Multistate Foodborne Outbreaks: Investigation and Communication Process

Transcription

1 National Center for Emerging and Zoonotic Infectious Diseases Multistate Foodborne Outbreaks: Investigation and Communication Process Matthew Wise, MPH, PhD Deputy Branch Chief for Outbreak Response Laura Whitlock, MPH Health Communication Lead Outbreak Response and Prevention Branch COSDA Annual Meeting September 30, 2018

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3 What is going on in 2018? January December outbreak announcements January September outbreak announcements October December 2018???

4 Challenging Year for Outbreak Communication February: Salmonella/ Kratom April: Salmonella/ 200 million eggs recalled July: Vibrio/Fresh crab meat August: Salmonella/ Kosher chicken January: Leafy Greens/ E. coli O157:H7 in U.S./Canada April: Romaine/ E. coli O157:H7 June: Salmonella/ Pre-cut melon July: MDR Salmonella/ Raw turkey products

5 Challenging Year for Outbreak Communication February: Salmonella/ Kratom April: Salmonella/ 200 million eggs recalled July: Vibrio/Fresh crab meat August: Salmonella/ Kosher chicken January: Leafy Greens/ E. coli O157:H7 in U.S./Canada April: Romaine/ E. coli O157:H7 June: Salmonella/ Pre-cut melon July: MDR Salmonella/ Raw turkey products May Present: Cyclospora and produce

6 Detecting and Investigating Multistate Foodborne Outbreaks

7 Detecting Outbreaks with PulseNet Subtyping enteric bacteria is essential to identifying highly disseminated outbreaks PulseNet laboratory network established in 1996 Over 80 participating laboratories in the US 60,000+ isolates subtyped annually Bacteria collected from ill people undergo DNA fingerprinting using pulse-field gel electrophoresis (PFGE) and whole genome sequencing (WGS) Bacteria with the same fingerprint are more likely to come from a common source

8 Detecting Outbreaks with PulseNet PFGE/WGS data from illness-causing bacteria are transmitted to CDC Monitored for temporal clusters PulseNet notifies epidemiologists to investigate clusters

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10 Why CDC Communicates about Foodborne Outbreaks #1 REASON: Specific source identified & public can take action Other reasons CDC may communicate include: State health department(s) communicate High risk group involved Deaths, high hospitalization rate Misinformation circulating

11 Questions to Consider before Communicating Is the outbreak ongoing? Is a vulnerable group at risk? Is there a clear action step for people to take? Are illnesses more severe than expected? What is the product shelf life? Is the germ drug-resistant? Where is the product distributed/sold? Is there strong evidence linking illness to the product?

12 Federal Roles in Multistate Foodborne Outbreaks CDC is the lead public health agency for multistate foodborne outbreaks Disease surveillance and outbreak detection Epidemiologic investigation (analyzing data from interviews of sick people) Risk communication USDA (meat/poultry) and FDA (most other foods) are the lead regulatory agencies for multistate foodborne outbreaks Traceback of suspected foods to their source Food and environmental testing Product recalls and actions Environmental assessments of farm and production facilities

13 State/Local Roles in Multistate Foodborne Outbreaks State and local health departments are responsible for the health of their residents Some centralized states conduct interviews of ill people in outbreaks Many states are de-centralized and local health departments are responsible for interviewing State and local regulatory/agriculture agencies: Collect records for traceback and understand product flow Conduct inspections and assessments throughout the food production chain Almost all data in multistate outbreaks is collected by state/local jurisdictions

14 2018 Outbreak of E. coli O157:H7 Infections Linked to Romaine Lettuce

15 Day 1: Outbreak Detection NJ Department of Health notifies CDC of a cluster of E. coli O157 infections in NJ and PA Most ill people reported eating salads from the same restaurant chain CDC Foodborne Outbreak Response Team begins coordinating the investigation

16 Day 4: Confirming a Multistate Outbreak PulseNet confirms 8 O157:H7 illnesses from 6 states with the same PFGE pattern Only common ingredient in the salads in NJ and PA appears to be romaine lettuce NJ collects records for romaine lettuce supplied to the restaurants NJ releases a media statement about their investigation

17 Day 9: What Did We Know? How many illnesses and where? 17 illnesses in 7 states Outbreak ongoing? Yes What evidence links the food to illness? Epi: Strong signal for salads/leafy greens, strength of romaine signal somewhat unclear Traceback: Ongoing Lab testing: None Is public communication needed? Case count increasing rapidly E. coli O157:H7 is serious Media aware of NJ illnesses Rumors about restaurant chain involvement Decision: Communicate about the multistate investigation

18 Day 9: CDC Investigation Notice 17 people infected with the outbreak strain of E. coli O157:H7 from 7 states Included infections recently reported by the NJ health department People infected with the outbreak strain of E. coli O157:H7, by state of residence This investigation is ongoing and a specific food item, grocery store, or restaurant chain has not been identified as the source.

19 Confirming the Source 12/12 (100%) reported eating romaine lettuce in the week before illness started 8/13 (62%) reported eating salads that contain romaine lettuce at the same restaurant chain in MO, OH, NJ, and PA Other restaurant and grocery store sub-clusters identified in additional states Restaurants reported using bagged chopped romaine lettuce to make salads According to records, romaine lettuce was grown in the Yuma, AZ growing region

20 Day 12: What Did We Know? How many illnesses and where? 35 illnesses in 11 states 22 hospitalized, 3 HUS Outbreak ongoing? Yes What evidence links the food to illness? Epi: Pre-chopped romaine Traceback: Pointing to chopped romaine from the Yuma, AZ region Lab testing: None Is public communication needed? Case count increasing rapidly E. coli O157:H7 is serious Romaine lettuce leading hypothesis about the source Traceback to Yuma, AZ growing region, but no farm ID ed Decision: Warn consumers and retailers not to eat or sell romaine lettuce grown in Yuma, AZ region

21 Day 12: CDC Issues Advice to Consumers and Retailers Restaurants and retailers should not serve or sell any chopped romaine lettuce from the Yuma, Arizona growing region. Consumers anywhere in the U.S. who have store-bought chopped romaine lettuce at home should not eat it and should throw it away. Before purchasing romaine lettuce at a grocery store or eating it at a restaurant, consumers should confirm with the store or restaurant that it is not chopped romaine lettuce from the Yuma, Arizona growing region.

22 Traceback Update: Not Just Pre-Chopped Romaine? State and local health officials in AK identified a cluster of illnesses at a correctional facility Ill people report eating romaine lettuce Traceback investigations showed the lettuce was whole heads of romaine from Yuma, AZ region

23 Day 19: What Did We Know? How many illnesses and where? 53 illnesses in 16 states 31 hospitalized, 5 HUS Outbreak ongoing? Yes What evidence links the food to illness? Epi: 95% reporting romaine lettuce Traceback: Chopped and whole head from the Yuma, AZ region Lab testing: None Is public communication needed? Case count increasing rapidly E. coli O157:H7 is serious Current advice only includes chopped romaine lettuce Decision: Warn consumers and retailers not to eat or sell any romaine lettuce grown in Yuma, AZ region

24 Day 19: CDC Advice Expands Based on new information, CDC expands its warning to consumers to cover all types of romaine lettuce from the Yuma, Arizona growing region Warning now includes whole heads and hearts of romaine lettuce, in addition to chopped romaine and salads and salad mixes containing romaine

25 Day 44: What Did We Know? How many illnesses and where? 172 people infected in 32 states Outbreak ongoing? Illnesses still being reported Lettuce past its shelf life What evidence links the food to illness? Epi: 91% reporting romaine lettuce Traceback: Chopped and whole head from the Yuma, AZ region Lab testing: None Is public communication needed? Last shipments from Yuma were one month ago Lettuce likely past its shelf life, so risk to consumers is lower Decision: Lift consumer warning about romaine lettuce from Yuma

26 Day 44: CDC Lifts Warning about Romaine from Yuma Romaine lettuce from the Yuma growing region is past its shelf life and is likely no longer being sold in stores or in restaurants. Last romaine shipments from Yuma Advice to consumers: See a clinician if you have symptoms of an E. coli infection

27 Day 88: Outbreak Declared Over Outbreak declared over on June 28, day maximum shelf life for romaine 2-4 week reporting delay in PulseNet People infected with the outbreak strain of E. coli O157:H7, by state of residence People infected with the outbreak strain of E. coli O157:H7, by illness onset date 210 ill people from 36 states 48% hospitalized; 27 people developed HUS; 5 deaths

28 Environmental Assessment Launched Environmental assessment to determine possible routes of romaine contamination Observation and record collection Soil, water, and other sampling Outbreak strain identified in irrigation canal water adjacent to many fields identified in traceback How did the outbreak strain get in the water? How did the water contaminate the romaine?

29 Outbreak Challenges Challenges collecting epidemiologic data People who eat lettuce eat it often, and many have multiple exposures Many people don t remember what type of lettuce eaten Challenges interpreting traceback data Romaine from multiple farms/ranches/lots comingled at processing Common identifiers not always used to track through production/distribution Challenges communicating clearly Labels on romaine lettuce do not typically list growing region Sometimes conflicting advice from various outlets and agencies Collateral damage to romaine producers outside of the Yuma growing region

30 Outbreak Conclusions Largest multistate outbreak of E. coli O157:H7 infections in over a decade Providing clear messaging was challenging; however, we needed to provide rapid advice to the public Outbreak grew quickly and was severe Moving forward, how might we do things differently if this happens again?

31 CDC Communication Changes and Improvements

32 Possible scenarios: Specific advice to consumers and retailers Product recall This outbreak of XXX infections is linked to Brand A XXX.

33 Possible scenarios: Fast moving investigations, before a food item is identified Generic food item linked to illness but brand unknown Regulatory action not possible Protracted outbreaks Reminder of general food safety practices for consumers and retailers Likely to be used less frequently than Food Safety Alerts

34 Other Changes and Improvements Applying Digital First Prioritized important content Fewer pages More icons and images Translating notices into Spanish Trying new tools Facebook Live Patient testimonial videos Focus groups project

35 Questions? Laura: Matt: For more information, contact CDC CDC-INFO ( ) TTY: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.