ADDRESSING FOODBORNE THREATS TO HEALTH

Policies, Practices, and Global Coordination

Workshop Summary

Forum on Microbial Threats

Board on Global Health

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington, D.C.
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Addressing Foodborne Threats to Health: Policies, Practices, and Global Coordination - Workshop Summary ADDRESSING FOODBORNE THREATS TO HEALTH Policies, Practices, and Global Coordination Workshop Summary Forum on Microbial Threats Board on Global Health INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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Addressing Foodborne Threats to Health: Policies, Practices, and Global Coordination - Workshop Summary THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. This project was supported by the American Society for Microbiology; Burroughs Wellcome Fund; Defense Threat Reduction Agency; GlaxoSmithKline; Infectious Disease Society of America; Lawrence Livermore National Laboratory; Merck Company Foundation; Pfizer; Sanofi Pasteur; U.S. Department of Health and Human Services’ National Institutes of Health, National Institute of Allergy and Infectious Diseases, Centers for Disease Control and Prevention, and Food and Drug Administration; U.S. Department of Defense’s Global Emerging Infections Surveillance and Response System and Walter Reed Army Institute of Research; U.S. Department of Homeland Security; U.S. Department of State; and U.S. Department of Veterans Affairs. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. International Standard Book Number-10 0-309-10043-7 (Book) International Standard Book Number-13 978-0-309-10043-4 (Book) International Standard Book Number-10 0-309-65457-2 (PDF) International Standard Book Number-13 978-0-309-65457-9 (PDF) Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2006 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. COVER: A detailed section of a stained glass window 21 × 56 depicting the natural history of influenza viruses and zoonotic exchange in the emergence of new strains was used to design the front cover. Based on the work done at St. Jude Children’s Research Hospital supported by American Lebanese Syrian Associated Charities (ALSAC) and the National Institute of Allergy and Infectious Diseases (NIAID). Artist: Jenny Hammond, Highgreenleycleugh, Northumberland, England.

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Addressing Foodborne Threats to Health: Policies, Practices, and Global Coordination - Workshop Summary “Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES Advising the Nation. Improving Health.

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Addressing Foodborne Threats to Health: Policies, Practices, and Global Coordination - Workshop Summary THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering, and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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Addressing Foodborne Threats to Health: Policies, Practices, and Global Coordination - Workshop Summary FORUM ON MICROBIAL THREATS STANLEY M. LEMON (Chair), School of Medicine, University of Texas Medical Branch, Galveston MARGARET A. HAMBURG (Vice-chair), Nuclear Threat Initiative/Global Health & Security Initiative, Washington, D.C. P. FREDERICK SPARLING (Vice-chair), University of North Carolina, Chapel Hill DAVID W. K. ACHESON, Center for Food Safety and Applied Nutrition, Food and Drug Administration, Rockville, Maryland RUTH L. BERKELMAN, Emory University, Center for Public Health Preparedness and Research, Rollins School of Public Health, Atlanta, Georgia ROGER G. BREEZE, Centaur Science Group, Washington, D.C. STEVEN J. BRICKNER, Pfizer Global Research and Development, Pfizer Inc., Groton, Connecticut GAIL H. CASSELL, Eli Lilly & Company, Indianapolis, Indiana RALPH L. ERICKSON, Global Emerging Infections Surveillance and Response System, Department of Defense, Silver Spring, Maryland MARK B. FEINBERG, Merck Vaccine Division, Merck & Co., West Point, Pennsylvania J. PATRICK FITCH, Battelle Memorial Institute, Livermore, California DARRELL R. GALLOWAY, Medical S&T Division, Defense Threat Reduction Agency, Ft. Belvoir, Virginia S. ELIZABETH GEORGE, Biological and Chemical Countermeasures Program, Department of Homeland Security, Washington, D.C. JESSE L. GOODMAN, Center for Biologics Evaluation and Research, Food and Drug Administration, Rockville, Maryland EDUARDO GOTUZZO, Instituto de Medicina Tropical–Alexander von Humbolt, Universidad Peruana Cayetano Heredia, Lima, Peru JO HANDELSMAN, College of Agricultural and Life Sciences, University of Wisconsin, Madison CAROLE A. HEILMAN, Division of Microbiology and Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland DAVID L. HEYMANN, Polio Eradication, World Health Organization, Geneva, Switzerland PHIL HOSBACH, New Products and Immunization Policy, Sanofi Pasteur, Swiftwater, Pennsylvania JAMES M. HUGHES, Global Infectious Diseases Program, Emory University, Atlanta, Georgia STEPHEN A. JOHNSTON, Arizona BioDesign Institute, Arizona State University, Tempe, Arizona GERALD T. KEUSCH, Boston University School of Medicine and Boston University School of Public Health, Massachusetts

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Addressing Foodborne Threats to Health: Policies, Practices, and Global Coordination - Workshop Summary RIMA F. KHABBAZ, National Center for Preparedness, Detection and Control of Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia LONNIE J. KING, Center for Zoonotic, Vectorborne, and Enteric Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia GEORGE W. KORCH, United States Army Medical Research Institute for Infectious Diseases, Ft. Detrick, Maryland JOSHUA LEDERBERG, The Rockefeller University, New York LYNN G. MARKS, Medicine Development Center, GlaxoSmithKline, Collegeville, Pennsylvania MARY McBRIDE, Science and Technology Chemical and Biological National Security Program, Lawrence Livermore National Laboratory, Livermore, California STEPHEN S. MORSE, Center for Public Health Preparedness, Columbia University, New York MICHAEL T. OSTERHOLM, Center for Infectious Disease Research and Policy, School of Public Health, University of Minnesota, Minneapolis GEORGE POSTE, Arizona BioDesign Institute, Arizona State University, Tempe DAVID A. RELMAN, Stanford University, Palo Alto, California GARY A. ROSELLE, Central Office, Veterans Health Administration, Department of Veterans Affairs, Washington, D.C. JANET SHOEMAKER, Office of Public Affairs, American Society for Microbiology, Washington, D.C. BRIAN J. STASKAWICZ, Department of Plant and Microbial Biology, University of California, Berkeley TERENCE TAYLOR, International Council for the Life Sciences, Washington, D.C. Liaisons ENRIQUETA C. BOND, Burroughs Wellcome Fund, Research Triangle Park, North Carolina NANCY CARTER-FOSTER, Program for Emerging Infections and HIV/AIDS, U.S. Department of State, Washington, D.C. EDWARD McSWEEGAN, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland Staff EILEEN CHOFFNES, Forum Director KIM LUNDBERG, Research Associate ALISON MACK, Science Writer KATE SKOCZDOPOLE, Research Associate

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Addressing Foodborne Threats to Health: Policies, Practices, and Global Coordination - Workshop Summary BOARD ON GLOBAL HEALTH Margaret Hamburg (Chair), Consultant, Nuclear Threat Initiative, Washington, D.C. George A.O. Alleyne, Director Emeritus, Pan American Health Organization, Washington, D.C. Yves Bergevin, Department of Child and Adolescent Health and Development, World Health Organization, Geneva, Switzerland Donald Berwick, Clinical Professor of Pediatrics and Health Care Policy, Harvard Medical School, and President and Chief Executive Officer, Institute of Healthcare Improvement, Boston, Massachusetts Jo Ivey Boufford (IOM Foreign Secretary), Professor, Robert F. Wagner School of Public Service, New York University, New York David R. Challoner, Vice President for Health Affairs, Emeritus, University of Florida, Gainesville Ciro de Quadros, Director of International Programs, Sabin Vaccine Institute, Washington, D.C. Sue Goldie, Associate Professor of Health Decision Science, Department of Health Policy and Management, Center for Risk Analysis, Harvard University School of Public Health, Boston, Massachusetts Richard Guerrant, Thomas H. Hunter Professor of International Medicine and Director, Center for Global Health, University of Virginia School of Medicine, Charlottesville Gerald Keusch, Assistant Provost for Global Health, Boston University School of Medicine, and Associate Dean for Global Health, Boston University School of Public Health, Massachusetts Jeffrey Koplan, Vice President for Academic Health Affairs, Emory University, Atlanta, Georgia Sheila Leatherman, Research Professor, University of North Carolina School of Public Health, Chapel Hill Michael Merson, Anna M. R. Lauder Professor, Dean of Public Health, and Chair, Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Connecticut Mark L. Rosenberg, Executive Director, the Task Force for Child Survival and Development, Emory University, Decatur, Georgia Philip Russell, Professor Emeritus, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland Staff Patrick Kelley, Director Allison Brantley, Senior Program Assistant

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Addressing Foodborne Threats to Health: Policies, Practices, and Global Coordination - Workshop Summary Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the NRC’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Johanna Dwyer, D.Sc., Frances Stern Nutrition Center, Tufts–New England Medical Center Craig Hedberg, Ph.D., Division of Environmental and Occupational Health, University of Minnesota Terence Taylor, International Council for the Life Sciences, Washington, D.C. Mary Wilson, M.D., Department of Population and International Health, Harvard University The review of this report was overseen by Floyd Bloom, M.D., Professor Emeritus, Department of Neuropharmacology, The Scripps Research Institute, and Melvin Worth, M.D., Scholar-in-Residence, National Academies, who were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Addressing Foodborne Threats to Health: Policies, Practices, and Global Coordination - Workshop Summary Preface The Forum on Emerging Infections was created in 1996 in response to a request from the Centers for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH). It was established by the Institute of Medicine (IOM) to provide structured opportunities for leaders from government, academia, and industry to meet and examine issues of shared concern regarding research, prevention, detection, and management of emerging or reemerging infectious diseases. In pursuing this task, the Forum provides a venue to foster the exchange of information and ideas, identify areas in need of greater attention, clarify policy issues by enhancing knowledge and identifying points of agreement, and inform decision makers about science and policy issues. The Forum seeks to illuminate issues rather than resolve them directly; for this reason, it does not provide advice or recommendations on any specific policy initiative pending before any agency or organization. Rather, its strengths are embodied in the diversity of its membership and the contributions of individual members expressed throughout the activities of the Forum. In September 2003, the Forum changed its name to the Forum on Microbial Threats. ABOUT THE WORKSHOP In December 2004, at a press conference called to announce his departure as Secretary of the Department of Health and Human Services (DHHS), Tommy Thompson raised both concern and controversy when he remarked that he could not understand why terrorists had not yet attacked our food supply “because it is

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Addressing Foodborne Threats to Health: Policies, Practices, and Global Coordination - Workshop Summary so easy to do.”1 Three days later, the Food and Drug Administration (FDA) announced the last in a series of four food safeguards mandated under the Biopreparedness Act of 2002.2 Although these provisions improve the FDA’s ability to intercept and track the origins of food that is suspected to pose a threat to health, they cannot prevent contamination. Biological and chemical agents can be—and have been—introduced, both accidentally and deliberately, at many vulnerable points along the farm-to-table food chain. Foodborne agents have been estimated to cause approximately 76 million illnesses, 325,000 hospitalizations, and 5,200 deaths in the United States each year.3 More than 250 different foodborne diseases, including both infections and poisonings, have been described, according to the CDC.4 The U.S. Department of Agriculture (USDA) estimates costs associated with medical expenses and losses in productivity due to missed work and premature deaths from five major types of foodborne illnesses (Campylobacter, Escherichia coli O157:H7, Shiga toxin-producing strains of E. coli, Listeria monocytogenes, and Salmonella) at $6.9 billion annually.5 This figure likely represents the tip of the iceberg, as it does not account for the broad spectrum of foodborne illnesses or for their wide-ranging repercussions for consumers, government, and the food industry. The potential impact on human health of deliberate adulteration of food can be estimated by extrapolation from the many documented examples of unintentional outbreaks of foodborne disease, some of which have sickened hundreds of thousands of people and killed hundreds.6 Given the wide variety of potential chemical and biological adulterants that can be introduced at many vulnerable points along the food supply continuum, contaminating food is perhaps one of the easiest means to intentionally distribute these agents. Although the many possibilities for foodborne bioterrorism cannot be specifically prevented, strategic preparations for surveillance, diagnosis, outbreak investigation, and medical response could mitigate foodborne threats of any origin. To examine issues critical to the protection of the nation’s food supply, the Institute of Medicine’s Forum on Microbial Threats hosted a public workshop on October 25 and 26, 2005, in Washington, D.C. The presentations and discussions 1 Branigin W, Allen M, Mintz J. 2004 (December 3). Tommy Thompson resigns from HHS: Bush asks Defense Secretary Rumsfeld to stay. Washington Post. [Online]. Available: http://www.washingtonpost.com/wp-dyn/articles/A31377-2004Dec3.html [accessed May 6, 2006]. 2 Gardner A. 2004 (December 6). U.S. Moves to Further Protect Food Supply. [Online]. Available: http://www.healthfinder.gov/news/newsstory.asp?docID=522737 [accessed June 27, 2006]. 3 Mead PS, Slutsker L, Dietz V, McCraig LF, Bresee JS, Shapiro C, Griffin PM, Tauxe RV. 1999. Food-related illness and death in the United States. Emerging Infectious Diseases 5(5):607–625. 4 CDC. 2005. Foodborne Illness. [Online]. Available: http://www.cdc.gov/ncidod/dbmd/diseaseinfo/foodborneinfections_g.htm#foodbornedisease [accessed June 27, 2006]. 5 Vogt DU. 2005. Food Safety Issues in the 109th Congress. CRS Report RL31853 Washington, D.C.: The Library of Congress. 6 Sobel J. 2005. Food and beverage sabotage. In: Pilch RF, Zilinskas RA, Ed. Encyclopedia of Bioterrorism Defense. New York: Wiley-Liss, Inc. Pp. 215–220.

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Addressing Foodborne Threats to Health: Policies, Practices, and Global Coordination - Workshop Summary of the workshop were structured to explore the existing knowledge and unanswered questions indicated by (but not limited to) the following topics: The globalization of the U.S. food supply The spectrum of microbial threats to food Case studies of food threats The organization of food safety systems Costs and benefits of reporting foodborne threats: the case of bovine spongiform encelphalopathy (BSE) Surveillance for foodborne illness ACKNOWLEDGMENTS The Forum on Microbial Threats and the IOM wish to express their warmest appreciation to the individuals and organizations who gave their valuable time to provide information and advice to the Forum through their participation in this workshop. A full list of presenters can be found in Appendix A. The Forum is indebted to the IOM staff who contributed during the course of the workshop and the production of this workshop summary. On behalf of the Forum, we gratefully acknowledge the efforts led by Eileen Choffnes, director of the Forum; Kim Lundberg, research associate; and Kate Skoczdopole, research associate, who dedicated much effort and time to developing this workshop’s agenda, and for their thoughtful and insightful approach and skill in translating the workshop proceedings and discussion into this workshop summary. We would also like to thank our science writer, Alison Mack, for her thoughtful and insightful approach and skill in translating the workshop proceedings and discussion into this workshop summary. Finally, the Forum also thanks the sponsors that supported this activity. Financial support for this project was provided by the U.S. Department of Health and Human Services’ National Institutes of Health, National Institute of Allergy and Infectious Diseases, Centers for Disease Control and Prevention, and Food and Drug Administration; U.S. Department of Defense’s Global Emerging Infections Surveillance and Response System, Walter Reed Army Institute of Research, and Defense Threat Reduction Agency; U.S. Department of State; U.S. Department of Veterans Affairs; U.S. Department of Homeland Security; Lawrence Livermore National Laboratory; American Society for Microbiology; Sanofi Pasteur; Burroughs Wellcome Fund; Pfizer; GlaxoSmithKline; Infectious Disease Society of America; and the Merck Company Foundation. The views presented in this workshop summary report are those of the editors and workshop participants and are not necessarily those of the funding organizations. Stanley M. Lemon, Chair P. Frederick Sparling, Vice-chair Margaret A. Hamburg, Vice-chair Forum on Microbial Threats

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Addressing Foodborne Threats to Health: Policies, Practices, and Global Coordination - Workshop Summary Contents     SUMMARY AND ASSESSMENT   1      Addressing Foodborne Threats to Health: Policies, Practices, and Global Coordination,   1      Organization of the Workshop Summary,   2      The Spectrum of Foodborne Threats,   3      The U.S. Food System: Globalized, Efficient, and Vulnerable,   4      Food Safety Oversight,   6      Accidental Foodborne Disease,   9      Foodborne Attacks: Scenarios and Consequences,   11      Surveillance of Foodborne Threats to Health,   14      Reporting Foodborne Threats: The Case of BSE,   19      Research and Policy Opportunities,   23      References,   26 1   THE U.S. FOOD SYSTEM   31      Overview,   31      The Food Supply and Biodefense: The Next Frontier of the Food Safety Agenda, Michael T. Osterholm, Ph.D.   32      The U.S. Food Supply—How Changing Demographics and Consumer Demand Pose New Challenges for Food Safety, Craig W. Henry, Ph.D.   43      References,   50

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Addressing Foodborne Threats to Health: Policies, Practices, and Global Coordination - Workshop Summary 2   FOOD SAFETY OVERSIGHT   53      Overview,   53      The U.S. Food Safety System, John Bailar, M.D., Ph.D.   54      Food Safety Threats—International Coordination, Jørgen Schlundt, Ph.D.   57      References,   67 3   INVESTIGATING FOODBORNE THREATS   70      Overview,   70      The Burden of Illness Associated with Foodborne Threats to Health, and the Challenge of Prevention, Robert V. Tauxe, M.D., M.P.H.   72      The Ongoing Saga of U.S. Outbreaks of Cyclosporiasis Associated with Imported Fresh Produce: What Cyclospora cayetanensis Has Taught Us and What We Have Yet to Learn, Barbara L. Herwaldt, M.D., M.P.H.   85      Surveillance and Investigation of a Large Statewide Cyclospora Foodborne Disease Outbreak Involving an Imported Stealth Ingredient, Roberta Hammond, Ph.D. and Dean Bodager, R.S., D.A.A.S., M.P.A.   115      Hepatitis A Outbreaks from Green Onions, Beth P. Bell, M.D., M.P.H. and Anthony E. Fiore, M.D., M.P.H.   125      References,   133 4   BIOTERRORISM AND THE FOOD SUPPLY   141      Overview,   141      The Threat Against Milk: Just One of Many, with More to Come, Clay Detlefsen, M.B.A., Esq.   142      Botulinum Toxin: The Linkage with Bioterrorism, Milton Leitenberg, M.S.   150      The Food and Drug Administration’s Approach to Food Defense, David W. K. Acheson, M.D.   168      References,   174 5   SURVEILLANCE OF THE FOOD SUPPLY   177      Overview,   177      Systems to Detect Microbial Contamination of the Food Supply, John M. Besser, M.S.   178      The Consumer Complaint Monitoring System: Enhancing Discovery and Mitigation of Foodborne Threats to Health Through Pattern Surveillance and Multiple-Attribute Algorithms, CDR Kimberly Elenberg, M.S., R.N. and Artur Dubrawski, Ph.D.   189      References,   192

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Addressing Foodborne Threats to Health: Policies, Practices, and Global Coordination - Workshop Summary 6   REPORTING FOODBORNE THREATS: THE CASE OF BOVINE SPONGIFORM ENCEPHALOPATHY (BSE)   195      Overview,   195      Prions and the Safety of the Food Supply, Stanley B. Prusiner, M.D.   196      Surveillance and Prevention of vCJD and BSE: The Australian Perspective, Steven Collins, M.D.   206      BSE as a Case Study of Public Health and the Public Good, Maura Ricketts, M.D., M.H.Sc., F.R.C.P.C.   212      Incentives and Disincentives for Disease Surveillance and Reporting: The BSE Case Study, Will Hueston, D.V.M., Ph.D.   221      References,   227 7   RESEARCH AND POLICY OPPORTUNITIES   232      Overview,   232      Animal Health at the Crossroads, Committee on Assessing the Nation’s Framework for Addressing Animal Diseases   233      Priorities for Research in Food Defense, Francis F. Busta, Ph.D., Shaun Kennedy, B.S.E., and Julie Ostrowsky, M.Sc.   247      References,   253     APPENDIXES     A   Agenda   255 B   Acronyms   259 C   Forum Member Biographies   263

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Addressing Foodborne Threats to Health: Policies, Practices, and Global Coordination - Workshop Summary Tables and Figures TABLES 1-1   Food Categories with the Fastest Growing Global Sales and Growth Rate Between 2003 and 2004,   44 1-2   Food Expenditure Patterns Among Selected Countries,   45 1-3   Food Expenditure Patterns Among Selected Countries, Food Share of Total Expenditures,   45 1-4   Food Expenditure Patterns Among Selected Countries, Bread and Cereals,   49 1-5   Food Expenditure Patterns Among Selected Countries, Meat and Seafood,   49 1-6   Food Expenditure Patterns Among Selected Countries, Dairy and Eggs,   49 1-7   Food Expenditure Patterns Among Selected Countries, Oils and Fats,   50 1-8   Food Expenditure Patterns Among Selected Countries, Fruits and Vegetables,   50 1-9   Food Expenditure Patterns Among Selected Countries, Sugar and Confectionary,   50 1-10   Grocery Shopper Trends for 2005,   46 1-11   Trends in Proportion of Shoppers Who Purchased Organic Food Within the Past Six Months,   47 2-1   Overlap in Federal Food Safety Oversight,   56

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Addressing Foodborne Threats to Health: Policies, Practices, and Global Coordination - Workshop Summary 3-1   Foodborne Pathogens in the United States,   73 3-2   Some New Pathogen-Food Combinations Characterized During Outbreak Investigations in the United States,   80 3-3   Cyclospora cayetanensis, and Cyclosporiasis: Perspectives and Status as of April 2006,   104 3-4   Characteristics of Foodborne Outbreaks and Investigations: Challenges, Opportunities, Approaches, and Advances, in General and Specific to Outbreaks of Cyclosporiasis Associated with Imported Fresh Produce,   107 3-5   Goals of Investigations of Foodborne Outbreaks: Challenges, Opportunities, Approaches, and Advances, in General and Specific to Outbreaks of Cyclosporiasis Associated with Imported Fresh Produce,   111 3-6   Factors that Have Complicated Efforts to Communicate About Foodborne Outbreaks of Cyclosporiasis,   114 3-7   Selected History, Cyclospora Outbreaks, and Vehicles: Florida, National, and International,   117 3-8   Cyclospora Clusters, Florida 2005: Range of Dates of Exposure, Dates of Onset, Confirmed and Probable Cases,   118 3-9   Source and Distribution of Cluster X Hepatitis A Virus Sequences, September–December 2003 and January 2002–August 2003,   130 5-1   Networks and Resources for Food Safety,   179 5-2   Comparison of Food Monitoring and Disease Surveillance,   181 5-3   Comparison of Disease Surveillance Approaches,   184 6-1   Cases of Transmissible Spongiform Encephalopathies (TSE) Reported to the Australian National CJD Registry (ANCJDR), January 1, 1970 Through June 30, 2005,   210 6-2   The Functions of Public Health,   214 6-3   Functions and Core Programs,   214 6-4   Activity Map for vCJD,   215 6-5   Health Protection and the Management of an Outbreak,   215 6-6   Controlling BSE,   219 7-1   National Center for Food Protection and Defense Research Initiatives,   250 FIGURES 1-1   Speed of global travel in relation to world population,   33 1-2   The problem: Global food systems,   36 1-3   Identifying the source of food in a global system is challenging,   37-38

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Addressing Foodborne Threats to Health: Policies, Practices, and Global Coordination - Workshop Summary     1-4   Food expenditures as a share of disposable personal income, United States, 1974–2003,   39 2-1   The WHO International Food Safety Authorities Network (INFOSAN): Set-up of focal points for information sharing,   65 2-2   The WHO International Food Safety Authorities Network (INFOSAN): Potential communication lines for national INFOSAN Emergency Contact Points,   66 3-1   Reported outbreaks of foodborne diseases, 1990–2004, United States,   76 3-2   Reported incidence of Listeria monocytogenes infections and reported outbreaks of listeriosis, United States, 1986–2004,   82 3-3   Reported outbreaks of E. coli O157 infections, United States, 1982–2002,   82 3-4   Generic and Cyclospora-specific challenges in bridging the chasm between disease and prevention and control,   89 3-5   Sporulation of Cyclospora cayetanensis oocysts,   93 3-6   Epidemiology curve by week of onset, Florida 2005 Cyclospora outbreak,   119 3-7   Laboratory-confirmed and probable cases of cyclosporiasis by state of residence, March–June 2005, Cyclospora outbreak, Florida,   121 3-8   Laboratory-confirmed and probable cases of cyclosporiasis by Florida county of residence, March–June 2005, Cyclospora outbreak, Florida,   122 3-9   Comparison of hepatitis A viral sequences among individuals with hepatitis A from northern Mexico (Border Infectious Disease Surveillance [BIDS] Project), 2002–2003; outbreak-related surveillance, October– December 2003; and six U.S. sentinel county sites, January 2002–August 2003,   127 3-10   Date of illness onset among restaurant patrons, September–November, 2003; n = 590,   128 4-1   U.S. domestic airline passengers,   143 6-1   Reported frequency of food consumption, odds ratio of vCJD cases versus general population controls,   208 6-2   BSE and vCJD outbreak development in the UK; Epidemic curve of BSE in Europe,   216 7-1   Interactions of emerging infectious diseases (EIDs) with a continuum that includes wildlife, domestic animal, and human populations,   237

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