Workshop Overview1

“Between animal and human medicine there is
no dividing line nor should there be.
The object is different but the experience obtained
constitutes the basis of all medicine.”

—Rudolf Virchow (1958)

IMPROVING FOOD SAFETY THROUGH A
ONE HEALTH APPROACH

The daily activity of producing, preparing, and consuming food directly links our health with the health of the planet in both direct and indirect ways. Over the past century, the distance between “farm” and “fork” has gone global such that the ingredients in a single meal may be obtained from numerous “local” and “global” sources. Food production and distribution for the developed world takes place across vast and complex global networks in increasingly shorter timescales. As consumers, many of us fail to recognize that our local and domestic food supplies are part of an increasingly interconnected, globalized, food production system.

The U.S. food supply comprises thousands of types of foods and food components—many grown and processed outside of the borders of the United States—as illustrated in Figure WO-1, “the well-traveled salad.” The well-traveled salad’s 10 ingredients originate in more than 37 countries. The increasingly global nature of both domestic and local food supplies underscores the need for a comprehensive One Health approach to food safety, as even common and “whole” ingredients may travel across the world before they reach the table. The

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1 The planning committee’s role was limited to planning the workshop. The workshop summary has been prepared by the workshop rapporteurs (with the assistance of Katherine McClure, LeighAnne Olsen, Rebekah Hutton, and Pamela Bertelson of the staff of the IOM’s Forum on Microbial Threats) as a factual summary of what occurred at the workshop. Statements, recommendations, and opinions expressed are those of individual presenters and participants and are not necessarily endorsed or verified by the Forum or the Institute of Medicine. They should not be construed as reflecting any group consensus.



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Workshop Overview1 “Between animal and human medicine there is n o dividing line n or s hould there be. T he object is different but the experience obtained constitutes the basis of all medicine.” —Rudolf Virchow (1958) IMPROVING FOOD SAFETY THROUGH A ONE HEALTH APPROACH The daily activity of producing, preparing, and consuming food directly links our health with the health of the planet in both direct and indirect ways. Over the past century, the distance between “farm” and “fork” has gone global such that the ingredients in a single meal may be obtained from numerous “local” and “global” sources. Food production and distribution for the developed world takes place across vast and complex global networks in increasingly shorter timescales. As consumers, many of us fail to recognize that our local and domestic food supplies are part of an increasingly interconnected, globalized, food production system. The U.S. food supply comprises thousands of types of foods and food components—many grown and processed outside of the borders of the United States—as illustrated in Figure WO-1, “the well-traveled salad.” The well- traveled salad’s 10 ingredients originate in more than 37 countries. The increas- ingly global nature of both domestic and local food supplies underscores the need for a comprehensive One Health approach to food safety, as even common and “whole” ingredients may travel across the world before they reach the table. The 1 The planning committee’s role was limited to planning the workshop. The workshop summary has been prepared by the workshop rapporteurs (with the assistance of Katherine McClure, LeighAnne Olsen, Rebekah Hutton, and Pamela Bertelson of the staff of the IOM’s Forum on Microbial Threats) as a factual summary of what occurred at the workshop. Statements, recommendations, and opin- ions expressed are those of individual presenters and participants and are not necessarily endorsed or verified by the Forum or the Institute of Medicine. They should not be construed as reflecting any group consensus. 1

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2 Figure WO-1 QR.eps bitmap FIGURE WO-1 The well-traveled salad. To view an interactive version of this infographic on your computer or to download the static version of this image, visit http://iom.edu/Activities/PublicHealth/MicrobialThreats/2011-DEC-13.aspx. Figure WO-1.eps To use your smartphone to link directly to the interactive version use the QR code. bitmap

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3 WORKSHOP OVERVIEW health of humans, animals, and crops plays a pivotal role in ensuring the safety of the world’s food supply. Globalization of the food supply has created conditions favorable for emer- gence, reemergence, and spread of food-borne pathogens and has compounded the challenge of anticipating, detecting, and effectively responding to food- borne threats to health. In the United States alone, food-borne agents cause approximately 48 million illnesses, 128,000 hospitalizations, and 3,000 deaths each year (Scallan et al., 2011b). This figure likely represents just the tip of the iceberg, because it fails to account for the broad array of food-borne infections that run the gamut from asymptomatic to serious disease with complications such as renal failure and death2 or for the wide-ranging repercussions they can have for consumers, government, and the food industry—both domestically and internationally. Most food-borne illnesses are preventable. The interconnectedness of individ- ual, regional, and global public health; the health of the planetary environment(s); and billions of food animals and wildlife would suggest the need for a new paradigm—one that shifts away from a reactive to a more anticipatory, proactive approach to food safety. Such a prime example might be captured in a “One Health” approach to food safety—which has been defined as “the collaborative effort of multiple disciplines—working locally, nationally, and globally—to attain optimal health for people, animals and the environment” (AVMA, 2008). 3 Were such an approach to be implemented for food safety, it may hold the promise of harnessing and integrating the expertise and resources from across the spectrum of multiple health domains including the human and veterinary medical, and plant pathology, communities with those of the wildlife and aquatic health and ecology communities. Statement of Task Such transdisciplinary synergies could reveal important insights into sources, reservoirs, and factors underlying emergence of infectious diseases; trace and disrupt pathways that lead to food contamination; and contribute to creating systems needed to anticipate and prevent adverse health impacts associated with emergence and spread of novel, emerging, or reemerging food-borne diseases. On December 13 and 14, 2011, the Institute of Medicine’s (IOM’s) Forum on Microbial Threats hosted a public workshop that examined the potential of a “One Health” approach to improve the safety of the food supply domestically and 2 For the purposes of this workshop summary report, food-borne illness refers to a broad group of illnesses that are caused by the consumption of food contaminated with viruses, bacteria, or parasites that are pathogenic in susceptible human hosts (Tauxe et al., 2010). Food-borne illness is also referred to as food-borne disease, food-borne infection, or food poisoning. 3 There are many, many definitions for “One Health.” The definition from the American Veterinary Medical Association (AVMA) is being used for convenience.

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4 IMPROVING FOOD SAFETY THROUGH A ONE HEALTH APPROACH globally. Through invited presentations and discussions, workshop participants explored existing knowledge and unanswered questions on the nature and extent of food-borne threats to health, and considered the structure of food systems, the spectrum of food-borne threats, and the particulars of illustrative case studies. Participants also reviewed existing research, policies, and practices to prevent and mitigate food-borne threats and identified opportunities to implement and strengthen practices informed by One Health throughout the global food system. Organization of the Workshop Summary This workshop summary was prepared by the rapporteurs for the Forum’s members and includes a collection of individually authored papers and com- mentary. Sections of the workshop summary not specifically attributed to an individual reflect the views of the rapporteurs and not those of the members of the Forum on Microbial Threats, its sponsors, or the IOM. The contents of the unattributed sections of this summary report provide a context for the reader to appreciate the presentations and discussions that occurred over the 2 days of this workshop. The summary is organized into sections as a topic-by-topic description of the presentations and discussions that took place at the workshop. Its purpose is to present information from relevant experience, to delineate a range of pivotal issues and their respective challenges, and to offer differing perspectives on the topic as discussed and described by the workshop participants. Manuscripts and reprinted articles submitted by some but not all of the workshop’s participants may be found, in alphabetical order, in Appendix A. Although this workshop summary provides a description of the individual presentations, it also reflects an important aspect of the Forum’s philosophy. The workshop functions as a dialogue among representatives from different sectors and allows them to present their views about which areas, in their opinion, merit further study. This report only summarizes the statements of participants at the workshop over the course of 2 consecutive days. This workshop summary is not intended to be an exhaustive exploration of the subject matter nor does it rep- resent the findings, conclusions, or recommendations of a consensus committee process. Recent Food-Borne Outbreaks: The Changing Nature of the “Threat” Recent, well-publicized, national and international outbreaks 4—discussed in greater detail in Box WO-3, “The Changing Nature of the Threat” (found on pages 36-43)—of food-borne illnesses and death illustrate their far-reaching 4 In public health practice, a food-borne disease outbreak is defined as the occurrence of two or more cases of similar illness resulting from the ingestion of a common food (CDC, 2012).

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5 WORKSHOP OVERVIEW public health and economic consequences. Today, the ecological context of food encompasses the planet, as food commodities are traded across the globe and the ingredients in a single meal may be obtained from hundreds of sources in dozens of countries. Multistate and multicountry outbreaks of food-borne morbidity and mortality linked to Listeria in cantaloupe; Salmonella spp. in eggs, ground turkey, and ground beef; and Escherichia coli in bean sprouts are but some of the most recent examples of a growing threat to health, trade, and local economies. Listeria Contamination of Cantaloupe One of the largest and deadliest multistate outbreaks of listeriosis in the United States occurred in late summer of 2011. The incident marked the first time that Listeria contamination had been linked to whole cantaloupe and one of the few times it had been linked to fresh produce (Figure WO-3-3) (CDC, 2011g). As of November 1, 139 individuals5 had become ill after being infected with the outbreak strain of Listeria; 29 deaths and 1 miscarriage had also been attributed to infection (CDC, 2011f). In response to the Centers for Disease Control and Prevention (CDC) outbreak investigation, the cantaloupe producer, Jensen Farms of Holly, Colorado, announced a voluntary recall of the 300,000 cases of cantaloupes produced between July 29 and September 10 (CDC, 2011f; FDA, 2011c). The recall included 1.5 to 4.5 million melons that were distributed at supermarkets and chain stores in at least 28 states. Salmonella Enteritidis Contamination of Chicken Eggs In late 2010, an outbreak of Salmonella Enteritidis infections led to the recall of more than half a billion shell eggs (CDC, 2010). More than 1,900 people in 11 states became ill, and epidemiological investigations traced the source of the outbreak to eggs supplied by two Iowa egg farms: Wright County Egg and Hillandale Farms. Environmental samples confirmed the presence of the outbreak strain on both farms. A contaminated feed mill provided a connection between these two farms, as Wright County Egg used finished feed from this mill to raise the flocks of egg-laying hens that populated all of the Wright County Egg and Hillandale Farms facilities in Iowa (FDA, 2010a). In August 2010, Wright County Egg and Hillandale Farms conducted nationwide voluntary recalls of shell eggs. Recalled eggs had been packaged under a dozen different brand names and distributed to grocery distribution centers, retail grocery stores, and food - service companies located in 22 states and in Mexico (FDA, 2010a). Salmonella Enteritidis contamination is not limited to large, industrial-scale, egg producers. In October 2011, an outbreak of Salmonella Enteritidis in Minnesota was traced to eggs produced by the Larry Schultz Organic Farm in Owatonna. These eggs 5 The mean age of all people infected was 78.

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6 IMPROVING FOOD SAFETY THROUGH A ONE HEALTH APPROACH were subsequently distributed to restaurants, grocery stores, food wholesalers, and co-ops in Minnesota, Wisconsin, and Michigan and sickened at least six individuals (Food Safety News, 2011). Salmonella Heidelberg in Ground Turkey Between March and September 2011, at least 136 persons from 34 states were infected with the outbreak strain of Salmonella Heidelberg (USDA, 2011a). On July 29, the U.S. Department of Agriculture’s (USDA’s) Food Safety and Inspection Service (FSIS) issued a public health alert about the potential associa- tion of these illnesses with the consumption of ground turkey (USDA, 2011a). The outbreak strain of Salmonella Heidelberg is resistant to several commonly prescribed antibiotics, such as ciprofloxacin, ceftriaxone, and trimethoprim- sulfamethoxazole. This antibiotic resistance may be associated with an increase in the risk of hospitalization or possible treatment failure in infected individuals (CDC, 2011b). Ill persons range in age from less than 1 year to 90 years old, with a median age of 23 years (CDC, 2011b). Epidemiological and traceback investigations, as well as in-plant findings, determined a link between disease outbreak and ground turkey products produced by the Springdale Arkansas establishment of Cargill Meat Solutions (USDA, 2011a). On August 3, 2011, Cargill recalled approximately 36 million pounds of fresh and frozen ground turkey products (CDC, 2011b). In addition to the recall, Cargill addressed conditions in the processing facility. The plant where the turkey was processed was completely disassembled, steam-cleaned, treated with an antibacterial wash, and equipped with the most current monitoring and sampling system. Unfortunately, less than a month later, another 185,000 pounds of turkey—produced at the same factory—was recalled with the same strain of Salmonella (CDC, 2011b). E. coli O104:H4 Contamination of Fenugreek Seeds Outbreaks of food-borne diseases increasingly span multiple states and coun- tries, and recall efforts can shut down global markets of entire product lines. The outbreak of a rare strain of E. coli O104:H4, first identified in northern Germany in May 2011, resulted in 4,321 outbreak cases, including 3,469 cases of Shiga toxin–producing E . coli and 852 cases of hemolytic-uremic syndrome (HUS), and 53 deaths had been reported in 14 European countries, the United States, and Canada6 when the epidemic was declared to be over at the end of July 2011 6 The majority of illnesses associated with this outbreak were reported in Germany and France. Cases were also reported in Austria, Canada, the Czech Republic, Denmark, Greece, Luxembourg, the Netherlands, Norway, Poland, Spain, Sweden, Switzerland, the United Kingdom, and the United States. Cases outside of Germany and France are suspected to be travel-related or incidences of secondary spread of infection by those who had recently travelled to the affected area in Germany.

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7 WORKSHOP OVERVIEW (Buchholz et al., 2011; Burger, 2011; Robert Koch Institute, 2001; WHO, 2011). Confusion over the source of the outbreak caused economic losses and political frictions that transcended national boundaries and continue to this day. The Euro- pean Union approved U.S.$287 million in emergency aid for European vegetable farmers affected by the crisis—a sum estimated to be a mere fraction of actual losses (Marucheck et al., 2011). THE GLOBAL FOOD SYSTEM Globalization of the food supply has served to expand the range of food- borne pathogens as well as to amplify health and economic impacts of a single contamination incident. Production, processing, and distribution of food increas- ingly takes place across vast and complex networks—each part or pathway of which must be working optimally—without the introduction of contaminants and/ or adulterants that could taint the final product(s). The U.S. food supply is composed of thousands of types of foods,7 much of it grown and processed elsewhere (Figure WO-2). The increased distance be- tween the sources of production and consumption is a global phenomenon; more than two-thirds of countries are now net importers of food (Buzby et al., 2008). In 2010, the United States imported an estimated 10 to 15 percent of all food consumed by U.S. households, including more than three-quarters of the fresh fruits and vegetables and more than 80 percent of fresh or frozen fish and seafood (FDA, 2011a). Upon arrival, these products—along with domestically produced foodstuffs—are typically distributed across the country from central facilities. The meat prepared and consumed at a typical American table, for example, has traveled 1,000 miles from its farm (or farms) of origin (Chalk, 2004). Innovations such as refrigeration, transportation (air, sea, and land), and instantaneous communication support food distribution systems that can rapidly transport perishable goods, provide just-in-time restocking of non-perishable items, and take advantage of economies of scale (ERS, 2001; FDA, 2011a). These innovations have also linked U.S. food safety concerns to conditions in the more than 200 countries and territories from which the United States imports food (IOM, 2010b). An estimated 200,000 overseas facilities are registered with the Food and Drug Administration (FDA) to sell foods to the United States, and there are likely substantial variations in the sanitation and hygiene practices at these facilities (Taylor, 2009). Screening processes at the more than 300 U.S. ports of entry identify and reject contaminated or damaged goods; yet, just barely 1 per- cent of all foods imported into the United States are subjected to border inspec - tions (CRS, 2009). This reality along with the complexity of food distribution 7 According to the Food Marketing Institute, the average number of items stocked by U.S. grocery stores is approximately 39,000 (FMI, 2010). In the 1950s, U.S. grocery stores stocked an average of 300 food items (Dupont, 2007).

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8 FIGURE WO-2 U.S. agricultural and seafood imports (millions of U.S. dollars). SOURCE: George Retseck and Lucy Reading-Ikkanda for Scientific American magazine in Fischetti (2007). Figure WO-2.eps bitmap

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9 WORKSHOP OVERVIEW makes food extremely vulnerable not just for inadvertent microbial and chemical contamination but also for potential intentional or bioterrorist activities. Emerging Food-Borne Diseases and the One Health Paradigm The workshop opened with a keynote presentation by two speakers, Lonnie King of The Ohio State University (Dr. King’s contribution to the workshop sum- mary report may be found in Appendix A, pages 218-225.) and Peter Daszak of EcoHealth Alliance (Dr. Daszak’s contribution to the workshop summary report may be found in Appendix A, pages 130-140.). They discussed the convergence of factors leading to the global emergence of food-borne diseases and defined the principles of One Health, which they characterized as a paradigm for addressing the complex problem posed by these conditions and diseases. King, referring to the Forum on Microbial Threat’s longstanding “conver- gence model” of factors influencing infectious disease emergence (IOM, 2003), characterized the spectrum of global threats to food safety and why diseases emerge (illustrated in Figure WO-3) as a “perfect microbial storm.” King went on to discuss the many factors that influence the complex inter- actions among host, pathogen, and environment that can lead to the emergence or reemergence of infectious diseases (IOM, 1992, 2003; and illustrated in Fig- ure WO-3). Several environmental factors are of particular relevance in driving emergence and spread of food-borne pathogens, including, but not limited to the following: • Intensive agricultural practices. In the drive for efficient production, prac- tices such as raising and transporting large livestock herds, flocks of birds, or schools of fish or shellfish in close quarters create ideal conditions for disease emergence and spread (King, 2004). • Increased interactions between humans, domestic animals, and wildlife. Often caused by habitat destruction, changing land-use patterns, and hunt- ing of animals for food or for the food trade, increased contact between humans, animals, and their associated microbes also increases the poten- tial for pathogen transmission between animal species or between humans and animals (Pike et al., 2010). • Environmental “commons” such as water. Contamination of common re- sources distributes and increases both the risk of pathogen emergence and chemical contaminants and can be spread across different farms, regions, states, and nations. As previously discussed, approximately 48 million cases of food-borne ill- ness occur annually in the United States—1 for every 6 residents (CDC, 2011a; Scallan et al., 2011a). Extrapolating that figure to a global scale, King estimated that at least 1 billion cases of food-borne disease arise annually—a largely silent

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10 IMPROVING FOOD SAFETY THROUGH A ONE HEALTH APPROACH Convergence Model Genetic and Physical and Biological Environmental Factors Factors Animals Humans Wildlife Social, Political, Ecological and Economic Factors Factors FIGURE WO-3 The convergence model. SOURCE: King (2011). “raging epidemic.” Moreover, as Daszak observed, significant emerging viral diseases such as HIV/AIDS8 and severe acute respiratory syndrome (SARS)9 should be characterized as food-borne pathogens, in view of the fact that their introduction into humans and subsequent transmission is intimately linked to the provision of food. These include a large number of viruses that have jumped from wildlife or livestock into humans who hunt for bush meat (HIV/AIDS) or who butcher and process exotic and domesticated animals in wet markets10 (Rasko et Figure WO -3 al., 2011). 8 Emergence of HIV and Ebola hemorrhagic fever is likely associated with the butchering and percutaneous and mucous membrane exposure to blood and body fluids of nonhuman primates hunted for food in Sub-Saharan Africa. 9 The SARS outbreak was associated with the trade of a small carnivore, the palm civet, sold for human consumption in Guangdong Province, China. Subsequent investigations found the virus in other wild animals sold in Guangdong’s markets as well as domestic cats. Human infection was the direct result of contact with these animals. The virus was later determined to be of bat origin. 10 A wet market is generally an open food market. The main characteristics of the market have traditionally been associated with a place that sells live animals out in the open. The collection may

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11 WORKSHOP OVERVIEW Trends Threatening Food Safety Several workshop presentations addressed the complex and interconnected factors influencing food safety, among them the following key trends introduced by King and Daszak. Several of these trends have been discussed in depth in previous Forum workshop summary reports, including Addressing Foodborne Threats to Health (IOM, 2006), Infectious Disease Movement in a Borderless World (IOM, 2010c), and Antibiotic Resistance: Implications for Global Health and Novel Intervention Strategies (IOM, 2010a). Growth, migration, and aging of human populations As depicted in Figure WO-4, the overwhelming majority of global population growth is occur- ring in developing countries. An estimated 1 billion people reside in periurban slums, which, King noted, are home to the fastest-growing human populations; by 2020 their numbers are expected to increase by 50 percent (UN, 2006). These areas are potential hotspots for infectious disease emergence, including water- and food-borne diseases, he observed. At the same time, human migration from rural to urban settings is just one facet of the more general phenomenon of increased migration—of humans, animals, plants, and diseases, King continued. “More than 1 billion people cross international borders every year, often bringing their food with them,” he stated. Meanwhile, populations in developed countries such as the United States are aging and, therefore, increasingly vulnerable to illness associated with consump - tion of foods tainted by food-borne pathogens. Globalization of food trade We live in a world of “collapsed space,” King observed, and it is becoming increasingly smaller, faster, and more intercon- nected. Vast amounts of food and food products move around the world, as he and several other workshop speakers observed. The global nature of food supply chains is reflected in the United States, he said, where approximately 75 percent of processed food items contain ingredients from another country.11 Upon arrival, these products—along with domestically produced raw and finished foodstuffs— are typically dispersed hundreds or thousands of miles across the country from central distribution or processing facilities. Food distribution networks are de- signed to rapidly move perishable goods, to provide just-in-time restocking of nonperishable items, and to take advantage of economies of scale (Sobel, 2005). Unfortunately, he added, there is a “disconnect between health and commerce” include poultry, fish, reptiles, and pigs. Depending on the region, animals are usually caged and killed for live preparation. Fresh fruits and vegetables are also available. Wet markets generally include butcher shops and fish markets, which are in a separate section from the fruit and vegetable stalls. (University of Hong Kong Social Mapping Project: http://www.wix.com/geog3414/geog3414-wet- market; accessed April 24, 2012). 11 On an annual basis, this country imports more than 75 percent of its fresh fruits and vegetables and more than 80 percent of its seafood (FDA, 2011a).

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