National Burden of Foodborne Diseases Studies - Current Country Protocols
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1 National Burden of Foodborne Diseases Studies - Current Country Protocols Elaine Scallan, PhD Centers for Disease Control and Prevention Atlanta, Georgia, USA WHO Consultation Geneva, September 2006
2 Purpose of presentation 1. Review methods used to estimate the overall burden of foodborne illness United States Compare to methods used in England and Wales and Australia 2. Highlight differences, issues and limitations
3 Why don t we know? Tip of the iceberg Clinical symptoms Medical care seeking behavior Diagnosis Reporting Proportion foodborne? Unknown pathogens
4 United States Estimate Mead et al. (1999) Food-Related Illness and Death in the United States EID:5(5); Widely used for cost estimates, riskassessment, model for other disease estimates Most cited EID paper >1,500 citations in peer reviewed journals
5 Known pathogens
6 Known pathogens 1. Estimate number of reported cases 2. Adjust for underreporting 3. Estimate the foodborne proportion
7 Number of reported cases Active, passive surveillance data Salmonella, Shigella, E. coli O157 Outbreak surveillance data S. aureus, B. cereus, C. perfringens Adjustment for outbreaks Sentinel surveillance data Published studies
8 Adjust for underreporting FoodNet Population Survey Proportion seeking medical care and submitting a stool sample FoodNet Laboratory Survey Proportion of labs testing for specific pathogens Multipliers 38 for Salmonella 20 for E. coli O157 2 for Listeria
9 Exceptions Limited routine surveillance data available Norovirus Estimate derived from studies in England and Wales and the Netherlands Rotavirus Every child has at least one symptomatic infection Toxoplasmosis Sero prevalence surveys
10 Foodborne proportion Method Literature review Outbreak data Expert opinion Varies by pathogen 1-100% Overall 36% foodborne
11 Unknown pathogens 1. Estimate total burden of gastroenteritis 2. Subtract proportion due to known pathogens 3. Estimate the foodborne proportion
12 Burden of gastroenteritis FoodNet Population Survey 12-month, retrospective telephone survey Estimate gastroenteritis 0.79 episodes per person/year
13 Estimate the proportion foodborne 0.79 x million (US popn) =211 million gastro episodes million (known) =173 million unexplained x 36% (known) =62 million 62 million cases of acute gastroenteritis of unknown etiology dues to foodborne transmission
14
15 Finally we have an estimate!
16 England and Wales Estimate
17 Australian Estimate
18 Estimating burden of illness Three components required to comprehensively assess burden of all enteric foodborne illness: Estimate of: 1. Incidence of gastroenteritis in the community 2. Number of cases due to known pathogens 3. Proportion cases due to contaminated food for both known and unknown pathogens
19 Incidence of gastroenteritis United States and Australia used 12-month cross-sectional telephone survey Respondents asked retrospectively about gastrointestinal symptoms in the past month England and Wales used prospective cohort study component Participants returned weekly postcards for 6 months declaring the absence of intestinal illness
20 Pros and cons of study design Study Design Pros Cons Cohort Study More reliable data Expensive Complex Long time to conduct Harder to standardise Possible study fatigue Cross- Sectional Survey Cheaper Quicker Assess over wide geographic area Easily standardised Possibility telescoping Higher likelihood of bias
21 Differences in results Cohort studies generally report lower incidence United States 0.76 per person-year Australia 0.95 per person-year England and Wales 0.19 per person-year How much difference is due to study design? Answer!?! 2 nd Infectious Intestinal Disease Study (IIDII) to estimate incidence using prospective cohort and cross-sectional telephone survey design
22 Estimating burden of illness Three components required to comprehensively assess burden of all enteric foodborne illness: Estimate of: 1. Incidence of gastroenteritis in the community 2. Number of cases due to known pathogens 3. Proportion cases due to contaminated food for both known and unknown pathogens
23 Known pathogens Cross-sectional studies did not allow for determination of pathogens causing illness Data on proportion of different pathogens obtained from other sources Active, passive and outbreak surveillance Adjusted for underreporting
24 Known pathogens England and Wales cohort study Prospective collection of faecal specimens Person reporting symptoms of gastroenteritis asked to submit stool specimen for testing Specimens tested to determine pathogens causing illness
25 Multipliers Number of cases in community for each case in national surveillance data Variation by country For Salmonella reported to surveillance United States estimated a multiplier of 38 Australia estimated a multiplier of 15 England and Wales estimated a multiplier of 3
26 Estimating burden of illness Three components required to comprehensively assess burden of all enteric foodborne illness: Estimate of: 1. Incidence of gastroenteritis in the community 2. Number of cases due to known pathogens 3. Proportion cases due to contaminated food for both known and unknown pathogens
27 Proportion foodborne Foodborne proportion each disease Literature review Outbreak data Expert opinion Estimates United States (36%) England and Wales (25%) Australia (32%)
28 Proportion foodborne Limited information available Weakest link in estimation! Norovirus!!! Proportion foodborne for unknown pathogens Based on overall proportion foodborne for known pathogens
29 Conclusions Burden of foodborne illness estimates useful Build capacity for foodborne surveillance Specific areas for disease prevention Currently revising estimates Australia, United States, England and Wales
30 Things to consider Inherent uncertainty in the data Australia modelled potential variation Distribution of plausible values with 95% credible intervals Future studies should account for uncertainty
31 Things to consider Why are they so different? Estimates of gastroenteritis IIDII Cohort and Cross-sectional telephone survey Pathogens specific multipliers Continual version of multipliers necessary Estimate of proportion foodborne? Estimating the burden of viral foodborne illness
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