Foodborne Disease and Public Health Summary of an Iranian-American Workshop (2008) / Chapter Skim
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2 Foodborne Disease Surveillance in Iran and in the United States
2 Foodborne Disease Surveillance in Iran and in the United States
Pages 9-26
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Tauxe's discussion of foodborne disease surveillance in the United States; and Jennifer A Kincaid's description of PulseNet USA, the national molecular subtyping network for foodborne disease surveillance in the United States.
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. In his presentation, Ardalan provided background information on surveillance in Iran, described the design and preliminary results of a surveillance system pilot project, identified the limitations and strengths of the surveillance system, and proposed future steps that could improve the surveillance.
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The goal of the project was to develop a model for a national foodborne disease surveillance system. The project had four objectives:
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For infants the definition was an increased frequency or decreased consistency of the stool compared to previous bowel habits that the mother considered to be diarrhea. Data-collection instruments included a questionnaire for diarrhea cases, a stool-sample form, and a case-number reporting form.
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Recorded data included complications, duration of illness, physician visits, medications, hospitalization, absence from work or school, costs, and whether the illness was fatal. Laboratory Tests During the pilot project, health care staffs were asked to provide a stool specimen for every patient who had a diarrheal episode, preferably within 48 hours after the onset of the illness.
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Closing Remarks -- Potential Future Steps Ardalan proposed a series of steps to improve foodborne disease surveillance in Iran: • Ensure that the surveillance system has been integrated into the health care system • Ensure that the surveillance system contributes to real-time decision making by health managers • Enable the health care system to analyze and interpret the data in the field • Conduct operational research to ensure the feasibility of the model and its adaptability to the current health care system • Improve data collection and transfer, data analysis, laboratory testing, and feedback processes • Improve the ability of the public health care system and of the Research Center on Gastroenterology and Liver Diseases to handle outbreak investigations quickly • Engage and train the community health volunteers • Conduct population-based surveys to obtain such information as the incidence of diarrhea and patterns of health utilization • Design and implement community intervention trials on health education and the prevention of foodborne disease
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There are several reasons to conduct foodborne disease surveillance: • To define the magnitude and burden of diseases that can be prevented or controlled • To identify outbreaks so that control actions can be taken and new problems can be identified • To provide a platform for applied research related to foodborne disease • To measure the effects of control and prevention efforts In the United States, public health surveillance is complex and occurs at four levels: the clinical level, the county level (approximately 3,500 county health departments) , the state level (50 state health departments plus 4 large cities)
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The CDC tracks outbreaks of foodborne diseases regardless of which microbe caused them. In the United States, the costs of surveillance are borne by the particular level of government carrying out the surveillance -- county, state, or federal -- so the information that is collected must be useful to each level.
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, the initiation of PulseNet USA (the national subtyping network for bacterial foodborne pathogens, described in the next section) , and the web-based electronic Foodborne Outbreak Reporting System.
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TABLE 2-1 Food Outbreak Scenarios Local/Focused Outbreaksa Diffused/Dispersed Outbreaks • Acute large local outbreak • Diffuse, widespread outbreak • High dose, high attack rate • Low dose, low attack rate • Increase in sporadic cases • Detected locally • etected by laboratory-based subtype D surveillance • Local investigation • Complex multistate investigation • nvolves a local food handling error, I • nvolves an industrial contamination I often egregious event • Local solution • Industry-wide implications aA series of local outbreaks may be a manifestation of the widespread distribution of a contaminated food product.
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Identifying and investigating new outbreaks and diseases will require a variety of surveillance strategies and a robust and flexible public health capacity. The following websites provide additional information related to foodborne illness and surveillance: • FoodNet: http://www.cdc.gov/foodnet • PulseNet: http://www.cdc.gov/pulsenet • Foodborne outbreak surveillance: http://www.cdc.gov/ foodborneoutbreaks • CDC Safe Water System: http://www.cdc.gov/safewater • General information about diseases: http://www.cdc.gov/health PulseNet USA: THE NATIONAL MOLECULAR SUBTYPING NETWORK FOR FOODBORNE DISEASE SURVEILLANCE Presenter: Jennifer A
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2-4 fig The three basic elements of PulseNet USA all involve data: its acquisition, analysis, and exchange. Participating laboratories use the Internet to upload and download information to and from the main database and server located at the CDC.
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The international family of subtyping networks is growing and now includes PulseNet USA, PulseNet Canada, PulseNet Europe, PulseNet Asia Pacific, PulseNet Latin America, and PulseNet Middle East, which is
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Its current PulseNet international collaborations include outbreak investigations; addressing various problems with laboratories, analyses, and protocol development and validation; and the development, evaluation, and validation of new typing methods. Among the methods being developed are a simple non-imagebased method to use in conjunction with PFGE; multi-locus, variablenumber, tandem assay analysis; and single nucleotide polymorphism analysis.
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Reportedly, they have come to agreement and will publish their definition soon. Iranian Foodborne Disease Surveillance During the discussion it was noted that Iran has a large private health care sector that is distinct from the public system described in Ardalan's presentation.
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Kincaid explained that PulseNet Middle East is not yet an official network; rather, it still is in development. Currently the main laboratory involved in PulseNet Middle East is the Oman laboratory, which has been receiving training from the only laboratory in the Middle East that is certified through PulseNet International to perform the method (namely, the Navy-Army Research Medical Laboratory in Cairo)
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Outbreaks caused by the rare Salmonella serotypes usually can be identified without using PFGE. PulseNet USA has improved the ability of public health departments to detect clusters of illnesses that may be foodborne disease outbreaks, in part because it brings together subtyping data from many public health departments of states, regions, and countries for comparison.
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The PulseNet system, which focuses on sporadic cases of foodborne illness, has made it possible to detect food sources that might have been common to cases that are widely dispersed geographically. For example, PulseNet made it possible to identify the contamination of eggs and poultry as contributing factors to acquiring salmonellosis and the undercooking of ground beef in the home as a risk factor for acquiring E
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