Foodborne Outbreak Investigations Food Research Institute FRESH Seminar Series October 23, 2018 Jordan Mason, DVM, MPH, and Rachel Klos, DVM, MPH Wisconsin Department of Health Services Division of Public Health Bureau of Communicable Diseases
Outline Foodborne Illness Investigations Foodborne Outbreak Investigations Salmonella Outbreak Associated with Raw Breaded Chicken Outbreak of Cyclosporiasis Associated with Veggie Trays 2
Public Health in Wisconsin ~99 local and tribal health departments (LHDs) Wisconsin Department of Health Services, Division of Public Health (DPH) Burnett Polk St. Croix Pierce Western Region Douglas Washburn Barron Dunn Pepin Buffalo Bayfield Saywer Rusk Chippewa Eau Claire Trempealeau LaCrosse Ashland Jackson Vernon Crawford Monroe Taylor Clark Richland Price Iron Juneau Wood Sauk Northern Region Vilas Oneida Lincoln Marathon Portage Waushara Adams Marquette Columbia Langlade Waupaca Green Lake Forest Menominee Shawano Winnebago Dodge Florence Outagamie Fond du Lac Marinette Oconto Calumet Brown Washington Manitowoc Sheboygan Northeast Region Ozaukee Door Kewaunee Southern Region Grant Iowa Dane LaFayette Green Rock Jefferson Walworth Waukesha Racine Kenosha Milwaukee Southeastern Region 3
Reportable Disease in Wisconsin Category I: Urgent public health importance and shall be reported immediately by telephone upon identification of a case or suspected case. Category II: Shall be reported within 72 hours upon recognition of a case or suspected case. 4
Foodborne Illnesses Definition: Any illness that is related to ingestion of food or drink Centers for Disease Control and Prevention (CDC) estimates of the burden of foodborne illness each year in the United States: o Affects 1 in 6 Americans each year. o Is responsible for 48 million illnesses, 128,000 hospitalizations and 3,000 deaths annually in the U.S. United States Department of Agriculture (USDA) estimates of the cost of foodborne illnesses annually is approximately $15.6 billion. 5
Enteric Case Counts, Wisconsin 2017 Campylobacter 1,756 Salmonella 1,048 Shiga toxin STEC E. coli 423 Cylcospora Cyclospora 23 Cryptosporidium 734 Giardia 696 0 300 600 900 1,200 1,500 1,800 6
Public Health Follow-up Public health conducts follow-up interviews with people diagnosed with reportable illnesses to: Provide education to prevent transmission and discourage highrisk behaviors or practices. Identify contacts who need follow-up. Collect information on exposures prior to illness (food, animals) Document clinical features of the illness. o Onset o Duration o Symptoms o Hospitalization
Foodborne Outbreaks Definition: Two or more cases of a similar illness resulting from ingestion of a common food Foodborne outbreaks are reportable to public health. Local or event-associated outbreaks Widespread or dispersed outbreaks Multistate Outbreak of Salmonella Braenderup Infections Associated with Mangoes Source: CDC 8
2016 Wisconsin - 32 Foodborne Outbreaks - Norovirus 14 Salmonella 6 Shiga toxin E. coli C. perfringens Other 3 3 3 44% of foodborne outbreaks are caused by norovirus. 22% of foodborne outbreaks are multistate. Unknown etiology 3 0 7 14 9
2016 United States - 841 Foodborne Outbreaks - Norovirus 329 Etiology not reported 175 All other etiologies Salmonella 139 137 39% of foodborne outbreaks are caused by norovirus. E. coli Campylobacter 33 28 4.6% of foodborne outbreaks are multistate. 0 100 200 300 National Outbreak Reporting System Dashboard: https://wwwn.cdc.gov/norsdashboard/ 10
Detecting an outbreak Complaints to the local health department or alert from a local health care provider or facility o Usually associated to an event or restaurant o Often single-state outbreaks Interviews with ill individuals o Routine surveillance of reportable illnesses o Compare exposures and foods consumed Additional laboratory testing o Genetic subtyping links seemingly unconnected cases o Whole Genome sequencing and pulsed-field gel electrophoresis o Key to detecting multistate outbreaks 11
Laboratory Surveillance 13
Laboratory Surveillance 14
Laboratory Surveillance 15
Laboratory Surveillance 16
Implicated Meal to Outbreak Recognition 1-3 days 1-5 days 1-3 days 0-7 days 2-10 days 2 to 4 weeks Source: CDC Timeline for Reporting Cases of Salmonella Infection 17
Develop, Evaluate, and Refine Hypotheses Develop hypotheses o Interview case-patients and consider the infectious agent. o Determine if there are nonclinical (environmental, animal, food) matches. o Review literature from previous outbreaks. Test your hypothesis o Do iterative interviewing or conduct an analytic study. o Sample (food, animals, environment). o Do a traceback of suspect food to look for a common source. 18
Caramel apple Eaters Wisconsin Department of Health Services Case Patients Traceback Distribution Chain Common Source 19
Why Investigate an Outbreak? Interrupt disease transmission if the outbreak is ongoing. o Remove the source, such as a food item. o Prevent person-to-person transmission in households. Identify preventable risk factors for the future. Characterize a public health problem. Evaluate existing prevention strategies. 20
Communicating with the Public What to consider: Is the outbreak ongoing? Are there action steps the public can take? Is the source still a risk (i.e., food available, contamination hasn t been removed)? Is there a vulnerable group at risk or is there severe illness occurring? How strong is the evidence? 21
Communicating with the Public What to say: The goal is to provide clear advice or action to the public or consumer on how to protect themselves and prevent illnesses. 22
Salmonella Outbreak Associated with Raw Breaded Chicken Photo Credit: Minnesota Health Department 23
Salmonella: United States 1.2 million illnesses, 23,000 hospitalizations, and 450 deaths occur annually. Food is the source for approximately 1 million Salmonella infections annually. Salmonella infections: o Symptoms include: diarrhea, fever, and abdominal cramping. o Illness usually occurs 12 to 72 hours after exposure. o Illness usually lasts 4 to 7 days. o Severe illnesses, such as bloodstream infections, can occur. o Hospitalization may be required. o Infants, older adults, and immune-compromised people are at increased risk of illness and severe outcomes. 24
Salmonella Surveillance: Wisconsin Case reporting and follow-up o Public health interviews are attempted with all reported cases of Salmonella. o Routine interviews ask about food and food sources, animal exposures, travel, etc. Laboratory surveillance o Wisconsin State Laboratory of Hygiene (WSLH) receives >95% of isolates and specimens from clinical laboratories. o Serotyping o Whole genome sequencing (WGS) o Pulsed-field gel electrophoresis (PFGE) o Antimicrobial susceptibility testing (AST) 25
Outbreak Detection A local health department called the Department of Health Services (DHS) on April 23, 2018. Three salmonellosis cases reported purchasing food from Food Pantry A on April 28, 2018. o Food Pantry A is a mobile food pantry. o They stop at locations in Wisconsin and Minnesota. Salmonella enterica detected in case-patient isolates. o Isolates had a common serotype (Enteritidis) and PulseNet pattern. o They were given PulseNet pattern designation JEGX01.0004. o Previous outbreaks have been linked to poultry, eggs, and chicken. 26
Next Steps Notified partners: o Minnesota Department of Health (MDH) o Minnesota Department of Agriculture (MDA) o Wisconsin Department of Agriculture, Trade, and Consumer Protection (DATCP) Contacted Ruby s Pantry o Placed a voluntary hold on offering chicken products o Offered to contact patrons Issued joint press release (DHS and MDH) on June 1, 2018 27
Case Finding Summary 34 WI pantry patrons were interviewed. 5 patron met the confirmed case definition linked to 2 pantry locations o Onset dates 5/2 5/31 o 20% female o Median age: 54 years o 4 person hospitalized o 5 PFGE matching cases of Salmonella Enteritidis Kewaunee MDH identified 6 cases linked to MN Food Pantry A locations. 28
Five patients received breaded chicken products. They described products as chicken patties and chicken tenders. Patron Interviews They reported that chicken products did not have labels or cooking instructions. 29
Environmental Health Findings Donated food was stored in two warehouses. Bulk food was divided into smaller portions for distribution. Food was trucked to mobile pantry locations. There were hundreds of patrons per pantry location. Products were unlabeled and lacked information on: o Ingredients. o Cooking instructions. o Raw versus cooked product. 30
Product Testing Meatballs and frozen breaded chicken were collected for testing. Two frozen breaded chicken samples were positive for Salmonella Enteritidis JEGX01.0004. 31
Laboratory Analysis Both chicken and patient isolates were matches by whole genome sequencing (WGS). Chicken Case-Patient 1 Case-Patient 2 Case-Patient 3 Sporadic 1 Sporadic 2 Chicken 0 0 0 0 43 54 Case-Patient 1 0 0 0 0 43 55 Case-Patient 2 0 0 0 0 39 51 Case-Patient 3 0 0 0 0 41 51 Sporadic 1 43 43 39 41 0 42 Sporadic 2 54 55 51 51 42 0 32
Interventions and Lessons-Learned DATCP and MDA working with Food Pantry A to ensure proper labeling. Breaded chicken products may appear fully cooked. WGS is key to helping identify outbreaks in common patterns. 33
Outbreak of Cyclosporiasis Associated with Veggie Trays 34
Cyclospora Intestinal parasite Not endemic in U.S. Usually travel-associated or linked to the consumption of imported produce Not transmitted person to person Treated with trimethoprimsulfamethoxazole 35
Symptoms Symptoms usually start one week after exposure and include: Waxing and waning watery diarrhea (could last for a month or more without treatment). Stomach cramps. Anorexia. Weight loss. 36
Public Health Follow-up Public health conducts follow-up interviews with people diagnosed with Cyclospora. o Document clinical features of the illness o Provide education o Identify exposures and outbreaks o Report information to Centers for Disease Control and Prevention (CDC) to help identify multistate outbreaks
Cyclosporiasis in Wisconsin 2017 23 2016 5 2015 12 2014 1 2013 24 20120 20110 2010 2009 2008 1 1 2 Increased detection of cyclosporiasis in recent years is a result of improved clinical testing. 2007 1 0 5 10 15 20 25 30 38
Cyclosporiasis in Wisconsin 2018* 2017 298 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 24 2018: Greater than tenfold increase compared to previous biggest year 0 50 100 150 200 250 300 350 * As of August 25, 2018 39
Outbreak Detection June 5, 2018: Division of Public Health notified local health departments of an unusual increase in cyclospora cases. May 29 June 4: 16 cases were reported from 11 counties. Health departments were encouraged to rapidly interview cases. Interviews were all conducted using the Center for Disease Control and Prevention s (CDC) Cyclosopriasis National Hypothesis Generating Questionnaire. 40
Outbreak Detection June 7 8, 2018: Newly reported cases from multiple counties were reporting purchase of vegetable trays from Convenience Store A. Similar exposures reported in Minnesota Local, state, and federal public health and regulatory partners notified Convenience Store A notified Suspect product pulled from sale by Convenience Store A Public notified of outbreak by public health 41
30 20 Dates of illness onset Health Alert Issued June 8 10 0 10-May 17-May 24-May 31-May 7-Jun 14-Jun 21-Jun 28-Jun 5-Jul 12-Jul 19-Jul 30 20 Dates cases reported to public health 10 0 10-May 17-May 24-May 31-May 7-Jun 14-Jun 21-Jun 28-Jun 5-Jul 12-Jul 19-Jul 42
Product Investigation June 15, 2018: Del Monte Fresh Produce recalled 6 oz., 12 oz., and 28 oz. vegetable trays containing: Fresh broccoli Cauliflower Celery sticks Carrots Dill dip 43
Product Investigation Recalled products were distributed to the following stores: Kwik Trip Kwik Star Demond s Sentry Potash Meehan s Country Market Food Max Supermarket Peapod 44
Case Summary - Wisconsin 177 cases ate veggie trays from Convenience Store A. Residents of 51 Wisconsin counties 53% female Median age: 44 years Median incubation: 8 days 7 people hospitalized Pierce Pepin Bayfield Ashland Iron Price Vilas Oneida Lincoln Adams Forest Florence Manitowoc Door Kewaunee Richland Sauk Ozaukee Washington Iowa LaFayette Racine Kenosha 45
Case Summary - National 250 cases ate veggie trays from Convenience Store A. Residents of 4 states 52% female Median age: 45 years 8 people hospitalized FDA investigation did not identify a single source or point of contamination. 46
Challenges There was a long incubation period (eight-day median). o Patient memory may have been affected. o No product packaging remained. This was a novel vehicle with multiple components. Many case-patients reported eating multiple veggie trays. There were no timely and reliable genotyping tools. 47
Cyclosporiasis in Wisconsin 2018* 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 121 177 Convenience Store A -Linked 0 50 100 150 200 250 300 350 * As of August 25, 2018 48
McDonalds Salad Outbreak: WI 10 cases reported eating salads from McDonald s. Onset Dates: 6/24-7/15 McDonalds stopped selling salads in certain states on 7/12 An unopened salad tested for cyclospora on 7/26 49
511 cases reported eating salads from McDonald s Case Summary - National Residents of 16 states 66% female Median age: 52 years 24 people hospitalized 50
2018 National Cyclospora Reports 51
Key Points Foodborne outbreaks are a reality. Improvements in laboratory technologies are enhancing foodborne outbreak detection. Investigation methodology is improving to help identify outbreak sources. Lessons learned from foodborne outbreaks help drive food safety. 52
Outbreak Pages https://www.dhs.wisconsin.gov/outb reaks/index.htm https://www.cdc.gov/foodsafety/out breaks/index.html 53
Contact Information Jordan Mason o Enteric Epidemiologist o Phone: 608-264-9871 o Email: jordan.mason@dhs.wisconsin.gov Rachel Klos o State Public Health Veterinarian o Phone: 608-266-2154 o Email: rachel.klos@dhs.wisconsin.gov Thank you to all of our local, state, academic, and federal partners that helped with these investigations. 54
2016 Outbreaks Wisconsin - Mode of Transmission - PTP 204 r/unknown 53 Food 33 Animals 8 Water 4 0 50 100 150 200 55
Key Components of an Investigation Epidemiologic Public health nurses Epidemiologists Health officers Laboratory Clinical laboratories Public health laboratories Food and regulatory laboratories Environmental Regulatory inspectors Public health inspectors 56