Zoonotic Foodborne Illnesses and Fecal-Oral Transmitted Bugs

1. Zoonotic Foodborne Illnesses and Fecal-Oral Transmitted Bugs Ben Sun, DVM, MPVM Infectious Diseases Branch CA Department of Health Services

2. Overview Changing epidemiology of FBI Foodborne disease surveillance Reptile-associated Salmonellosis Animal exhibits

3. Fecal � Oral route Types of transmission Food / water contamination Direct contact Indirect contact Fomites Other

4. Fecal � Oral route Animal fur, hair, skin, and saliva may become contaminated Exposure may occur through petting, touching, or being licked Contamination of envrionment

5. Burden of Food-Related Illness Over 200 known diseases are transmitted through food viruses, bacteria, parasites, toxins, metals, prions illnesses range from gastroenteritis to death I want to start by talking a bit about the impact of food-related ilnness. There are over 200 known diseases that are transmitted through food. In addition to things that we usually think about, such as viruses, bacteria, and parasites, other things, such as prions, toxins, and heavy metals can also be transmitted through food. Illnesses can range from mild gastroenteritis to death. CDC estimates that each year in the U.S. there are approximately 76 million illnesses, 325,000 hospitalizations, and 5,000 deaths due to foodborne diseases.I want to start by talking a bit about the impact of food-related ilnness. There are over 200 known diseases that are transmitted through food. In addition to things that we usually think about, such as viruses, bacteria, and parasites, other things, such as prions, toxins, and heavy metals can also be transmitted through food. Illnesses can range from mild gastroenteritis to death. CDC estimates that each year in the U.S. there are approximately 76 million illnesses, 325,000 hospitalizations, and 5,000 deaths due to foodborne diseases.

6. Zoonotic Enteric Diseases E. coli O157:H7 Campylobacter Salmonella Cryptosporidium Typically foodborne route via livestock products but can be by wildlife etc. Contamination of produce etc. Food handler etc. propagation

7. Zoonotic Enteric DiseasesChallenges Many animals are reservoirs and harbor enteric pathogens Often asymptomatic May shed intermittently Antibiotics may not eliminate infection or shedding

8. Zoonotic Enteric Diseases Challenges Antibiotic resistance issues Organisms survive in environment Low infectious dose No specific treatment for many Secondary cases

9. Foodborne Illness Estimated that over 76 million persons in the U.S. develop foodborne illness / yr. Estimated 325,000 hospitalizations / yr. Estimated 5000 deaths due to foodborne illness in the U.S. / yr.

10. Foodborne Illness In California 9 million illnesses (viral>bacteria>parasitic) 39,000 hospitalizations (bacterial>viral>parasitic) 600 deaths (bacterial>parasitic>viral)

11. Changing Epidemiology-Host More elderly, immunocompromised persons Increased susceptibility, complications Changes in eating habits Raw, fresh food, eating out Immigration and travel Ethnic practices - raw meat Souvenir foods

12. Changing Epidemiology-Environment Globalization of the food supply Rapid distribution of perishable foods Centralized production with large producers Large outbreaks Low level contamination causes outbreaks Difficult detection Large geographic areas

14. Changing Epidemiology-Agent Newly recognized pathogens E. coli O157:H7, Cyclospora, vCJD New resistance Salmonella Typhimurium DT 104 Salmonella Newport Ciprofloxacin resistant Campylobacter Pandemics SE Phage Type 4, DT 104

15. FB Disease Surveillance Disease Prevention and Control Knowledge of Disease Causation Administrative Guidance

16. Disease Reporting Passive surveillance system Mandatory disease reporting to LHD Standardization CCR, Title 17 � Section 2500 LHD case follow-up and further investigation if needed LHD transmit data to DHS to CDC

17. Laboratory Disease Reporting Passive surveillance system Mandatory disease reporting to LHD Standardization CCR, Title 17 � Section 2505 For select agents, must report immediately

18. Other FBD Surveillance Electronic disease reporting and analysis Complaints from public Detection of contaminated food through monitoring Special projects FoodNet

19. Molecular FBD Surveillance Centralized laboratory Molecular subtyping (i.e. PFGE) PulseNet

20. LHD Investigation Receive individual CMRs Case interview Determine possible source of exposure Determine potential contacts / job Health education Detection of an outbreak

22. Surveillance Data Limitations Many foodborne pathogens are reportable diseases to the local health dept. from physicians and laboratories Underreporting issues Estimated that for every 1 case of Salmonella that is diagnosed, 38 cases are undiagnosed Not all reported cases are foodborne Person to person, animal contact, water

23. Reported Cases of Selected Diseases

24. Notifiable Foodborne Diseases, CA 2000 To give you an idea of what we see in CA, here is a listing of some of the notifiable foodborne diseases in CA. The first column is the number of cases that were reported to the state in 2000, and the second column is an estimate of the true number of cases, which takes into consideration the problem of under-reporting.To give you an idea of what we see in CA, here is a listing of some of the notifiable foodborne diseases in CA. The first column is the number of cases that were reported to the state in 2000, and the second column is an estimate of the true number of cases, which takes into consideration the problem of under-reporting.

26. Foodborne Outbreak Scenarios Traditional scenario usually event associated, or affects a discrete population acute and localized high inoculum, high attack rate Newer scenario diffuse and widespread low-level contamination of widely distributed food product There are two general types of foodborne outbreak scenarios. The first is the traditional outbreak scenario that epidemiologists cut their teeth on- the outbreak that follows a church supper, family picnic, wedding reception, or other event affecting a discrete population. This is an acute and highly localized outbreak, often with a high inoculum dose (that is, the implicated product tends to be highly contaminated) and with a high attack rate (that is, most people who ate the implicated product becomes ill). More recently, we have the �newer� outbreak scenario, that has been reported with increasing frequency. This occurs as a result of low level or intermittent contamination of a widely distributed commercial food product. This type of outbreak tends to be much more difficult to detect and investigate. The approaches to these two types of outbreaks differ, and I will be covering each in detail.There are two general types of foodborne outbreak scenarios. The first is the traditional outbreak scenario that epidemiologists cut their teeth on- the outbreak that follows a church supper, family picnic, wedding reception, or other event affecting a discrete population. This is an acute and highly localized outbreak, often with a high inoculum dose (that is, the implicated product tends to be highly contaminated) and with a high attack rate (that is, most people who ate the implicated product becomes ill). More recently, we have the �newer� outbreak scenario, that has been reported with increasing frequency. This occurs as a result of low level or intermittent contamination of a widely distributed commercial food product. This type of outbreak tends to be much more difficult to detect and investigate. The approaches to these two types of outbreaks differ, and I will be covering each in detail.

27. Although I am going to be talking about the epidemiologist�s role in a foodborne outbreak investigation, I do want to emphasize that this is a team effort. A complete and successful outbreak investigation also requires the participation of the laboratory and environmental health.Although I am going to be talking about the epidemiologist�s role in a foodborne outbreak investigation, I do want to emphasize that this is a team effort. A complete and successful outbreak investigation also requires the participation of the laboratory and environmental health.

28. Communication and cooperation is critical at every level- local, state, and national. Consider: Local health departments are usually the first to detect an outbreak. If it is a restaurant, for example, the communicable disease department will conduct the epidemiologic investigation, while environmental health department will inspect the restaurant. The local PH laboratory will process both the patient and environmental samples. The local CD department generally talks to the Disease Investigations and Surveillance Branch; environmental health works with the Food and Drug Branch; and the local PH lab may work with the State Microbial Disease Laboratory. If it is a really big outbreak, is multi-state, or involves a commercially distributed product, then the Feds get involved- usually CDC and FDA. We in DISB work very closely with MDL and FDB, along with our local and federal partners when working on an outbreak investigation. Communication and cooperation is critical at every level- local, state, and national. Consider: Local health departments are usually the first to detect an outbreak. If it is a restaurant, for example, the communicable disease department will conduct the epidemiologic investigation, while environmental health department will inspect the restaurant. The local PH laboratory will process both the patient and environmental samples. The local CD department generally talks to the Disease Investigations and Surveillance Branch; environmental health works with the Food and Drug Branch; and the local PH lab may work with the State Microbial Disease Laboratory. If it is a really big outbreak, is multi-state, or involves a commercially distributed product, then the Feds get involved- usually CDC and FDA. We in DISB work very closely with MDL and FDB, along with our local and federal partners when working on an outbreak investigation.

29. Goals of a Foodborne Illness Investigation (or, Why go through all of this trouble?) Control current outbreak, prevent future disease determine the magnitude of the outbreak identify the risk factors for illness recall contaminated product trace the contaminated product to its source determine how the product was contaminated develop guidelines to prevent such contamination in the future Investigating a foodborne outbreak is remarkably time-consuming. The question is, why do we bother? What are our objectives when we embark on such an investigation? The primary public health reason to investigate an outbreak are to control the current outbreak and to prevent future disease. We do this by determining the magnitude of the outbreak- how many people were affected, and what symptoms they had. We then do an investigation that helps guide us in determining what the risk factors for illness were. Once we identify the risk factor, frequently a contaminated food product, we would work to recall the product. We would then attempt to trace the contaminated product to its source and try to determine how the product was contaminated in the first place, in order to develop guidelines to prevent similar contamination in the future. Investigating a foodborne outbreak is remarkably time-consuming. The question is, why do we bother? What are our objectives when we embark on such an investigation? The primary public health reason to investigate an outbreak are to control the current outbreak and to prevent future disease. We do this by determining the magnitude of the outbreak- how many people were affected, and what symptoms they had. We then do an investigation that helps guide us in determining what the risk factors for illness were. Once we identify the risk factor, frequently a contaminated food product, we would work to recall the product. We would then attempt to trace the contaminated product to its source and try to determine how the product was contaminated in the first place, in order to develop guidelines to prevent similar contamination in the future.

30. Foodborne Outbreak Surveillance Foodborne outbreaks may be detected at the local, state, or national levels. Most are initially picked up at the local level- a person who became ill after eating at a party or restaurant may call into their local health department, for example. In addition, the local clinical laboratories, and at least in theory, the health care workers, fill out Confidential Morbidity Reports on each reportable illness, and submit them to the local health department. The local HD may detect an increase in a particular enteric organism, or an unusual clustering of cases in that manner. The state HD collects foodborne outbreak reports. In addition, the local health departments are usually very conscientious about reporting larger or unusual outbreaks to the state. We at the state detect a lot of Salmonella outbreaks because only the MDL and the LAC PHL have the capability to serotype Salmonella isolates. Thus, if there is an increase in the number of a particular Salmonella serotype, this is identified by MDL or LAC PHL and epidemiologists are alerted. Since MDL also does PFGE, outbreak strains may be detected in that manner. Finally, at the national/CDC level, there is PulseNet, which is the CDC based molecular subtyping network for foodborne bacterial disease surveillance. Foodborne outbreaks may be detected at the local, state, or national levels. Most are initially picked up at the local level- a person who became ill after eating at a party or restaurant may call into their local health department, for example. In addition, the local clinical laboratories, and at least in theory, the health care workers, fill out Confidential Morbidity Reports on each reportable illness, and submit them to the local health department. The local HD may detect an increase in a particular enteric organism, or an unusual clustering of cases in that manner. The state HD collects foodborne outbreak reports. In addition, the local health departments are usually very conscientious about reporting larger or unusual outbreaks to the state. We at the state detect a lot of Salmonella outbreaks because only the MDL and the LAC PHL have the capability to serotype Salmonella isolates. Thus, if there is an increase in the number of a particular Salmonella serotype, this is identified by MDL or LAC PHL and epidemiologists are alerted. Since MDL also does PFGE, outbreak strains may be detected in that manner. Finally, at the national/CDC level, there is PulseNet, which is the CDC based molecular subtyping network for foodborne bacterial disease surveillance.

31. Salmonella Enteritidis, 1993-2000, CA

32. Reported SE Outbreaks, CA

33. Food Vehicles Implicated 1999-2000 � 43 FBDO with confirmed vehicles 14 � fresh produce (sprouts, cilantro, cantaloupe, mango, grapes, juice) 16 � animal related (beef, chicken, fish, goat, bear, eggs, dairy) 9 � other (beans, etc.) 4 � multiple (salad, sandwich)

34. FB Illness Resources 1999 FDA video courses Microbiology Foodborne Illness Investigation Traceback Investigation IAMFES FBDO Investigation book www.foodprotection.org CDC MMWR, reports

35. http://www.dhs.ca.gov/ps/dcdc/disb/pdf/Foodborne%20Disease%20Outbreaks%20in%20California%201999-2000.pdf

36. Conclusions The epidemiology of foodborne illness has changed in the past decade We are faced with these new challenges and must develop mew strategies to protect citizens from foodborne illnesses

37. Reptile-Assoc. Salmonellosis Popular pets, ownership doubled from 850,000n households in 1991 to 1.7 million homes in 2001 Approx 74,000 people get Salmonella from reptiles in U.S. / year Dec. 2001 � 3 month old infant gets it from father who handled snakes at his work

38. Reptile-Assoc. Salmonellosis CCR � Title 17 Section 2612.1 No sale <4 inches Warning sign and sales slip notice http://www.dhs.ca.gov/ps/dcdc/disb/pdf/Turtle%20Salmonellosis%20Title%2017.pdf MMWR � 12/12/03 Reptile-associated Salmonellosis article http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5249a3.htm FDA Compliance issues

39. Reptile-Assoc. Salmonellosis Inform owners Avoidance for high-risk Avoidance if <5 years old Not in child-care centers Wash hands No free-roaming Keep out of kitchen / bathtub Avoid contact in public settings

40. Animal Exhibits Increased reports of infections / outbreaks of GI illness assoc. with animal exhibits (fairs, farm visits, petting zoos, etc.) or animals in public settings NASPHV compendium developed 2004 version http://www.nasphv.org/ (under publications) 2005 version coming in March 2005 in MMWR

41. Animals in Public Settings Petting zoos Fairs Shows Circuses Pet stores Zoos Pet-assisted therapy Farm tours Schools Nature parks Animal displays Swap meets Etc.

42. Animal Exhibits Enteric Diseases (greatest risk) E. coli O157:H7 Campylobacter Salmonella Cryptosporidium Fecal-oral route, fomites, environment Increased risk Stress induced shedding Commingling Immature animals Shedding highest in summer and fall

43. Animal Exhibit Recommendations Education Facility design Animal area No food Cleaning Supervision Staff Limited feeding Use for other purposes

44. Trichinosis outbreak x 2 72 human cases reported from 1997-2001 in U.S. 31 assoc. with wild game (29 bear meat) 12 commercial pork (mostly imported 9 non-commercial pork Outbreak #1 Bear hunter�s family gets trichinosis from undercooked bear meat

45. Trichinosis outbreak x 2 Outbreak #2 Hunter gives entrails to friend who feeds it to backyard pigs Friend has a party and serves �Lahb� 14 of 24 attendees get trichinosis

46. Conclusions Fecal-orally transmitted zoonotic diseases are the most common Many animals are natural reservoirs of disease and may be asymptomatic or shed intermittently Prevention strategies aim and reducing or eliminating exposure by Food safety Avoidance Sanitation

47. Thanks for your attention Contact me for any questions Ben Sun � 916-552-9740 bsun@dhs.ca.gov