Investigating Foo
                  odborne Disease
  Outbreaks: The CCDC Perspective



                   Ian William Ph...
The Spectrum of Foodb
                    borne Disease Outbreaks

• Old focal scenario              • New dispersed scena...
Public Health Infrastruct
                        ture in the United States
 • The county or city health d   department
  ...
Federal Roles


• CDC:                      • FDA & FSIS:
  – Disease surveillance        –   Food safety policies
  – Out...
Foodborne Disease Ou
                   utbreak Investigations
 • Goals of investigations
   – Immediate control of outbrr...
Cycle of Foodborn Disease Control
                ne
          and Pre
                evention

            Survei
      ...
Cycle of Foodborne Outbreak Control &
 Prevention: Stages of an I
 P      ti   St      f    Investigation
                ...
National Surveilla
                      ance for Bacterial
           Foodborne I f i
           F db      e Infections
•...
What is PulseN USA?
                      Net

• National net ork of >75 p b health and reg lator
           network      ...
PulseNet Data Analysis: Searching for Clusters
                  y             g

                                        ...
Cycle of Foodborne Outbreak Control &
             Preve ti
             Preve
                 ention

             Surve...
CDC’s Outbre
                           eakNet Team
• Supports a national network of epidemiologists and other
           ...
Cycle of Foodborne Disea Control & Prevention:
 y                      ase
       Stages of an Outbreak Investigation

   ...
Hypothesis Gener
                    rating Interviews
• Strategies include:
  –I t i
   Interviews with structured questi...
Hypothesis-
    Hypothesis-Genera
                    ating Tracebacks

• Data on product distribbution production can
  b...
Testing Hy
                              ypotheses
• Systematically compare exp
                           posures of ill ...
Cycle of Foodborne Disea Control & Prevention:
                        ase
       Stages of an O tbreak I
       St      f...
Prevention Measures

         Traceback In
         T    b k Investigations
                       ti ti


Epidemiologic  ...
http://www.cdc.gov/f
 http://www cdc gov/f
                    foodborneoutbreaks/

The findings and conclusions in this p...
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Ian Williams CDC Chief, Outbreak Response And Prevention

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Dr. Ian Williams of the CDC submitted this presentation to the joint FDA/FSIS meetings on Produce Traceability on Dec. 9, 2009 in Washington D.C.

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Ian Williams CDC Chief, Outbreak Response And Prevention

  1. 1. Investigating Foo odborne Disease Outbreaks: The CCDC Perspective Ian William PhD, MS ms, Chief, Outbreak Respons and Prevention Branch se Division of Foodborne, bac cterial and Mycotic Diseases Centers for Disease CControl and Prevention The findings and conclusions in this presentation are tho of the author and do not necessarily represent the ose views of the Centers for Disease Control and Prevention
  2. 2. The Spectrum of Foodb borne Disease Outbreaks • Old focal scenario • New dispersed scenario • Large number of cases in • Small numbers of cases in one jurisdiction many jurisdictions • Detected by affected • Detected b lab based by lab-based group subtype surveillance • Local investigation • Multistate/Countryy • Local food handling error investigation • Local solution • Industrial contamination event • Broad implications These changes make coordination among multiple states and agencies, and countries even m more important than before
  3. 3. Public Health Infrastruct ture in the United States • The county or city health d department • The front line of public hea p alth • The State health departme ent • Epidemiologists • Laboratorians • Sanitarians • Th federal agencies: The f d l i • Risk identification agency: CDC (non-regulatory) • Risk management/regulato agencies: FDA USDA EPA ory FDA, USDA, • "Tiered response" to emer rgencies • CDC provides back-up to S back up States: epidemiologists epidemiologists, laboratory support, coordination
  4. 4. Federal Roles • CDC: • FDA & FSIS: – Disease surveillance – Food safety policies – Outbreak detection and – Inspection and enforcement I ti d f t investigation – Product recall and traceback – Education and training of public health staff bli h l h ff – Investigation of farm and production facilities Problem identification Risk assessment and management Source implication Source assessment
  5. 5. Foodborne Disease Ou utbreak Investigations • Goals of investigations – Immediate control of outbrreak and prevention of illnesses – Provide opportunities to id dentify gaps in food safety systems • Outbreak epidemiology c changing – Globalization, centralizatio industrialization on, – Number of possible outbre eaks detected has grown substantially • Effective investigations k to reducing burden of key foodborne disease – Identify food vehicles and factors which lead to outbreaks y
  6. 6. Cycle of Foodborn Disease Control ne and Pre evention Survei illance Applied Epidemiologic Research Investigation Prevent tion Measures
  7. 7. Cycle of Foodborne Outbreak Control & Prevention: Stages of an I P ti St f Investigation ti ti Surveillance Detecting a cluster (inc crease # of infections above baseline for time period) Applied Epidemiologic Research Investigation Prevention Meas sures
  8. 8. National Surveilla ance for Bacterial Foodborne I f i F db e Infections • Reports to CDC of susp pected outbreaks by state and local health departm ments • Laboratory-based surve eillance of clinical isolates – Serotype results yp – PulseNet
  9. 9. What is PulseN USA? Net • National net ork of >75 p b health and reg lator network pub blic regulatory laboratories • Perform molecular typing of foodborne disease causing f disease-causing bacteria – Current method is pulsed fie gel electrophoresis (PFGE) pulsed-fie eld – Create DNA “fingerprints” • Share DNA “fingerprints” electronically fingerprints • DNA “fingerprints” are kept in dynamic database at CDC – available on-demand to part on demand ticipants
  10. 10. PulseNet Data Analysis: Searching for Clusters y g •State health depts submit patterns electronically •CDC searches for similar patterns in past 2 4 months 2-4 •CDC compares patterns visually •When cluster identified, PulseNet contacts epidemiologists Cluster of indistinguishable patt terns
  11. 11. Cycle of Foodborne Outbreak Control & Preve ti Preve ention Surveillance Applied Epidemiologic Research R h Investigation Preven ntion Measu ures
  12. 12. CDC’s Outbre eakNet Team • Supports a national network of epidemiologists and other f public health officials who inve estigate outbreaks of foodborne, waterborne, and other enteric ill t b d th t i illnesses in the United States i th U it d St t • Collaboration between CDC an nd – U S State and local health departmen U.S. nts – U.S. Department of Agriculture (USDA A) – U.S. Food and Drug Administration (F FDA) • Works in close partnership wit PulseNet th – The national molecular subtyping net twork for foodborne disease surveillance • Helps ensure – Rapid, coordinated detection & respo onse to multi-state enteric disease outbreaks – Promotes comprehensive outbreak s surveillance
  13. 13. Cycle of Foodborne Disea Control & Prevention: y ase Stages of an Outbreak Investigation Surveillance Detecting a cluster in the first place - Generating hypotheses Applied Epidemiologic - Testing hypotheses Research Inve ti ti I estigation - Reconstructing how and where contamination is likely to have occurred Prevention Measures
  14. 14. Hypothesis Gener rating Interviews • Strategies include: –I t i Interviews with structured questionnaire with many ith t t ti i ith food items: “trolling, traw wling, or shotgun” –I t Intensive open-ended i t i i d d int terviews about f d eaten in 7 b t food t i days before illness bega an • In depth interview with pe In-depth eople in their homes including homes, refrigerator, pantry – Some combination of the two e – All should be done the sa ame way • A food product is not the source of all outbreaks! e
  15. 15. Hypothesis- Hypothesis-Genera ating Tracebacks • Data on product distribbution production can be critical in developm ment of hypothesis – Evaluate potential sour rces • Ways to obtain this inf formation – State Departments of A Agriculture – Regulatory agencies • Involvement before a pro oduct has been implicated can pose unique problem for some agencies m
  16. 16. Testing Hy ypotheses • Systematically compare exp posures of ill and those who remained well – Two structures of investigatio on • Illness in a defined group (coho after an event: interview whole group ort) about exposures and subseque illness ent • Illness in cases and controls: in nterview the ill people and comparable healthy persons (controls) abou preceding exposures ut – Measure statistical associatio of illness with each exposure on • Direction of association (Sh hould be positive) • Probability of chance alone (Sh hould be < 5%) • Strength of association g ( o fixed rule) (No ) • Dose-response relationship (Suupports if present) • Plausibility of association • R Repeat process as necessa t ary
  17. 17. Cycle of Foodborne Disea Control & Prevention: ase Stages of an O tbreak I St f Outb k Investigation ti ti Survei illance Applied Epidemiologic Research Investigation Preve ention Meas sures
  18. 18. Prevention Measures Traceback In T b k Investigations ti ti Epidemiologic Environmental Investigations Assessments Lab boratoryy Inves stigations
  19. 19. http://www.cdc.gov/f http://www cdc gov/f foodborneoutbreaks/ The findings and conclusions in this presentation are those of the author and do not necessarily represent the views of the Centers for Disease Control and Prevention e

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