The Poultry Federation SALMONELLA SUMMIT MARCH 26, 2013 9:15-10:00AM Salmonella Illness & Attribution Arthur P. Liang, M.D., M.P.H. Senior Advisor for Food Safety Division of Foodborne Waterborne & Environmental Diseases Centers for Disease Control & Prevention CHEROKEE CASINO & HOTEL WEST SILOAM SPRINGS, OKLAHOMA
Executive Summary Salmonella & Attribution 1,027,561 foodborne illnesses and 378 deaths annually 1 Since 1997, incidence of Salmonella infections have remained unchanged. Many different sources based on outbreaks 2 Eggs Meat Poultry Produce Animal contact Scanning electron micrograph, Salmonella enterica 1. Scallan E, Hoekstra RM, Angulo FJ, et al. Foodborne illness acquired in the United States--major pathogens. Emerging infectious diseases 2011;17:7-15. 2. Centers for Disease C, Prevention. Surveillance for foodborne disease outbreaks--united States, 2008. Morbidity & mortality weekly report 2011;60:1197-202.
Executive Summary (continued) Chicken identified as a risk factor for sporadic Salmonella & Campylobacter infection Attribution models based on outbreaks identifies poultry as a frequent source of Salmonella & Campylobacter illness Preliminary results of a Danish model prevalence estimates of Salmonella contamination on food at processing suggests poultry most common source
Some Context The vast majority of meals are safe Lean meats, poultry, fish, fruits and vegetables are among the essential parts of a healthy diet
Mortality Rate per 100,000 Infectious Disease Mortality, United States, 1900-1996 1000 800 600 400 200 0 1900 1920 1940 1960 1980 Armstrong et al, JAMA 1999 Year
Foodborne Disease: 1900 vs. 2000 Amoebiasis Botulism Brucellosis Cholera Diphtheria Hepatitis Polio Salmonellosis Scarlet fever Septic sore throat (Strep zooepidemicus) Staph food poisoning Tapeworms Trichinosis Tuberculosis, bovine Typhoid fever 1900-39 2011* 1. Norovirus 2. Salmonella 3. Clostridium perfringens 4. Campylobacter 5. Staphylococcus 6. Shigella 7. STEC non-o157 8. Yersinia enterocolitica 9. Toxoplasma gondii 10. Giardia * Scallan et al, 2011
Incidence per 100,000 population Reported Salmonella Typhi infections USA, 1920-2010 50 Typhoid Fever 40 30 20 10 0 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 Years Preliminary Data : National Notifiable Diseases & FoodNet
Incidence per 100,000 population The rise of reported other Salmonella infections USA, 1920-2011 30 Non-typhoid salmonellosis 20 10 0 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 Years Preliminary Data : National Notifiable Diseases & FoodNet
9 CDC: THE VITAL LINK CDC provides the vital link between illness in people & the food safety systems of government agencies & food producers.
Roles in Food Safety CDC Not regulatory Disease surveillance Outbreak detection, investigation & response Analysis of burden, trends & attribution of illnesses to sources Education & training FDA, USDA, Industry Regulatory Inspection & enforcement Product traceback & recall Investigation of farm & processing facilities Risk assessment & management 3
Roles in Food Safety State & local public health CDC depends on state & local public health Reportable conditions reported by law to local or state officials State officials notify CDC voluntarily through longstanding agreements States invite CDC investigators for assistance State & local investigators constitute the front line State & local public health depend on CDC Serve as the national resource for expertise & reference laboratory work, training, & funding Coordinate & lead multi-jurisdictional investigations Assemble & analyze national-level data
Major Foodborne Illness Surveillance Systems Main Categories I. National surveillance PulseNet Foodborne outbreak surveillance PulseNet FoodNet NNDSS-LEDS FDOSS II. Sentinel site surveillance NARMS CaliciNet III. Outbreak investigation Listeria Initiative NVEAIS
INTRAMURAL VS EXTRAMURAL Foodborne Disease Active Surveillance Network FoodNet Population-based, active surveillance at 10 sites: California Colorado, Connecticut Georgia, Maryland Minnesota, New Mexico New York, Oregon Tennessee >650 clinical laboratories for laboratory-confirmed infections bacteria: Salmonella, Shigella, Campylobacter, E. coli O157 & non- O157, Listeria, Yersinia, Vibrio parasites: Cryptosporidium & Cyclospora with pediatric nephrologists for hemolytic uremic syndrome (HUS)
Salmonella in the United States 42,000 cases reported annually Estimate 1,027,561 illnesses & 378 deaths annually 1 from food 4 different clinical manifestations: gastroenteritis bacteremia enteric fever asymptomatic carrier state Infectious Dose: 10 3 bacilli 1. Scallan E, Hoekstra RM, Angulo FJ, et al. Foodborne illness acquired in the United States--major pathogens. Emerging infectious diseases 2011;17:7-15.
Incidence rate per 100,000 Salmonellosis by age group FoodNet 2011 70.00 67.55 60.00 50.00 40.00 30.00 20.00 10.00 20.31 12.07 11.65 16.31 0.00 <5yo 5-9 10-19 20-64 65+ Age Group
Salmonellosis by age group Children < 5 years of age highest incidence of Salmonella Adults 65 years old accounted for 11% of infections 35% of hospitalizations 44% of deaths. Scallan E et al. Foodborne illness acquired in the United States major pathogens. Emerg Infect Dis. 2011 Jan.
25 20 15 Pathogen rates per 100,000 FoodNet 1996-2011 Campylobacter Salmonella Since 1996-1998 E. coli O157 42% Campylobacter 22% Listeria 35% Shigella 65% Yersinia 52% 10 5 0 Shigella Cryptosporidium E.coli 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 ±Salmonella Vibrio 76% Cyclospora Vibrio Listeria Yersinia
3 Pathogen rates per 100,000 FoodNet 1996-2011 2 E.coli Since 1996-1998 E. coli O157 44% Listeria 38% Yersinia 52% Vibrio 115% 1 Yersinia Listeria Vibrio 0 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Cyclospora
Poultry-Associated Foodborne Outbreaks United States, 1998 2008* FOR EXAMPLE 2007 Salmonella & pot pies 2010 Salmonella & Cheesy Chicken Rice Frozen Entrée 2011 Salmonella & Kosher Chicken Livers 2011 Salmonella & turkey burgers 2011 Salmonella & ground turkey 2013 Salmonella & chicken
Number of outbreaks Detecting & Responding to Multistate Outbreaks ~1000 Outbreaks in USA each year Multistate Foodborne Disease Outbreaks by 5 year intervals, 1990-2009 80 Multistate outbreaks detected more frequently 70 60 CDC tracks 15 40 clusters of human illnesses per week About 30 major multistate investigations in 2011 50 40 30 20 10 0 1990-94 1995-99 2000-04 2005-09 Data from Foodborne Disease Outbreak Surveillance System
In 1995, the Hubble Space Telescope found distant galaxies & star clusters never seen before.
1998-2008 Results 7,724 outbreaks reported an implicated food 1,184 outbreaks (15%) with confirmed food (epidemiologic or laboratory evidence) 679 (57%) outbreaks with a simple food 21,269 illnesses 5,212 healthcare visits 1,481 hospitalizations 41 deaths 229 (34%) outbreaks associated with poultry More than any other commodity & more than the second & third most frequently implicated commodities combined (fish, 129; beef, 97) 35% of illnesses Median number of illnesses was 14 (range 2-741) *Data are preliminary and may change.
Onset of symptoms Stool culture result Submit isolate to PH lab Consume food Collect stool sample Case report to PH dept Case interview 0 2 4 7 9 10 14 Hedberg, CW, et al. Timeliness of enteric disease surveillance in 6 US states. JEID 14(2), February, 2008.
Foods Associated with Outbreaks Foodborne disease outbreaks by food vehicle reported,1998-2008 N=13,405 No food reported 42% Simple Commodity 24% Complex Commodity 34%
Confirmed etiologies of reported outbreaks Percent of FBDOs of confirmed etiology, 1998-2008 N=5,059 Campylobacter jejuni 2% Ciguatoxin 3% Staphylococcus enterotoxin 3% Scrombroid toxin 5% Clostridium perfringens 5% Other etiology 12% Norovirus 39% E.coli, Shiga toxin-producing 6% Salmonella enterica 25% Serotype Enteritidis was one third of all confirmed Salmonella outbreaks reported from 1998 2008. *Data are preliminary and may change.
Commodities Implicated in Foodborne Disease Outbreaks, 1998 2010 (n=3,565) Eggs 4% Other 9% Poultry 18% Grains-Beans 5% Dairy 6% Fruits-Nuts 6% Fish 18% Mollusk 6% Leafy 8% Pork 8% Beef 12% Other includes crustaceans, game, oils-sugars, fungi, root, sprout & vine-stalk Data are preliminary & may change. *Data are preliminary and may change.
Foods Associated with Salmonella Outbreaks
Reported characteristics of foodborne outbreaks with confirmed association with poultry, 1998-2008 Characteristic Pathogen (confirmed & suspected) Chicken (N=156) no./total no. reported (%) Turkey (N=72) no./total no. reported (%) All poultry (N=229)* no./total no. reported (%) Salmonella enterica 36/113 (32) 18/57 (32) 54/171 (32) Clostridium perfringens 29/113 (26) 22/57 (39) 51/171 (30) Norovirus 15/113 (13) 7/57 (12) 23/171 (13) Staphylococcus aureus 9/113 (8) 1/57 (2) 10/171 (6) Campylobacter 7/113 (6) 2/57 (4) 9/171 (5) Bacillus cereus 6/113 (5) 2/57 (4) 8/171 (5) Listeria monocytogenes 1/113 (1) 4/57 (7) 5/171 (3) Other 10/113 (9) 1/57 (2) 11/171 (6) *Data are preliminary and may change.
Poultry-associated outbreaks by setting FDOSS, 1998-2008 (n = 229) Other Home Restaurant Caterer *Data are preliminary and may change.
Reported characteristics of foodborne outbreaks with confirmed association with poultry, 1998-2008 Characteristic Chicken (N=156) no./total no. reported (%) Turkey (N=72) no./total no. reported (%) All poultry (N=229)* no./total no. reported (%) Contributing factors (not mutually Exclusive) Improper storage / handling 75/111 (68) 30/49 (61) 105/161 (65) Inadequate cooking 53/111 (48) 32/49 (65) 85/161 (53) Inherent contamination 26/111 (23) 21/49 (43) 47/161 (29) Contaminated equipment 31/111 (28) 10/49 (20) 41/161 (25) Infected food worker 27/111 (24) 10/49 (20 38/161 (24) * Includes 1 additional restaurant-associated outbreak in the Midwest of Norovirus illnesses associated with duck *Data are preliminary and may change.
sporadic Case-control study Salmonella Serogroups B and D, 1996 Salmonella Enteritidis & eating chicken prepared outside the home (MOR, 2.0; 95% CI, 1.1 3.6) Reptile contact was associated with infection Salmonella Heidelberg & eating eggs prepared outside the home & (MOR, 6.0; 95% confidence interval [CI], 1.2 29.6).
sporadic case-control studies Salmonella Heidelberg* Eggs outside home Salmonella Enteritidis & Salmonella Heidelberg* Eating chicken outside home Campylobacter* Campylobacter Case-Control Study, 1998 Turkey or chicken cooked outside the home Other meat cooked outside the home * FoodNet case-control studies
Attribution of foodborne illnesses, hospitalizations, & deaths to food commodities by using outbreak data, United States, 1998 2008 By Painter, Hoekstra, Ayers, Tauxe, Braden, et al Painter JA, et al. Attribution of foodborne illnesses, hospitalizations, and deaths to food commodities by using outbreak data, USA, 1998 2008. Emerg Infect Dis 2013 Mar http://dx.doi.org/10.3201/eid1903.111866
Produce was the dominant source for illnesses driven by norovirus Poultry & Meat together was the dominant source for deaths
Estimating the Number of Illnesses Recent work using complex food attribution combined information from simple and complex food outbreaks to estimate the number (and range) of illnesses attributable to each commodity Painter et al.
The top 10 pathogen-food combinations in terms of annual disease burden by combined rank Batz MB, Hoffmann S, Morris JG Jr., Ranking the disease burden of 14 pathogens in food sources in the United States using attribution data from outbreak investigations and expert elicitation. J Food Prot. 2012 Jul;75(7):1278-91
Adaptation of a Danish Attribution Model With FSIS, adapted a Bayesian model used in Denmark & adapted to other countries Combines consumption data, sporadic human illness data, & FSIS data FOODBORNE PATHOGENS & DISEASE Volume 8, Number 4, 2011
Trends in Chicken Consumption, ERS Food Availability (Per Capita) Data System (Aug 2012) http://www.ers.usda.gov/data-products/food-availability-(per-capita)-data-system/summary-findings.aspx
Thank you The findings & conclusions in this presentation are those of the author & do not necessarily represent the views of the Centers for Disease Control & Prevention