GIDSAS A Review of Foodborne Illness an Outbreak
GIDSAS A Review of Foodborne Illness & an Outbreak Investigation that Lead to a Product Recall Rashid A. Chotani, MD, MPH Assistant Professor & Director Global Infectious Disease Surveillance & Alert System (GIDSAS) Center for International Emergence, Disaster & Refugee Studies Johns Hopkins Schools od Medicine & Public Health Phone: 410 -614 -8330 9/13/2021 E-mail: rchotani@jhsph. edu
Significance n GIDSAS n n n 9/13/2021 Foodborne illness is one of the largest preventable public health problem in the world In the US it causes an estimated 9, 000 deaths/yr (CDC) 6. 5 to 81 mil cases of diarrheal disease/yr Most of the infections go undiagnosed & unreported
Sequelae n GIDSAS 9/13/2021 n Guillain-Barre Syndrome (C. jejuni) Renal Disease (E. coli O 157: H 7 and other Shiga-like toxin producing bacteria)
Contributing Factors n GIDSAS n n n 9/13/2021 n Poor foodhandler hygiene (inadequate handwashing, open wounds, etc. ) Inadequate cooking of raw products or holding temperatures Cross contamination (equipment/work surface/hands) Improper cooking Food obtained from an unsafe source Inadequate washing of fresh produce Others
Events and potential contamination sources during produce processing Event Production and harvest Growing, picking, bundling Initial processing Washing, waxing, sorting, boxing Distribution Trucking Contamination sources Irrigation water, manure, lack of field sanitation Wash water, handling Ice, dirty trucks Final processing Slicing, squeezing, shredding, peeling Wash water, handling, cross-contamination 9/13/2021 Rashid A. Chotani, MD, MPH GIDSAS-JHU
Enteric Host Defense n n GIDSAS n n n 9/13/2021 Saliva Gastric Acid Intestinal motility Enteric flora Shedding & replication of epithelium Mucus layer Immune system Proteolytic enzymes
Changing Patterns of Foodborne Diseases GIDSAS 9/13/2021 1. Newly identified pathogens, routes & vehicles (e. g. increasing frequency of outbreaks associated with consumption of raw fruits and vegetables) 2. Increasing complexity of of foodborne disease outbreaks Old Outbreak Scenario New Outbreak Scenario acute: local diffuse: multi-state & inter dose & attack rate: high dose & attack rate : low detected : by groups detected : by lab-based surveillance
Factors in the Emergence of Foodborne Diseases GIDSAS 9/13/2021 1. Changes in agricultural practices 2. New methods of food processing, especially mass production 3. Globalization of food industry 4. Changes in consumer behavior 5. Changes in consumer susceptibility 6. Epidemiology & laboratory
Food. Net GIDSAS 9/13/2021 Rashid A. Chotani, MD, MPH GIDSAS-JHU
The Foodborne Disease Activity Surveillance Network n GIDSAS n n Established in 1995 in 5 states Minnesota, Oregon, Georgia, California, and Connecticut; MD & NY joined the program in 1997 Foodborne disease component of Emerging Infections Program (EIP) Collaborative project – CDC – EIP states – USDA – FDA 9/13/2021 n Active surveillance system
Food. Net Goal n GIDSAS n n 9/13/2021 Determine & monitor the burden of foodborne diseases Determine the proportion of foodborne diseases attributable to specific foods Develop a network to respond to new & emerging foodborne diseases
Food. Net Components n GIDSAS n n 9/13/2021 Active lab-based surveillance Surveys of clinical labs Survey of physicians Survey of the population Case-Control studies
9/13/2021 Rashid A. Chotani, MD, MPH GIDSAS-JHU
9/13/2021 Rashid A. Chotani, MD, MPH GIDSAS-JHU
9/13/2021 Rashid A. Chotani, MD, MPH GIDSAS-JHU
Classification 9/13/2021 Rashid A. Chotani, MD, MPH GIDSAS-JHU
Definition n GIDSAS n n n 9/13/2021 Poisoning: results from eating foods containing poisons (chemicals or toxins) Infections: result from eating food containing pathogenic microorganisms Toxin: a poison produced by a living organism Intoxication: disease caused by consumption of food containing toxins
Epidemiologic Triad Agent GIDSAS Host 9/13/2021 Environment Rashid A. Chotani, MD, MPH GIDSAS-JHU
Mechanisms of foodborne Agents n GIDSAS n 9/13/2021 Preformed toxin in food = rapid onset of nausea, vomiting, and cramps e. g. S. aureus and Bacillus cereus emetic syndrome Direct tissue invasion = inflammatory diarrhea (often fever &/or bloody stool) e. g. Salmonella, Shigella, Campylobacter, Vibrio parahaemolyticus, Yersinia, and Entamoeba histolytica Rashid A. Chotani, MD, MPH GIDSAS-JHU
Mechanisms of foodborne Agents n GIDSAS n 9/13/2021 Enterotoxin producing in the gut = noninflammatory (watery) diarrhea e. g. Clostridium perfringens, Bacillus cereus diarrhea syndrome, Vibrio cholerae, and Enterotoxigenic E. coli Neurotoxin producing = e. g. Clostridium botulinum; mushroom, shellfish, ciguatera fish and puffer fish poisioning Rashid A. Chotani, MD, MPH GIDSAS-JHU
Etiologic Agents of foodborne Disease 1. Bacteria GIDSAS S. aureus, B. cereus, C. perfringens, C. botulinum, E. coli, Salmonella, Shigella, Streptococcus, Brucella, Listeria monocytogenes, Yersinia sp. Campylobacter sp. Vibrio sp. , others 2. Parasites 9/13/2021 Protozoa Giardia, Cryptosporidium, Entameoba histolytica, Toxoplasma gondii, Cylospora, others Helminths Trichinella spiralis, Tapeworms (e. g. taenisis, cysticercosis), others. Rashid A. Chotani, MD, MPH GIDSAS-JHU
Etiologic Agents of foodborne Disease 3. Virus Hepatitis A, Norwalk virus & Norwalk like viruses, others 4. Intoxicants & Chemical Poisons a) Poisonous plant tissue (jimson weed, rhubarb GIDSAS leaves) b) Poisonous animal tissues (puffer fish, blow fish, moray eels) c) Mycotoxins and poisonous fungi (ergot alkaloids, trichothecenes, zearalenone, alfatoxins, poisonous mushrooms) d) Dinoflagellate toxins (ciguatera fish poisoning, shell fish poisoning f) Chemicals (pesticides, heavy metals, MSG, drugs, nitrates) 9/13/2021 g) Others Rashid A. Chotani, MD, MPH GIDSAS-JHU
Bacteria n GIDSAS n n 9/13/2021 Single cell organisms Multiply by single division; can multiply in foods Most common cause of foodborne outbreak Some can produce resistant strains Some may produce toxins in food or gut Rashid A. Chotani, MD, MPH GIDSAS-JHU
Parasites n GIDSAS n n n 9/13/2021 Live on another organism (host) Transmitted through food & water Do not multiply outside host Some require favourable environment to become infectious (e. g. Cyclospora) Rashid A. Chotani, MD, MPH GIDSAS-JHU
Viruses n GIDSAS n n n 9/13/2021 Obliterate intracellular organisms Require host cell to multiply Do not produce toxins or multiply in food Reservoirs are humans Rashid A. Chotani, MD, MPH GIDSAS-JHU
Foodborne disease Case Investigation GIDSAS I. Sources of case report II. Goals of foodborne illness case investigation III. Information collection Demographics Illness information Exposure information Miscellaneous information 9/13/2021 IV. Interventions & public health actions Rashid A. Chotani, MD, MPH GIDSAS-JHU
Source n GIDSAS n n 9/13/2021 Public Laboratory reports Healthcare providers Health departments Other state departments Rashid A. Chotani, MD, MPH GIDSAS-JHU
Goal n GIDSAS n n 9/13/2021 Prevent transmission Early detection Understanding outbreak disease epidemiology Evaluate food safety programs Identify high risk food & processes Rashid A. Chotani, MD, MPH GIDSAS-JHU
Information n GIDSAS 9/13/2021 Timing is ESSENCE – Designate team leader – Assign responsibilities – Obtain maximum information on first contact – Use standardized form Rashid A. Chotani, MD, MPH GIDSAS-JHU
Information n Demographic – Name, address, phone no. , age, occupation, gender GIDSAS n Illness – Symptoms, onset, duration, have they been to a physician Ø Name, n Dx, Lab tests, results, Tx Exposure – 72 hour food history Ø What 9/13/2021 was eaten, who else was there, when was the meal eaten, where was the meal eaten, was there anything unusual Rashid A. Chotani, MD, MPH GIDSAS-JHU
Definition n GIDSAS n The occurrence of more cases of disease than expected in a given area or among a specific group of people over a particular period of time Single case is considered an outbreak (inclusive) – Anthrax, botulism, brucellosis, cholera, diptheria, encephalitis, measles, plauge, polio, psisticosis, human rabies, rubella, trichinosis, typhoid fever, hepatitis A, H. influenza type b, or meningococcal disease 9/13/2021 Rashid A. Chotani, MD, MPH GIDSAS-JHU
Interpretation of Outbreak Curves n Common source transmission: – Occur via point, intermittent or a continuous source GIDSAS n Propagated transmission: – Person-to-person transmission – Cases increase gradually and than decrease gradually (uncommon foodborne outbreak) 9/13/2021 Rashid A. Chotani, MD, MPH GIDSAS-JHU
Point Source Outbreak 10 8 # of Cases GIDSAS 6 Catered event 4 2 0 4/1/01 4/2/01 4/3/01 4/4/01 4/5/01 4/6/01 4/7/01 4/8/01 Days 9/13/2021 Rashid A. Chotani, MD, MPH GIDSAS-JHU
Intermittent Source Outbreak GIDSAS # of Cases 10 8 6 4 2 9/13/2021 10 /0 1 4/ 01 9/ 4/ 01 8/ 7/ 4/ 4/ 01 01 6/ 4/ 01 5/ 4/ 01 4/ 4/ 01 3/ 4/ 01 2/ 4/ 4/ 1/ 01 0 Days Rashid A. Chotani, MD, MPH GIDSAS-JHU
Continuous Source Outbreak 10 GIDSAS # of Cases 8 6 4 2 9/13/2021 10 /0 1 4/ 01 9/ 4/ 01 8/ 4/ 01 7/ 4/ 01 6/ 4/ 01 5/ 4/ 01 4/ 4/ 01 3/ 4/ 01 2/ 4/ 4/ 1/ 01 0 Days Rashid A. Chotani, MD, MPH GIDSAS-JHU
9/13/2021 Days 01 13 / 4/ 01 12 / 4/ 01 11 / 4/ 1 01 10 / 4/ 9/ 0 4/ 1 8/ 0 4/ 1 7/ 0 4/ 1 6/ 0 4/ 1 5/ 0 4/ 1 4/ 0 4/ 1 3/ 0 4/ 1 2/ 0 4/ 1 1/ 0 4/ GIDSAS # of Cases Propagated Source Outbreak 10 8 6 4 2 0 Rashid A. Chotani, MD, MPH GIDSAS-JHU
Analytical Epidemiology: Measures of association: Case-Control Study n Odds Ratio (OR) = odds of exposure in cases odds of exposure in controls GIDSAS Ate suspected Food item? n 9/13/2021 ill YES a NO c well b d OR = ad/bc Done when you CANNOT interview everyone Rashid A. Chotani, MD, MPH GIDSAS-JHU
Analytical Epidemiology: Measures of association: Cohort Study n Relative Risk (RR) = attack rate in exposed attack rate in non-exposed GIDSAS Ate suspected Food item? n ill YES a NO c well b d RR = [(a/a+b)x 100] / [(c/c+d)x 100] Done when you CAN interview everyone 9/13/2021 Rashid A. Chotani, MD, MPH GIDSAS-JHU
GIDSAS A Foodborne Outbreak of Gastroenteritis in a Teaching Hospital Reference: Chotani et al. SHEA Annual Meeting 1998 9/13/2021
Hospital n 940 bed hospital with 4 cafeterias. n Cafeteria A, located in the OPD, serves approximately 600 visitors and employees daily. GIDSAS 9/13/2021 Rashid A. Chotani, MD, MPH GIDSAS-JHU
Events n GIDSAS 9/13/2021 On 12/9/97 individuals who ate at Cafeteria A reported nausea and projectile vomiting after eating a noon meal. Rashid A. Chotani, MD, MPH GIDSAS-JHU
Method: case definition GIDSAS Any person who ate lunch prepared at cafeteria A on December 9, 1997 and developed sudden onset of l l l vomiting or diarrhea or abdominal cramps and Any of the following symptoms including nausea, fever, body aches, headache, chills or fatigue. 9/13/2021 Rashid A. Chotani, MD, MPH GIDSAS-JHU
Method: case finding GIDSAS We identified all cases who identified individuals who ate with them. All non-Ill persons were used as controls. Additional cases were found when we contacted: l l 9/13/2021 Nurse managers Hospital managers Directors of nursing, functional unit directors, JHH vice-presidents Several employee groups were notified via e-mail and asked to identify cases. Rashid A. Chotani, MD, MPH GIDSAS-JHU
Methods: questionnaires GIDSAS 9/13/2021 Standard questionnaires were used to obtain medical and food history from l Food service workers l Ill and non-ill employees Menu reviewed at Cafeteria A. Rashid A. Chotani, MD, MPH GIDSAS-JHU
Control Measures and Interventions: Cafeteria A Cafeteria: l l GIDSAS l l l Kitchen was inspected Leftover foods recovered and cultured Food preparation, kitchen cleaning procedures reviewed Certain food items quarantined Employees were interviewed, inspected for sores, boils, cuts, IV tract marks and sent to occupational health services We obtained nares swabs 3 cafeteria staff members submitted stool samples or rectal swabs All staff (n=17) were questioned daily for symptoms 9/13/2021 Rashid A. Chotani, MD, MPH GIDSAS-JHU
Laboratory n – – – GIDSAS n n n 9/13/2021 Food was processed in standard fashion Blood agar plate R/O Bacillus CAN plate R/O Staphylococcus Plates for enteric pathogens R/O Salmonella, Shigella, Aeromonas, Campylobacter, Yersinia Samples sent to city, state, FDA, and commercial laboratory Sequencing preformed Heavy metal testing Rashid A. Chotani, MD, MPH GIDSAS-JHU
Results n GIDSAS n n 9/13/2021 N = 75 (ill = 40; non-ill = 35) Mean age: 39 years (range 2556) Sex: 85% female Rashid A. Chotani, MD, MPH GIDSAS-JHU
Incubation period: JHH employees (n=40) 9/13/2021 Rashid A. Chotani, MD, MPH GIDSAS-JHU
Symptoms 9/13/2021 Rashid A. Chotani, MD, MPH GIDSAS-JHU
Results: outcomes n GIDSAS n n n 9/13/2021 Duration of illness: mean--24 hr. (range <24 - 72 hr. ) Bedridden 62. 5% Sought medical care 27. 5% Hospitalized 2. 5% Rashid A. Chotani, MD, MPH GIDSAS-JHU
Results: univariate analysis GIDSAS Food item OR CI 95% p-value Green beans Tortellini Corn soup Veg soup 36. 4 5. 50 0. 23 6. 93, 341. 60 1. 03, 54. 50 0. 04, 1. 10 <0. 0001 0. 02 0. 03 Not associated: bread, breadsticks, chicken salad, broccoli salad, cheese salad, caesar salad, havarti cheese, swiss cheese, beef stew, Thai beef, cous, honey turkey, chicken fingers, cheese pizza, sausage pizza, chow mein noodles, marinated tomatoes, onions, mixed greens, cucumbers, dressing tomatobacon/peppercorn, creamy, sunflower seeds, crackers, chips, cookies, yogurt, and fresh fruits 9/13/2021 Rashid A. Chotani, MD, MPH GIDSAS-JHU
Results: multivariate analysis GIDSAS 9/13/2021 Variable OR CI 95% p-value Green beans Tortellini Corn soup Veg soup 1. 84 1. 25 0. 89 0. 93 1. 49, 2. 27 0. 98, 1. 59 0. 69, 1. 16 0. 71, 1. 21 <0. 005 NS NS NS Rashid A. Chotani, MD, MPH GIDSAS-JHU
Results: laboratory n GIDSAS n n n 9/13/2021 Bacillus sp. recovered from garlic mix (opened/unopened jars), Moroccan beef stew and vegetable soup. Bacillus subtilis was identified based on the library profiles. Heavy metals negative. Patient/employees culture negative. Rashid A. Chotani, MD, MPH GIDSAS-JHU
Food preparation n GIDSAS n n 9/13/2021 Frozen green beans steamed for 10 minutes. Seasoned with salt, pepper, olive oil and garlic mix. Baked in oven for 15 minutes at 375 OF. Stored in warmer at 180 degrees. Placed in pan and sent to serving line (140 degrees); maximum time 4 hours. Rashid A. Chotani, MD, MPH GIDSAS-JHU
Summary n GIDSAS n n 9/13/2021 40 persons became ill after eating green beans. We under-estimated magnitude of problem because case ascertainment difficult. The symptoms pointed to a toxin mediated illness. The process of preparing green beans with garlic (in soy oil base) most likely led to the illness. Bacillus was isolated from opened/unopened jars. Rashid A. Chotani, MD, MPH GIDSAS-JHU
Conclusions n – Inspected the manufacturing facility – Inspected food supplier – Ordered recall of all garlic jars produced by company A – Mandated new control protocols GIDSAS n n 9/13/2021 FDA Aggressive control measures should be taken to prevent the spread of any outbreak particularly in a hospitals in order to protect not just the patients but the staff. Rarely bacillus subtilis has been associated in food poisoning. Rashid A. Chotani, MD, MPH GIDSAS-JHU
GIDSAS 9/13/2021 n Thank you Rashid A. Chotani, MD, MPH GIDSAS-JHU
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