Improving inclusion and exclusion criteria in foodborne illness outbreak investigations: a case study.

The practice of foodborne illness outbreak investigations has evolved, shifting away from large-scale community case-control studies towards more focused case exposure assessments and sub-cluster investigations to identify contaminated food sources. Criteria to include or exclude cases are established to increase the efficiency of epidemiological analyses and traceback activities, but these criteria can also affect the investigator's ability to implicate a suspected food vehicle. A 2010 outbreak of Salmonella ser. Hvittingfoss infections associated with a chain of quick-service restaurants (Chain A) provided a useful case study on the impact of exclusion criteria on the ability to identify a food vehicle. In the original investigation, a case-control study of restaurant-associated cases and well meal companions was conducted at the ingredient level to identify a suspected food vehicle; however, 21% of cases and 22% of well meal companions were excluded for eating at Chain A restaurants more than once during the outbreak. The objective of this study was to explore how this decision affected the results of the outbreak investigation.

Developing a risk management framework to improve public health outcomes by enumerating Salmonella in ground turkey.

Salmonella spp. continue to be a leading cause of foodborne morbidity worldwide. To assess the risk of foodborne disease, current national regulatory schemes focus on prevalence estimates of Salmonella and other pathogens. The role of pathogen quantification as a risk management measure and its impact on public health is not well understood. To address this information gap, a quantitative risk assessment model was developed to evaluate the impact of pathogen enumeration strategies on public health after consumption of contaminated ground turkey in the USA. Public health impact was evaluated by using several dose-response models for high- and low-virulent strains to account for potential under- or overestimation of human health impacts. The model predicted 2705-21 099 illnesses that would result in 93-727 reported cases of salmonellosis. Sensitivity analysis predicted cooking an unthawed product at home as the riskiest consumption scenario and microbial concentration the most influential input on the incidence of human illnesses. Model results indicated that removing ground turkey lots exceeding contamination levels of 1 MPN/g and 1 MPN in 25 g would decrease the median number of illnesses by 86-94% and 99%, respectively. For a single production lot, contamination levels higher than 1 MPN/g would be needed to result in a reported case to public health officials. At contamination levels of 10 MPN/g, there would be a 13% chance of detecting an outbreak, and at 100 MPN/g, the likelihood of detecting an outbreak increases to 41%. Based on these model prediction results, risk management strategies should incorporate pathogen enumeration. This would have a direct impact on illness incidence linking public health outcomes with measurable food safety objectives.

Factors associated with recovery of meat products following recalls due to Shiga toxin-producing Escherichia coli.

Food-product recall data for recalls due to Shiga toxin-producing Escherichia coli (STEC) from 2000 to 2012 were obtained for establishments regulated by the United States Department of Agriculture, Food Safety and Inspection Service (FSIS). Statistical tests were used to assess the factors associated with recovery of product following STEC recalls along with the relationship between cluster detection and jurisdictions. Our results indicated that the percentage of recalled product recovered following a recall action due to STEC was dependent on the complexity of distribution, type of distribution, amount of time between production and recall dates, and the number of pounds of product recalled. Illness-related STEC recalls were associated with a lower percentage of product recovery which was probably impacted by larger amounts of product recalled, broader production scope, and delays from epidemiological and traceback investigations. Further, detection of illnesses related to STEC recalls seemed to be enhanced in states with additional resources and a history of successful foodborne investigations. This makes an argument for additional resources dedicated to public health agencies specifically for the surveillance of foodborne illnesses.

Characterization of "peak E," a novel amino acid associated with eosinophilia-myalgia syndrome.

Epidemiologic studies strongly associate eosinophilia-myalgia syndrome (EMS) with ingestion of tryptophan containing a contaminant ("peak E"). Prior reports have suggested that peak E is the di-tryptophan N alpha-animal of acetaldehyde. Spectral and chemical studies now demonstrate that peak E is 1,1'-ethylidenebis[tryptophan]. This novel amino acid may be the etiological agent responsible for EMS, or it may be a marker of a still unidentified causal agent.

Disinfection of fabrics and carpets artificially contaminated with calicivirus: relevance in institutional and healthcare centres.

Fabrics and carpets are used widely as surface coverings or linens in healthcare settings and are prone to contamination with infectious agents such as noroviruses (NoVs). Laundering, water cleaning and vacuuming are considered to be adequate for routine cleaning of these materials, but no standard procedure for their disinfection is available in case of contamination. Testing disinfectants for their efficacy against NoVs is difficult because these viruses cannot be cultivated in vitro. Therefore, feline calicivirus (FCV) has gained acceptance as a surrogate model for NoVs in disinfectant efficacy testing. The present study evaluated five disinfectants against FCV on various fabrics or carpets. FCV was dried on fabrics and carpets, followed by treatment with a given disinfectant for a defined contact time of 1, 5 or 10 min. The surviving virus was then eluted and titrated in Crandell-Reese feline kidney cells to determine virus inactivation. A disinfectant was considered to be effective if it inactivated at least 99% of the applied virus. Metricide, an activated dialdehyde-based product, was found to be the most effective disinfectant on all types of fabric and carpet, inactivating more than 99.99% of the virus in 1-10 min. In general, effectiveness of disinfectants increased with an increase in exposure time from 1 to 10 min. The disinfection of carpets was more difficult than the disinfection of fabrics; 100% polyester was the least amenable to disinfection. Only Metricide and Microbac-II (a phenolic compound) were able to inactivate 99% of FCV on 100% polyester. In summary, activated dialdehyde was found to be uniformly active against FCV on all types of material tested.

A statewide survey of immunization rates in Minnesota school age children: implications for targeted assessment and prevention strategies.

BACKGROUND: A retrospective statewide immunization survey of the 69115 Minnesota children who entered kindergarten in 1992 was conducted. METHODS: Information was collected from school immunization records on date of birth, dates of vaccination for each dose of vaccine, address of residence and race/ethnicity (when available). Immunization rates were assessed retrospectively for each month of a child's life from 2 to 48 months of age. Age-appropriate immunization was defined as receipt of all scheduled vaccines within 30 days of the recommended age. RESULTS: Immunization levels varied by vaccine, age of the child and race/ethnicity. For example at 19 months of age, 73% of students had received measles, mumps, rubella vaccine; however, only 39% had received their fourth dose of diphtheria, tetanus and pertussis vaccine. White, non-Hispanic students consistently had higher vaccination rates than children of other racial/ ethnic groups. For example 45% of white, non-Hispanic students were age-appropriately vaccinated at 16 months of age compared with 25% of Blacks, 30% of American Indians, 30% of white Hispanics and 28% of Asian-Pacific Islanders (Mantel-Haenzel chi square, P < 0.001 for each comparison). Furthermore coverage rates frequently varied significantly by neighborhood, thereby identifying pockets of underimmunization within communities. CONCLUSION: Our data demonstrate that vaccination rates can vary substantially by age, race/ ethnicity and neighborhood. Detailed immunization assessment is necessary so that effective targeted interventions can be developed.

Outbreak of erythromycin-resistant staphylococcal conjunctivitis in a newborn nursery.

We investigated an outbreak of erythromycin-resistant Staphylococcus aureus conjunctivitis in a hospital newborn nursery that used erythromycin eye ointment to prevent ophthalmia neonatorum. Cases occurred in 2 clusters; 20 (14%) of 146 infants in the nursery developed conjunctivitis from July through October, 1987; and 5 (7%) of 69 infants in the nursery developed conjunctivitis during April and May, 1988. A case-control study of the first cluster demonstrated that culture-confirmed cases were more likely than controls to have received prophylactic erythromycin eye ointment or their initial bath from one nurse (odds ratio, 9.0; P = 0.01) or to have been delivered by one physician (odds ratio, 12.7; P = 0.03). The nurse was the only staff person to have a nasopharyngeal culture which yielded erythromycin-resistant S. aureus. Control measures, instituted in October, 1987, included using silver nitrate drops instead of erythromycin eye ointment for prophylaxis; however, in January, 1988, the hospital resumed use of erythromycin eye ointment. No additional cases were identified until mid-April, 1988, when the second cluster of cases occurred. At that time the hospital reinstituted the use of silver nitrate and no additional cases were identified. This investigation illustrates the potential for conjunctival infection with an antimicrobial-resistant pathogen when antimicrobials are used to prevent ophthalmia neonatorum.

Efficacy of commonly used disinfectants for the inactivation of calicivirus on strawberry, lettuce, and a food-contact surface.

Norwalk and Norwalk-like viruses (NLVs) are important causes of foodborne gastroenteritis in restaurant-related outbreaks. Efficacy of common disinfection methods against these viruses on food-contact surfaces and fresh produce is not known partially because of their nonculturability. Seven commercial disinfectants for food-contact surfaces and three sanitizers for fruits and vegetables were tested against cultivable feline calicivirus (FCV). Disks of stainless steel, strawberry, and lettuce were contaminated with known amounts of FCV. The disinfectants were applied at one, two, and four times the manufacturer's recommended concentrations for contact times of 1 and 10 min. The action of disinfectant was stopped by dilution, and the number of surviving FCVs was determined by titration in cell cultures. An agent was considered effective if it reduced the virus titer by at least 3 log10 from an initial level of 10(7) 50% tissue culture infective dose. None of the disinfectants was effective when used at the manufacturer's recommended concentration for 10 min. Phenolic compounds, when used at two to four times the recommended concentration, completely inactivated FCV on contact surfaces. A combination of quaternary ammonium compound and sodium carbonate was effective on contact surfaces at twice the recommended concentration. Rinsing of produce with water alone reduced virus titer by 2 log10. On artificially contaminated strawberry and lettuce, peroxyacetic acid and hydrogen peroxide was the only effective formulation when used at four times the manufacturers' recommended concentration for 10 min. These findings suggest that FCV and perhaps NLVs are very resistant to commercial disinfectants. However, phenolic compounds at two to four times their recommended concentrations appear to be effective at decontaminating environmental surfaces and may help control foodborne outbreaks of calicivirus in restaurants.

Food safety for the 1990s.

The epidemiology of foodborne disease has evolved as a result of changes in the types and sources of food consumed, new methods of food production, the emergence of new infectious agents, and new trends involving known infectious agents. The results of foodborne disease surveillance at the Minnesota Department of Health demonstrate the importance of these factors and suggest that foodborne disease problems are actually much more widespread than previously acknowledged. The public health agenda for the 1990s must include a comprehensive review of food safety.

The growing burden of foodborne outbreaks due to contaminated fresh produce: risks and opportunities.

Foodborne outbreaks from contaminated fresh produce have been increasingly recognized in many parts of the world. This reflects a convergence of increasing consumption of fresh produce, changes in production and distribution, and a growing awareness of the problem on the part of public health officials. The complex biology of pathogen contamination and survival on plant materials is beginning to be explained. Adhesion of pathogens to surfaces and internalization of pathogens limits the usefulness of conventional processing and chemical sanitizing methods in preventing transmission from contaminated produce. Better methods of preventing contamination on the farm, or during packing or processing, or use of a terminal control such as irradiation could reduce the burden of disease transmission from fresh produce. Outbreak investigations represent important opportunities to evaluate contamination at the farm level and along the farm-to-fork continuum. More complete and timely environmental assessments of these events and more research into the biology and ecology of pathogen-produce interactions are needed to identify better prevention strategies.

Analysis of the FoodNet case-control study of sporadic Salmonella serotype Enteritidis infections using persons infected with other Salmonella serotypes as the comparison group.

Use of well persons as the comparison group for laboratory-confirmed cases of sporadic salmonellosis may introduce ascertainment bias into case-control studies. Data from the 1996-1997 FoodNet case-control study of laboratory-confirmed Salmonella serogroups B and D infection were used to estimate the effect of specific behaviours and foods on infection with Salmonella serotype Enteritidis (SE). Persons with laboratory-confirmed Salmonella of other serotypes acted as the comparison group. The analysis included 173 SE cases and 268 non-SE controls. SE was associated with international travel, consumption of chicken prepared outside the home, and consumption of undercooked eggs prepared outside the home in the 5 days prior to diarrhoea onset. SE phage type 4 was associated with international travel and consumption of undercooked eggs prepared outside the home. The use of ill controls can be a useful tool in identifying risk factors for sporadic cases of Salmonella.

The use of clinical profiles in the investigation of foodborne outbreaks in restaurants: United States, 1982-1997.

Improving the efficiency of outbreak investigation in restaurants is critical to reducing outbreak-associated illness and improving prevention strategies. Because clinical characteristics of outbreaks are usually available before results of laboratory testing, we examined their use for determining contributing factors in outbreaks caused by restaurants. All confirmed foodborne outbreaks reported to the Centers for Disease Control and Prevention (CDC) from 1982 to 1997 were reviewed. Clinical profiles were developed based on outbreak characteristics. We compared the percentage of contributing factors by known agent and clinical profile to their occurrence in outbreaks of unclassified aetiology. In total, 2246 foodborne outbreaks were included: 697 (31%) with known aetiology and 1549 (69%) with aetiology undetermined. Salmonella accounted for 65% of outbreaks with a known aetiology. Norovirus-like clinical profiles were noted in 54% of outbreaks with undetermined aetiology. Improper holding times and temperatures were associated with outbreaks caused by Clostridium perfringens, Bacillus cereus, Staphylococcus aureus, and Salmonella, and also with outbreaks of undetermined aetiology that fitted diarrhoea-toxin and vomiting-toxin clinical profiles. Poor personal hygiene was associated with norovirus, Shigella, and Salmonella, and also with outbreaks that fitted norovirus-like and vomiting-toxin clinical profiles. Contributing factors were similar for outbreaks with known aetiology and for those where aetiology was assigned by corresponding clinical profile. Rapidly categorizing outbreaks by clinical profile, before results of laboratory testing are available, can help identification of factors which contributed to the occurrence of the outbreak and will promote timely and efficient outbreak investigations.

Outbreaks of food-borne and waterborne viral gastroenteritis.

Norwalk virus infection is the epidemiologic prototype for outbreaks of food-borne and waterborne gastroenteritis. Around the world, Norwalk virus and Norwalk-like viruses appear to be major causes of food-borne and waterborne illness. Assessment of the overall significance of viral agents to the epidemiology of food-borne and waterborne illness is hampered by the lack of surveillance throughout much of the world. In areas where food-borne and waterborne illness surveillance is conducted, outbreaks of viral gastroenteritis are underreported because of the lack of availability of routine laboratory services to confirm the viral etiology. Routine use of epidemiologic criteria as an alternative to laboratory confirmation will allow better assessments of the importance of viral gastroenteritis until effective laboratory methods can be widely implemented. Outbreaks of viral gastroenteritis have been propagated by contamination of water supplies, raw foods, and ill food handlers. Controlling an outbreak depends on identifying and removing the source of contamination. The demonstrated occurrence of person-to-person transmission and the likely occurrence of transmission of Norwalk-like viruses by aerosol make it necessary to evaluate the potential for transmission by food handlers and servers in every outbreak, regardless of primary source.

Relationship between day care and health care providers.

Effective control and prevention of infectious diseases in child day care depend on affirmative relationships between parents, day care providers, public health authorities, and primary health care providers (especially pediatricians). The role played by each of these groups varies in accordance with the specific infectious disease problems, legal requirements, and voluntary relationships that exist in a given locality, but each of these roles is important. Major barriers to productive working relationships between day care and health providers are inadequacy of communication channels, uncertainty in role definition, and overlap in function of different health providers. Public health authorities can play a major role in improving the relationship between day care and health providers, largely by disseminating information regarding disease-reporting laws and other legal requirements, prescribed measures for control and prevention of diseases, and resources that are available for these activities.

An outbreak of giardiasis in a nursing home with evidence for multiple modes of transmission.

During a 6-w period from 20 April through 7 June 1986, an outbreak of giardiasis occurred in residents and employees of a nursing home and children participating in day care at the nursing home. Eighty-eight cases of giardiasis (defined by presence of clinical symptoms or results of stool examination) were identified from groups associated with the nursing home including 35 in nursing home residents, 15 in children in day care, and 38 in employees (including kitchen staff and child care providers). Multiple modes of transmission of Giardia lamblia, including food-borne and person-to-person transmission, occurred for these groups. Evidence of transmission by food included a significant association between sandwich consumption and illness in nursing home staff (P = .04) and a significant lack of illness among nursing home residents who consumed only a pureed diet (P = .007), where all food items are cooked before serving. The primary case among the food handlers, whose illness began in mid-April, had an infected child in the day care center. Person-to-person transmission is supported by a significant association between illness and physical contact with children from the day care facility through an "adopted grandparent" program (P = .03). This is the first reported outbreak of giardiasis in a nursing home, and these findings have implications for disease control in other facilities that combine child day care and care of the elderly.