SURVEILLANCE AND DETECTION OF FOODBORNE ILLNESSES
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1 SURVEILLANCE AND DETECTION OF FOODBORNE ILLNESSES Ratih Dewanti-Hariyadi Department of Food Science and Technology SEAFAST Center Bogor Agricultural University INTRODUCTION Detecting outbreaks requires efficient mechanisms to capture and respond to a variety of data sources In most countries, the main data sources for detecting foodborne disease outbreaks are obtained from: Complaint system : - the public - the media Pathogen-specific Surveillance - reports of clinical cases from health care providers - surveillance data (laboratory reports, disease notifications) Ra)h Dewan)- Hariyadi/2IPB/016 1
2 Reports of Suspected Outbreaks from Public and Media Public health authorities should have guidelines on how to deal with and respond to public and media information on suspected outbreaks (complaint system) Information to be gathered, i.e: - the person(s), including journalist (s) reporting the outbreak - characteristics of the suspected outbreak (clinical information, suspected etiologies, suspected foods) - persons directly affected by the outbreak (epidemiological information). Help public health authorities in controlling public anxiety caused by outbreak rumors in the media. Steps in Receiving Complaints Illness in individual or group Complaint to local health department Starts with complaint by consumer Interview of complainant Evaluation of individual reports for immediate action Documentation of information Key information entered into log Routine review of log Common exposures link cases over time Evaluation of reports over time for outbreaks Ra)h Dewan)- Hariyadi/2IPB/016 2
3 Interview of Complainant Who is affected? (name, age, and sex) What is the problem? (symptoms, diagnosis) When did problem occur? (date/time of onset) Where? (place of residence and exposure) Why/how? (travel, water, contact with ill persons or animals, suspect food or meal, food history) Reports Of Clinical Cases From Health Care Providers Health care providers (doctor working in ER of a large hospital, a general practitioner, a public health nurse, or the medical department of a large company may report clinical cases or unusual health events directly to the public health authorities Information sharing of this kind is common and often enables faster and more efficient detection of foodborne outbreaks than legally mandated reporting channels (e.g. statutory disease notification). Ra)h Dewan)- Hariyadi/2IPB/016 3
4 Surveillance The systematic collection, analysis and interpretation of data essential to the planning, implementation and evaluation of public health practice, and the timely dissemination of this information for public health action Surveillance Objectives : Determine the magnitude and trends of public health problems due to foodborne diseases Determine the role of food as the vehicle of certein pathogen, identify high risk foods, risky food handling practices and sensitive populations Identify foodborne disease outbreaks as early as possible to determine the preventive measures Evaluate the effectiveness of food safety programs Provide information for the policy development on health pertaining diseases due to food consumption Ra)h Dewan)- Hariyadi/2IPB/016 4
5 Surveillance Surveillance activities are conducted at local, regional and national levels through a variety of systems, organizations and pathways : - laboratory reporting - disease notification - hospital-based surveillance - sentinel site surveillance - reports of death registration Laboratory-based surveillance Laboratories receive and test clinical specimens from patients with suspected foodborne disease Often positive microbiological findings are also sent by laboratories to the relevant public health authorities Some laboratories send patient material or isolates to a central reference laboratory for confirmation, typing or determination of resistance patterns : early typing facilitate detection of outbreaks, routine typing detect a surge of a particular subtype and link apparently unrelated infections Collation of the reports & their systematic and timely analysis can provide useful information for outbreak detection, especially when cases are geographically scattered or clinical symptoms are nonspecific Generally passive surveillance Ra)h Dewan)- Hariyadi/2IPB/016 5
6 Disease Notification In most countries medical practitioners are required to notify public health authorities (PHA) of cases of certain specified diseases based on clinical judgement and may not require confirmation by other diagnostic means. Most disease notification systems : under-reporting of diagnosed cases and long delays in notification. People with foodborne disease do not seek medical advice or will not be diagnosed because of the nonspecific symptoms Medical practitioners who become aware of unusual clusters of diarrheal disease or other syndromes that may indicate foodborne disease should also be urged to report to PHA Information : diagnose, date, age, sex, (sometimes) name & address, symptoms and risk factors Sentinel Surveillance` A surveillance system to acquire high-quality data a about a particular disease that cannot be obtained through a passive system that receive data from health workers or health facilities A sentinel system involves a limited network of carefully selected reporting sites, i.e. a network of large hospitals to collect highquality data on certain diseases and their causative organisms, such as EHEC, Cronobacter spp Data can be used to signal trends, identify outbreaks and monitor the burden of disease in a community, providing a rapid, economical alternative to other surveillance methods. Criteria for selection of sentinel health facility (site) - It should be willing to participate. - It serves a relatively large population with easy access to it - It has medical staff sufficiently specialized to diagnoze, treat and report cases of the disease under surveillance - It has a high-quality diagnostic laboratory Ra)h Dewan)- Hariyadi/2IPB/016 6
7 Report of Death Certificates Data on death certificates of a patient in hospital - name, address, sex, reasons and time of death - yearly report should be available Data of people released from a hospital name, age, sex, diagnosis, length of stay in the hospital Can be used to estimate health problem due to food, including cost of illnesses Laboratory Surveillance Network PulseNet : - a national laboratory network (US), 87 labs minimum 1/ state - connects foodborne illness cases together to detect and define outbreaks using DNA "fingerprinting" of bacteria causing illness with a standardized process pulsed-field gel electrophoresis (PFGE) Salm-net : - a laboratory network for human Salmonella surveillance in Europe - Has an on-line European database of compatible data available to all participants - The network consists of microbiologists and epidemiologists responsible for national salmonella surveillance in 14 European countries. Ra)h Dewan)- Hariyadi/2IPB/016 7
8 Steps in Pathogen-specific Surveillance* Illness in individual Common pathogen links cases over time Follow-up interview of case Individual seeks health care Specimen collected Diagnosis by health-care provider/laboratory Initial report to health department Entry into electronic database Starts with positive lab result Submission of isolate to public health laboratory Further characterization Analysis of cases for clusters/outbreaks Forward to CDC *lab surveillance, notifiable/reportable diseases Initial Report From health-care provider or laboratory Standardized form (often pathogen-specific) Information of interest Patient identifiers Basic demographic information Clinical information Laboratory results Ra)h Dewan)- Hariyadi/2IPB/016 8
9 Follow-up Interview of Case To identify potential exposures leading to illness Similar to interview for complaint system but tailored to specific pathogen High-risk food exposures for agent Other exposures related to agent (e.g., contact with ill people, animals, water) Often occurs weeks after exposure leading to illness resulting in poor recall Laboratory Characterization of Pathogen Submission of patient isolate to public health laboratory for confirmation and subtyping Increased detail about the pathogen (e.g., serotyping, PFGE) that improves recognition of clusters linking an outbreak with an exposure Most critical with common pathogens Ra)h Dewan)- Hariyadi/2IPB/016 9
10 Analysis for Clusters Examine cases by pathogen over time using - different levels of specificity of pathogen (e.g., species, selected subtypes) - subgroups of population (certain time, place, or person characteristics) Look for increase in number of cases over expected or baseline, indicating a cluster Analysis by Causative Agent Lab-confirmed salmonellosis cases by month of diagnosis, 2010 Number of Case All Salmonella Month of Diagnosis Ra)h Dewan)- Hariyadi/2IPB/016 10
11 Analysis by Causative Agent Subtype Lab-confirmed salmonellosis cases by month of diagnosis, 2010 Number of Case All Salmonella Salmonella Javiana Month of Diagnosis Analysis by Causative Agent & Age Group Lab-confirmed salmonellosis cases by month of diagnosis, 2010 Number of Case All Salmonella Salmonella Javiana among persons <5 yrs. Salmonella Javiana Month of Diagnosis Ra)h Dewan)- Hariyadi/2IPB/016 11
12 Pathogen-specific Surveillance Issues Reported Incomplete detection and reporting Culture-confirmed Case Lab Tests for Organism Specimen Obtained Person Seeks Care Person Becomes Ill Population Pathogen-specific Surveillance Issues Elapsed Time for Salmonella Reporting Incomplete detection and reporting Elapsed time Pa)ent eats food Time to contact with health care=1-5 d Incubation period=1-3 d Pa)ent becomes ill Stool sample collected Isolates received by public health lab Time to diagnosis=1-3 d Shipping time=0-7 d Salmonella iden)fied Serotyping and PFGE=2-10 d Case confirmed as part of cluster Ra)h Dewan)- Hariyadi/2IPB/016 12
13 Pathogen-specific Surveillance Issues Incomplete detection and reporting Elapsed time Availability of isolate for further characterization Comparison of Surveillance Systems Complaint system Pathogen-specific surveillance Types of foodborne illnesses detected All Only selected diseases Initiating event Consumer complaint Positive lab result Means to link cases Common exposures Same pathogen Linkage of cases across jurisdictions Exclusion of unrelated cases Not usually Difficult Yes Good Speed Fast Relatively slow Types of outbreaks best detected Localized outbreaks; short incubation illnesses Widespread; low-level contamination events; long incubation illnesses Ra)h Dewan)- Hariyadi/2IPB/016 13
14 Surveillance System in Indonesia Ra)h Dewan)- Hariyadi/2IPB/016 14
15 Ra)h Dewan)- Hariyadi/2IPB/016 15
16 Developing A Surveillance System Organize System and Procedures Government prioritizes, supports with funding and organize the institutions Develop complaint system (a procedure to obtain and organize consumer complaint on suspect foodborne disease outbreaks) Identify health care facilities, hospital, puskesmas, doctors/health practitioners Kegiatan-kegiatan penyuluhan dan pendidikan (brosur, newsletter) Pemberdayaan industri makanan, turisme, rumah sakit, laboratorium Developing A Surveillance System Determine Assignments and Responsible Par4es Professionals trained to lead the surveillance program : to lead when an outbreak occurs and to handle publicities during outbreak List of experts : chemist, epidemiologist,, microbiologist, nurse, doctor, PR, sanitarians, veterinarians etc Dissemination plan Ra)h Dewan)- Hariyadi/2IPB/016 16
17 Developing A Surveillance System Provide Training to all Staffs and Personnels Information regarding the objectives, procedure program and the importance of surveillance in consumer/food protection Specific skills must be obtained through seminar/ training: Staff/personnels who recieve complaint has to be educated on outbreak, etc Developing A Surveillance System Develop Investigation Materials Tools for investigation has to be developed and listed Forms for investigation References on foodborne illness accessible by staff member Ra)h Dewan)- Hariyadi/2IPB/016 17
18 Reading Materials World Health Organization Foodborne Disease Outbreaks : Guideline for Investigation and Controls Kementerian Kesehatan Permenkes No tentang Penyelenggaraan Surveilans permenkes_ri_no_45_tahun_2014_tent ang_penyelenggaraan_surveilans_kesehatan.pdf Kementerian Kesehatan Permenkes No tentang Kejadian Luar Biasa Keracunan Pangan. Centers for Disease Control. Epi Ready Training materials. Thank You hlp ://ra)hde.staff.ipb.ac Ra)h Dewan)- Hariyadi/2IPB/016 18
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