGI-related diagnosis (including pathogen-specific and nonspecific or symptom-based diagnoses) and for those with a pathogen-specific diagnosis for 1 of 29 pathogens commonly transmitted through food (including pathogens that cause AGI and some that do not). Our estimates included the per-case cost of office visits and associated laboratory tests and procedures as well as the conservative estimates of prescription cost. Most AGI outpatient visits were coded using nonspecific codes (e.g., infectious gastroenteritis), rather than pathogen-specific codes (e.g., Salmonella). From 2012 to 2015, we identified more than 3.4 million initial outpatient visits with any AGI diagnosis and 45,077 with a foodborne pathogen-specific diagnosis. As is typical of treatment cost data, severe cases of illness drove mean costs above median. The mean cost of an outpatient visit with any AGI was $696 compared with the median of $162. The mean costs of visits with pathogen-specific diagnoses ranged from $254 (median $131; interquartile range [IQR]: $98-184) for Streptococcus spp. Group A (n = 22,059) to $1761 (median $161; IQR: $104-$1101) for Clostridium perfringens (n = 30). Visits with two of the most common causes of foodborne illness, nontyphoidal Salmonella and norovirus, listed as a diagnosis, had mean costs of $841 and $509, respectively. Overall, the median per-case costs of outpatient visits increased with age, with some variation by pathogen. More empirically based estimates of outpatient costs for AGI and specific pathogens can enhance estimates of the economic cost of foodborne illness used to guide food policy and focus prevention efforts.

Training Public Health Professionals on Adaptive Challenges-An Innovative Approach Using Remote Learning Modalities.

CONTEXT: Remote learning opportunities increase access to public health training. Innovative approaches are needed to promote active engagement and learning when tackling more complex, adaptive challenges that are nuanced, lack quick and easy solutions, and require a transformation of values and beliefs. PROGRAM: The Rocky Mountain Public Health Training Center's (RM-PHTC's) training framework considers the complexity of the challenge (technical to adaptive) when selecting the learning modality. Remote learning opportunities on adaptive challenges are addressed using virtual workshops, online courses, ECHO (Extension for Community Healthcare Outcomes) series, and communities of practice that include a combination of multiple sessions, cohort-based learning, peer learning, practice-based application, and live, interactive sessions. The specific modality chosen depends on the audience and amount of content delivery. IMPLEMENTATION: Virtual workshops are single events that encourage peer learning using a blend of instruction and practice-based work. Online courses deliver content to learning cohorts through an online platform combined with multiple, facilitated "live learning sessions." ECHO series include a short delivery of content, combined with multiple, facilitated, face-to-face, case-based learning sessions with a cohort of peers. Communities of practice encourage a bidirectional peer exchange of resources, approaches, and challenges through online sharing platforms and virtual meetings. EVALUATION: Using the Kirkpatrick training evaluation model, learners of public health reported that their understanding of the subject matter improved and that they had identified actions that they would apply to their work. In qualitative feedback, learners shared feedback on elements that facilitated learning on adaptive challenges, including interactive breakout groups with peers and practice-based applications. DISCUSSION: Remote learning opportunities increase access for public health professionals in rural areas and encourage knowledge exchange region-wide. The RM-PHTC's training framework matches learning opportunities that address adaptive challenges with modalities that include elements that encourage the sharing of ideas and cocreation of solutions.

Hypothesis Generation During Foodborne-Illness Outbreak Investigations.

Hypothesis generation is a critical, but challenging, step in a foodborne outbreak investigation. The pathogens that contaminate food have many diverse reservoirs, resulting in seemingly limitless potential vehicles. Identifying a vehicle is particularly challenging for clusters detected through national pathogen-specific surveillance, because cases can be geographically dispersed and lack an obvious epidemiologic link. Moreover, state and local health departments could have limited resources to dedicate to cluster and outbreak investigations. These challenges underscore the importance of hypothesis generation during an outbreak investigation. In this review, we present a framework for hypothesis generation focusing on 3 primary sources of information, typically used in combination: 1) known sources of the pathogen causing illness; 2) person, place, and time characteristics of cases associated with the outbreak (descriptive data); and 3) case exposure assessment. Hypothesis generation can narrow the list of potential food vehicles and focus subsequent epidemiologic, laboratory, environmental, and traceback efforts, ensuring that time and resources are used more efficiently and increasing the likelihood of rapidly and conclusively implicating the contaminated food vehicle.

Decreased Incidence of Infections Caused by Pathogens Transmitted Commonly Through Food During the COVID-19 Pandemic - Foodborne Diseases Active Surveillance Network, 10 U.S. Sites, 2017-2020.

Foodborne illnesses are a substantial and largely preventable public health problem; before 2020 the incidence of most infections transmitted commonly through food had not declined for many years. To evaluate progress toward prevention of foodborne illnesses in the United States, the Foodborne Diseases Active Surveillance Network (FoodNet) of CDC's Emerging Infections Program monitors the incidence of laboratory-diagnosed infections caused by eight pathogens transmitted commonly through food reported by 10 U.S. sites.* FoodNet is a collaboration among CDC, 10 state health departments, the U.S. Department of Agriculture's Food Safety and Inspection Service (USDA-FSIS), and the Food and Drug Administration. This report summarizes preliminary 2020 data and describes changes in incidence with those during 2017-2019. During 2020, observed incidences of infections caused by enteric pathogens decreased 26% compared with 2017-2019; infections associated with international travel decreased markedly. The extent to which these reductions reflect actual decreases in illness or decreases in case detection is unknown. On March 13, 2020, the United States declared a national emergency in response to the COVID-19 pandemic. After the declaration, state and local officials implemented stay-at-home orders, restaurant closures, school and child care center closures, and other public health interventions to slow the spread of SARS-CoV-2, the virus that causes COVID-19 (1). Federal travel restrictions were declared (1). These widespread interventions as well as other changes to daily life and hygiene behaviors, including increased handwashing, have likely changed exposures to foodborne pathogens. Other factors, such as changes in health care delivery, health care-seeking behaviors, and laboratory testing practices, might have decreased the detection of enteric infections. As the pandemic continues, surveillance of illness combined with data from other sources might help to elucidate the factors that led to the large changes in 2020; this understanding could lead to improved strategies to prevent illness. To reduce the incidence of these infections concerted efforts are needed, from farm to processing plant to restaurants and homes. Consumers can reduce their risk of foodborne illness by following safe food-handling and preparation recommendations.

Estimating the Number of Illnesses Caused by Agents Transmitted Commonly Through Food: A Scoping Review.

Estimates of the overall human health impact of agents transmitted commonly through food complement surveillance and help guide food safety interventions and regulatory initiatives. The purpose of this scoping review was to summarize the methods and reporting practices used in studies that estimate the total number of illnesses caused by these agents. We identified and included 43 studies published from January 1, 1995, to December 31, 2019, by searching PubMed and screening selected articles for other relevant publications. Selected articles presented original estimates of the number of illnesses caused by ≥1 agent transmitted commonly through food. The number of agents (species or subspecies for pathogens) included in each study ranged from 1 to 31 (median: 4.5; mean: 9.2). Of the 40 agents assessed across the 43 studies, the most common agent was Salmonella (36; 84% of studies), followed by Campylobacter (33; 77%), Shiga toxin-producing Escherichia coli (25; 58%), and norovirus (20; 47%). Investigators used a variety of data sources and methods that could be grouped into four distinct estimation approaches-direct, surveillance data scaled-up, syndrome or population scaled-down, and inferred. Based on our review, we propose four recommendations to improve the interpretability, comparability, and reproducibility of studies that estimate the number of illnesses caused by agents transmitted commonly through food. These include providing an assessment of statistical and nonstatistical uncertainty, providing a ranking of estimates by agent, including uncertainties; describing the rationale used to select agents and data sources; and publishing raw data and models, along with clear, detailed methods. These recommendations could lead to better decision-making about food safety policies. Although these recommendations have been made in the context of illness estimation for agents transmitted commonly through food, they also apply to estimates of other health outcomes and conditions.

Cost of Hospitalizations for Leading Foodborne Pathogens in the United States: Identification by International Classification of Disease Coding and Variation by Pathogen.

Foodborne illness is a continuing public health problem in the United States. Seven pathogens-Campylobacter, Clostridium perfringens, Shiga toxin-producing Escherichia coli O157, Listeria monocytogenes, nontyphoidal Salmonella, norovirus, and Toxoplasma gondii-are estimated to cause >90% of the foodborne illnesses, hospitalizations, and deaths attributed to 31 known pathogens. The purpose of this article was to inform estimates of the cost of hospitalizations associated with these pathogens using National Inpatient Survey data from January 2012 through September 2015. The article explored two methodological issues. First, is it more appropriate to use hospitalizations identified using principal or all diagnosis codes when estimating cost? Second, should pathogen-specific or overall mean cost estimates be used? After excluding C. perfringens because of low sample size, the remaining six pathogens included in the analysis were associated with 17,102 hospital discharge records. Of these 55% have the pathogen listed as a principal diagnosis (FBP-PD), ranging from 6% for T. gondii to 68% for nontyphoidal Salmonella. The mean per-case cost of records with the pathogen listed as a secondary diagnosis (FBP-SD) was 2.7 times higher than FBP-PD. FBP-SD were also more severe than FBP-PD with longer lengths of stay, increasing loss of function, and increasing risk of mortality. Severity was the main driver of cost. We also found severity of illness and cost of hospitalizations vary by pathogen. Based on identifying cases with a pathogen in either FBP-PD or FBP-SD, we found mean per-case hospitalization cost across the six pathogens included in this study was $17,515, ranging from $11,552 for Campylobacter to $34,206 for norovirus. In summary, if only FBP-PD cases were used to estimate cost, estimates would likely underestimate hospitalization costs among those cases with a pathogen-specific diagnosis. Because these foodborne pathogens varied in severity of illness, the mean cost of hospitalizations also varied significantly by pathogen.

Using Online Surveys for Enteric Disease Case Investigations: A Pilot Project.

Typically conducted by telephone, routine enteric disease case interviews are critical for foodborne illness surveillance, outbreak detection, and disease control. However, an increasing case load, along with the increased use of mobile telephones, has made case interviews more challenging to complete. For this reason, the Colorado Integrated Food Safety Center of Excellence developed and evaluated a pilot program using online surveys to supplement routine telephone-based enteric disease case investigations. From April to September 2019, investigators offered laboratory-confirmed Giardia cases from three Colorado counties the option of either a telephone interview or an online survey. The paper-based Giardia case investigation form was mapped to an online survey in Research Electronic Data Capture. We evaluated the pilot project response rates, timeliness, data quality, demographics, and user feedback. Of the 32 Giardia cases contacted, 66% requested the online survey, and of these, 81% completed the survey. Online survey cases were slightly younger (median: 42 vs. 48 years) and the majority agreed that the survey was easy to use (93%), did not take too much time (87%), and was easy to understand (67%). Staff time decreased for online surveys compared with telephone interviews (median: 6 vs. 19 min); however, the time from case report to interview completion doubled (median: 4 vs. 2 d for telephone interview cases) and data quality decreased slightly. Given limited public health agency resources, supplementing telephone interviews with online surveys may increase the efficiency of routine enteric case investigations. The results of this pilot project indicate online surveys are popular with enteric disease cases and substantially reduce staff time. Methods to improve the timeliness and data quality of online surveys should be explored to reduce the impact on disease control and outbreak detection activities.

Cannabis-Infused Edible Products in Colorado: Food Safety and Public Health Implications.

Cannabis-infused "edibles" are a popular means of cannabis use, and the variety of edible food products available to consumers continues to grow. Although there has been much discussion on dose standardization, childproof packaging, and the prevention of overconsumption, the important topic of food safety has received less attention.We discuss potential food safety hazards associated with cannabis-infused edible food products, drawing on examples from Colorado, and describe edible-associated foodborne illness outbreaks and other contamination events.It is important for public health agencies, particularly environmental health and enteric disease programs, to be familiar with the cannabis industry, including regulatory partners, signs and symptoms of cannabis ingestion, the scope of edible products sold and consumed, and the food safety risks unique to cannabis products.

Acute Complications and Sequelae from Foodborne Infections: Informing Priorities for Cost of Foodborne Illness Estimates.

Cost of foodborne illness (CoFI) estimates provide estimates of the overall impact of foodborne illnesses, including hospitalizations, long-term complications, and deaths. CoFI estimates are needed in countries that require cost-benefit analysis as part of the process of adopting new regulations, as is the case in the United States. Monetary estimates of the impact of disease also provide a meaningful way of communicating with the public about the impact of foodborne disease. In 2014, researchers at the U.S. Department of Agriculture, Economic Research Service (ERS), published CoFI estimates for 15 pathogens that account for roughly 95% of illnesses and deaths from the 31 major foodborne pathogens included in the Centers for Disease Control and Prevention (CDC) foodborne disease incidence estimates. ERS is currently updating their estimates to include all 31 known pathogens and unspecific agents included in CDC incidence estimates. CoFI estimates are based on quantitative models of the health outcomes people experience as a result of these illnesses and an assessment of the costs associated with these health outcomes. Research on the incidence of foodborne disease provides a starting point for this disease modeling, but it usually must be supplemented by other additional synthesis of research on acute complications and long-term health outcomes of different foodborne diseases. As part of its current work revising CoFI estimates, ERS convened a workshop attended by leading foodborne disease public health scientists to discuss how changes in scientific research on the incidence and outcomes of foodborne illnesses should inform the next revision of ERS's CoFI estimates. This article presents a summary, based on discussion at this workshop, of the state of scientific research available to inform updated economic modeling of the CoFI in the United States.

Hospital Discharge Data Underascertain Enteric Bacterial Infections Among Children.

Many enteric pathogens disproportionately infect children. Hospital discharge data can provide information on severe infections, including cost. However, the diagnosis must be recorded on the discharge record and coded accurately. We estimated the rate of underascertainment in hospital discharge data among children with culture-confirmed Campylobacter, Salmonella, and Escherichia coli O157 infections using linked laboratory and hospital discharge data from an integrated health care organization. We reviewed the International Classification of Diseases, 9th and 10th Revisions, Clinical Modification (ICD-9/10-CM) diagnosis codes on each patient's discharge record. We determined the percentage of patients who had a pathogen-specific diagnosis code (for Campylobacter, Salmonella, or E. coli O157) or nonspecific gastroenteritis code. We included the first admission or positive test and calculated the number of days between specimen submission (outpatient ≤7 days before admission or inpatient) and hospital discharge. Of 65 hospitalized children with culture-confirmed Campylobacter (n = 30), Salmonella (n = 24), or E. coli O157 (n = 11) infections, 55% had that pathogen-specific diagnosis code listed on the discharge record (79% Salmonella, 54% E. coli O157, 37% Campylobacter). The discharge records of the 35 children with a specimen submitted for culture ≥3 days before discharge were 16 times more likely to have a pathogen-specific diagnosis than the records of the 30 children with a specimen submitted <3 days before discharge (83% vs. 23%; odds ratio 15.9, 95% confidence interval: 4.7-53.8). Overall, 34% of records of children with culture-confirmed infection had ≥1 nonspecific gastroenteritis code (Campylobacter 43%, Salmonella 29%, E. coli O157 18%), including 59% of those for children without a pathogen-specific diagnosis (Campylobacter 63%; Salmonella 60%; E. coli O157 40%). This study showed that hospital discharge data under-ascertain enteric illnesses in children even when the infections are culture confirmed, especially for infections that usually have a short length of stay.