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Publisher’s Platform: It is Past Time to Step Up on Foodborne Illness Surveillance

Cyclospora outbreak going on since June 1 and we do not know the source.

Did you hear the joke about the two doctors and a trial lawyer?

I am sure there might be something funny here if it were not that part of the story involves 321 sick with Cyclospora in 15 states and me getting a bit between Dr. Patricia Quinlisk, medical director for the Iowa Department of Public Health and Dr. Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota, in an recent article by Tony Leys of the Des Moines Register entitled: “Iowa’s Cyclospora response criticized – Expert: Source should have been pinpointed quickly.”

In a nutshell the unfunny joke goes something like:

“If this same number of cases had happened in Minnesota as happened in Iowa, this would have been solved weeks ago.”  – Dr. Osterholm

“I guess it’s easy to be critical if you’re not involved in the investigation.”  – Dr. Quinlisk

“It seems to me that by now the health departments and the CDC and the FDA should have identified the products.” “[I] don’t know all the details of the investigation, [but I agree] with Osterholm that the Minnesota health department, along with the one in Oregon, often manages to quickly track down the source of tainted food.”  – Ambulance Chaser Marler

The reality is that Minnesota’s and Oregon’s foodborne illness surveillance works and works well.  They work in large part because of the people and the commitment to good epidemiology.  The goal for both is to find the source of the outbreak fast so illnesses are stopped as quickly as possible and so the correct food product gets off the shelves.  There is a misconception that you must go slowly to confirm that the right product is implicated.  In 20 years of following foodborne illness outbreaks worldwide, I have not seen Minnesota’s and Oregon’s prompt responses name a wrong product or manufacturer.

Beyond stopping an outbreak is the traceback to the source so lessons can be learned to prevent another outbreak.  Minnesota and Oregon do not wait for the U.S. Food and Drug Administration or the USDA’s Food Safety and Inspection Service to do a product traceback. Certainly, the Feds play a role, but there have been times in the past where federal traceback was unusually slow and manufacturers, shippers and retailers were left unnamed.

In Minnesota, Team D (D for diarrhea) is a squad of graduate students at the University of Minnesota School of Public Health and epidemiologists at the Minnesota Department of Health (MDH) performing epidemiological interviews in trace back investigations. Armed with tantalizing knowledge of the gastrointestinal system, telephones, and a lot of gumption, the work of Team D gives Minnesota an unusual prowess in cracking some of the most infamous foodborne illness cases in the U.S.

By Minnesota state law (oddly, only 35 states in the U.S. mandate Cyclospora as reportable), doctors must send stool cultures believed to be from cases of foodborne illness to the MDH laboratory where they are pulsed field gel electrophoresis (PFGE) tested to create DNA finger printing – which tell investigators if different samples likely came from a common host.  Team D gets to work immediately, interviewing the victims, often as they are suffering symptoms, looking for commonalities in what, where, and when they ate. Whereas some states may take weeks to perform the interview portion of an investigation, it is this real-time history gathering that adds an invaluable level of depth to trace back investigations, something it seems that this Cyclospora outbreak desperately needs.

Team D is a model that all states should emulate.

Of course, you cannot do without individual knowledge.  Dr. William Keene, senior epidemiologist is the top foodborne illness investigator at Oregon’s Division of Public Health. Keene has been unraveling the path of pathogens from victims to the source for over 30 years, and has an impressive list of solved cases under his belt.  One of his most valuable contributions to the food safety world is the shotgun questionnaire, which lists hundreds of foods for foodborne illness victims to choose from to help them recall what they recently ate.

But, do not take it just from me.

In 2011, the Center for Science in the Public Interest released a nationwide report card grading the 50 states and the District of Columbia on how well they detect, investigate, and report outbreaks of foodborne illness (See Report). The report shows that there is a need for improvement. CSPI assigned a letter grade and created an outbreak profile for each state.

A: Oregon, Minnesota, Florida, Hawaii, Maryland, Washington, and Wyoming.

B: Colorado, Illinois, Kansas, Maine, Michigan, Ohio, and Vermont.

C: Alabama, Alaska, California, Connecticut, Iowa, New Hampshire, North Dakota, and Wisconsin.

D: Delaware, the District of Columbia, Georgia, Idaho, Massachusetts, Montana, New Jersey, New York, North Carolina, Pennsylvania, Rhode Island, South Dakota, Tennessee, Utah and Virginia.

F: Arizona, Arkansas, Indiana, Kentucky, Louisiana, Mississippi, Missouri, Nebraska, Nevada, New Mexico, Oklahoma, South Carolina, Texas, and West Virginia.

In addition to states being committed quickly and accurately seeking the source of a foodborne illness outbreak, perhaps too the answer to the low grades and the lack of a source in this Cyclospora outbreak may lie in overlooked Sec. 205 of the Food Safety Modernization Act.  The Section should:

- Coordinate Federal, State and local systems, including complaint systems and networks of public health, food regulatory agencies and labs;

- Facilitate sharing of findings between FDA, USDA, State and local agencies, and the public;

- Develop improved epidemiological tools;

- Improve systems that attribute an outbreak to a specific food;

- Expand fingerprinting and other detection strategies for food-borne agents;

- Allow public access to aggregated, de-identified surveillance data;

- Publish findings at least yearly;

- Rapidly initiate scientific research by academic institutions;

- Integrate surveillance systems and data with other bio surveillance and public health entities.

Also, is the creation of “PARTNERSHIPS,” which appears to actually be a “working group of experts and stakeholders from Federal, State and local food safety and health agencies, the food industry, consumer organizations and academia.”  In addition, Sec. 205 (c) adds “strengthen[ing] the capacity of State and local agencies to carry out inspections and enforce safety standards” and, “the Secretary to (within a year) complete a review of State and local capacities, including staffing levels, laboratory capacity, outbreak response, inspection and enforcement functions.”

Stopping outbreaks sooner, means less ill people. Honestly, that is not good for my business. Tracing it to the source gives everyone a better understanding of how the outbreak happened and what can be done to prevent the next one.  Hmm, that does not help my bottom line either.

So, if the states and the federal government did a better job of figuring out foodborne illness outbreaks, there would be fewer ill people and fewer outbreaks?

Wait, I just figured out, this joke could well be on me!

Photo courtesy of FDA’s flickr page.

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