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Food Safety and Foodborne Disease Surveillance Systems: Proceedings of an Iranian-American Workshop (2006)

Chapter: Foodborne Disease Investigations, Including Surveillance: A Collaborative Pilot Project--Ali Ardalan

« Previous: Surveillance for Foodborne and Diarrheal Diseases, Including Outbreak Investigations: An American Perspective--William E. Keene
Suggested Citation:"Foodborne Disease Investigations, Including Surveillance: A Collaborative Pilot Project--Ali Ardalan." National Research Council. 2006. Food Safety and Foodborne Disease Surveillance Systems: Proceedings of an Iranian-American Workshop. Washington, DC: The National Academies Press. doi: 10.17226/11526.
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Page 46
Suggested Citation:"Foodborne Disease Investigations, Including Surveillance: A Collaborative Pilot Project--Ali Ardalan." National Research Council. 2006. Food Safety and Foodborne Disease Surveillance Systems: Proceedings of an Iranian-American Workshop. Washington, DC: The National Academies Press. doi: 10.17226/11526.
×
Page 47
Suggested Citation:"Foodborne Disease Investigations, Including Surveillance: A Collaborative Pilot Project--Ali Ardalan." National Research Council. 2006. Food Safety and Foodborne Disease Surveillance Systems: Proceedings of an Iranian-American Workshop. Washington, DC: The National Academies Press. doi: 10.17226/11526.
×
Page 48
Suggested Citation:"Foodborne Disease Investigations, Including Surveillance: A Collaborative Pilot Project--Ali Ardalan." National Research Council. 2006. Food Safety and Foodborne Disease Surveillance Systems: Proceedings of an Iranian-American Workshop. Washington, DC: The National Academies Press. doi: 10.17226/11526.
×
Page 49
Suggested Citation:"Foodborne Disease Investigations, Including Surveillance: A Collaborative Pilot Project--Ali Ardalan." National Research Council. 2006. Food Safety and Foodborne Disease Surveillance Systems: Proceedings of an Iranian-American Workshop. Washington, DC: The National Academies Press. doi: 10.17226/11526.
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Page 50

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Foodborne Disease Investigations, Including Surveillance: A Collaborative Pilot Project Ali Ardalan Epidemiologist, Research Center for Gastroenterology and Liver Disease Surveillance of foodborne diseases is receiving increased priority in the public health agenda of many countries. It is instrumental in estimating the bur- den of foodborne disease, assessing its relative impact on health and economics, and evaluating disease prevention and control programs. It allows rapid detec- tion and response to outbreaks. In addition, it is a major source of information for conducting risk assessment and, more broadly, for risk management and communication. Ideally, foodborne disease surveillance should be integrated with food mon- itoring data along the entire feed-food chain. Integrating such data would result in robust surveillance information and allow appropriate priority setting and pub- lic health intervention. For this purpose, intersectoral and interinstitutional col- laboration are of paramount importance. Therefore, within Iran a strategic plan was developed by the highest authorities. Proposing a plan to integrate the dif- ferent organizational activities that are involved in food safety is the concern of the Commission on Health and Medicine of the Iranian Parliament. The main organization in charge of foodborne disease surveillance is the Department of Food and Waterborne Disease at the Center for Disease Control in the Ministry of Health (MOH). The focus of the current system is the Health Network, mainly active in rural areas, to report dysentery and cholera and to detect outbreaks; however, sporadic cases are not receiving sufficient attention. Physicians in Iran must report cases of certain diseases, such as polio, measles, and diphtheria, but there is no obligation to report cases of foodborne disease. In addition, in the Health Network, physicians are expected to report cases of dysentery and suspect chol- era, but there is no reporting of other foodborne diseases. The same is true about 46

FOODBORNE DISEASE INVESTIGATIONS, INCLUDING SURVEILLANCE 47 outbreaks of these illnesses, and most outbreaks go undetected unless they are huge or cause severe signs and symptoms or mortality. Hence, many cases of foodborne disease and the relevant outbreaks may never be reported. When a person becomes ill with a foodborne disease, he or she may be part of an outbreak or may have a sporadic illness that is not part of a recognized outbreak. Based on 1997 statistics, the U.S. Centers for Disease Control and Prevention (CDC) estimates that 76 million Americans have foodborne illnesses each year, although only approximately 400 to 500 outbreaks are reported to the CDC each year, accounting for only 10,000 to 12,000 persons with foodborne illness. There is no supportive evidence that we are in a better situation. Conse- quently, sporadic cases should be the prime target for prevention efforts because sporadic cases are far more common than outbreaks; however, it does not mean ignoring outbreaks. Traditional passive surveillance systems or laboratory-based reporting can- not provide precise estimates to evaluate food safety reforms and program chang- es, or tell us how they will affect the incidence of foodborne disease. These systems rely on a number of events. First, an individual with foodborne illness must seek medical care. Then, the physician must order a test and request labora- tory analysis. Next, results must be reported locally and, finally, to the national health system. If any step in the process is missed, the case will go unreported. Before the active foodborne surveillance system project, the CDC estimated that only 1 percent to 5 percent of foodborne disease cases were reported. The CDC conducts surveillance for foodborne diseases in the United States in several dif- ferent ways to obtain the necessary information. So, it seems the only practical solution is a multipronged approach to overcome our information deficiency about foodborne diseases. The main objective of this collaborative pilot project is to develop a model for a National Foodborne Disease Surveillance System (FBDS) in Iran. The organizations involved are the Department of Food and Waterborne Disease, MOH, and the National Department of Foodborne Diseases of the Re- search Center for Gastroenterology and Liver Disease (RCGLD) at Shaheed Beheshti University of Medical Sciences. Joining policy makers and administra- tors with researchers can be a valuable opportunity that we have often missed in our country. This has led to a waste of limited resources in administration, train- ing, and research. The project has some specific objectives, including developing the following: • An FBDS plan with such stages or sections as formulation of objectives, case definition, data sources, data collection instruments, communication sys- tem, analysis strategies, feedback system, and assessment; • An outbreak investigation package;

48 FOOD SAFETY AND FOODBORNE DISEASE SURVEILLANCE SYSTEMS • Training courses on establishing FBDS at the national, regional, and pro- vincial levels; and • An FBDS network for information exchange, learning, and training. The main criteria of the model should include: • Compliance with MOH policy; • Accuracy; • Cost-effectiveness; • Feasibility; and • Resource adjustment. The main parts of the project will be the following: • Laboratory-based surveillance; • Physician-based surveillance; • Population-based survey; • Outbreak investigation; • Case-control studies; and • An FBDS network. A most critical step is selecting the appropriate location for the project. The following criteria should be considered for selecting the project site and popula- tion: feasibility, representativeness, and cooperation of the authorities. Regarding the aforementioned criteria, it seems that Karaj district is appro- priate. It is located 48 km west of Tehran, about a 30 minute drive. The RCGLD has the experience of conducting a foodborne project there, its health authorities are cooperative, and its demography is representative of the country. In addition, an important point is that it is a large city. Since the main current and future problems of an FBDS are large cities, the Karaj project would be a valuable experience for establishing a national system. I wish to review a summary of the results of a study the RCGLD conducted in seven health centers, three hospitals, and three private clinics in the Karaj district. Note that no private physician’s office was included because of our resource limitations. In total, 734 stool samples of patients receiving the diagno- sis of acute diarrhea were studied. The annual incidence of shigellosis was 17 percent with the most common type being S. flexneri comprising up to 45 per- cent of the cases. The seasonal trend of shigellosis decreased from the hot to cold seasons although the pathogen existed all year without leading to outbreaks. Let us return to the Foodborne Disease Surveillance Pilot Project and the different stages of the project.

FOODBORNE DISEASE INVESTIGATIONS, INCLUDING SURVEILLANCE 49 Laboratory-Based Surveillance • Include laboratories that conduct microbiological testing of stool samples to determine the culture-confirmed cases of foodborne illnesses. • Propose a guideline to laboratories to standardize their practices for pro- cessing and culturing samples. • Conduct diagnostic accuracy studies at the beginning and end of the project. • Conduct a molecular epidemiology study based on culture-confirmed samples to determine the serotypes of pathogens. Physician-Based Surveillance • Include physicians in both the public and private sectors to determine the cases of public health emergency illnesses, such as botulism. • Include reporting of diarrheal cases by Health Network physicians on a regular basis. • Conduct surveys to estimate the burden of diarrheal diseases over time and to determine how often and under what circumstances physicians order tests. Population-Based Survey To estimate the numbers of diarrheal cases that occur in the catchment area over time, the proportion of persons with diarrhea who seek health care, the proportion of patients who follow the physician’s order for stool testing, and these patients’ food handling behaviors and practices are particularly important. Outbreak Investigation • Conduct epidemiological studies followed by molecular studies to inves- tigate the source of outbreaks. • Develop an outbreak investigation package including a manual that cov- ers investigation design, forms, the analysis plan, required software, and report format. Case-Control Studies Case-control studies consist of interviews with selected persons who had laboratory-confirmed cases of E. coli (including E. coli O157:H7), Shigella, Sal- monella, and Campylobacter and a randomly selected control group of people in the community who were not ill. The objective is to statistically determine risks associated with different foods and to obtain information on potential exposure.

50 FOOD SAFETY AND FOODBORNE DISEASE SURVEILLANCE SYSTEMS Developing an FBDS Network for Information Exchange, Learning, and Training We are going to turn the “alley” of information exchange into a “super highway” in our community through developing a website and establishing an e- mail group, including national and international experts and authorities. The website could be a part of the existing RCGLD Web site at http://www.rcgld.org. A very important point is that these activities will be managed by the Network Committee, which will work with others. It means that there will be no distur- bance of other administrative activities of the project. The necessary documents will also be developed, both in hard and soft copy about the FBDS process and about lessons learned from FBDS and the outbreaks. There will be the reports of the FBDS and the investigations. An important aspect of the network will be the just-in-time lectures on the noted subjects during different stages of the project. The main idea is a super- course, run by a Pittsburgh University team, in the form of a freely available online library of public health. It has a Web-based, icon-driven format, mainly with PowerPoint slides, graphic presentation, and a multilingual text. The super- course developer, Professor LaPorte, named it Hypertext Comic Book. Examples of lectures on foodborne outbreaks can be found on the website. You can find another example of these lectures about the disease surveil- lance system in the town of Bam, which has been developed by the Center of Disease Management, in the MOH after the disastrous earthquake in 2003. It is of great importance that all parts of this system and all activities be evaluated to ensure the main objectives are met. In summary: • The collaborative pilot project will develop a national model for a food- borne disease surveillance system. • It is a multipronged approach by the MOH and the RCGLD to correct our lack of information about foodborne illness. • The collaborative pilot project will be enriched by molecular studies and by the Foodborne Disease Network.

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In October 2004 the Research Center for Gastroenterology and Liver Diseases of Shaheed Beheshti University hosted in Tehran an Iranian-American workshop on Food Safety and Surveillance Systems for Foodborne Diseases. The purposes of the workshop were to initiate contacts between Iranian and American specialists, exchange information about relevant activities in the two countries, and set the stage for future cooperation in the field. The participants also identified important aspects of food safety that should be addressed more intensively by both countries, including surveillance, research, international trade, and risk assessment. The framework for the workshop had been developed during a meeting of Iranian and American specialists in June 2003 in Les Treilles, France. More that 100 specialists participated in the workshop in their personal capacities, along with representatives of the World Health Organization and the Food and Agriculture Organization. These proceedings include a number of papers that were presented at the workshop together with summaries of discussions following presentation of the papers.

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