Improving Food Safety Through a One Health Approach Workshop Summary (2012) / Chapter Skim
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Workshop Overview
Workshop Overview
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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.
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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.
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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)
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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.
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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.
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. 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)
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. THE GLOBAL FOOD SYSTEM Globalization of the food supply has served to expand the range of foodborne pathogens as well as to amplify health and economic impacts of a single contamination incident.
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8 FIGURE WO-2 U.S. agricultural and seafood imports (millions of U.S.
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as a "perfect microbial storm." King went on to discuss the many factors that influence the complex interactions among host, pathogen, and environment that can lead to the emergence or reemergence of infectious diseases (IOM, 1992, 2003; and illustrated in Figure WO-3)
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. "raging epidemic." Moreover, as Daszak observed, significant emerging viral diseases such as HIV/AIDS8 and severe acute respiratory syndrome (SARS)
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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.
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As illustrated in Figure WO-5, this exponential growth in the developing world is expected to continue through the next decade. In 2010, nearly 30 billion food animals were produced to help feed the world's 7 billion people, King reported.
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"What we have now is an incredibly difficult system, a mixture of very intensively farmed production animals in developed countries, with a huge global connectivity," Daszak added. At the same time, in some parts of the world, and in increasingly remote areas, wildlife continues to be hunted, in increasingly remote areas, he said, "so it really is no surprise that we're seeing new pathogens that have a higher and higher impact and are emerging at a growing rate." Addressing the "Wicked Problem" of Food Safety with a One Health Paradigm King introduced the concept of the "wicked problem," as defined in Box WO-1, and explained why the quest for safe food in a globalized environ ment fits that definition.
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14 IMPROVING FOOD SAFETY THROUGH A ONE HEALTH APPROACH Why Diseases Emerge Genetic and biological factors • Microbial adaptation and change • Human susceptibility to infection Physical environmental factors • Climate and weather • Economic development and land use Ecological factors • Changing ecosystems • Human demographics and behavior Social, political, and economic factors • International travel and commerce • Poverty and social inequity • War and famine • Lack of political will • Intent to harm FIGURE WO-6 Why diseases emerge.
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The scope of One Health is impressive, broad, and growing. Much of the recent focus of One Health has been limited to emerging infectious diseases, yet the concept clearly embraces environmental and ecosystem health, social sciences, ecology, non-infectious and chronic diseases, wildlife, land use, antimicrobial resistance, biodiversity, and much more.
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. Taking a One Health approach to food safety is an example of changing paradigms, as described by philosopher of science Thomas Kuhn in his seminal work, The Structure of Scientific Revolutions (Kuhn, 1996)
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Many workshop participants suggested that the questions captured in bullet points below might stimulate new ways of thinking about the process of adopting a One Health approach to food safety: • What are the greatest threats to the global food supply, and which of these threats are most amenable to intervention? • Despite the "wickedness" of emerging food-borne diseases, can promising "control points" be identified that will increase the likelihood of predict ing or preventing potential outbreaks?
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Hueston predicted that the future will bring even longer and more complex food supply chains, in part because of the increasingly urbanized global population, and also in response to consumer demand in terms of purchasing power combined with a desire to purchase any kind of food year-round. Moreover, as illustrated in Figure WO-8, vast -- and, in some cases, unknown -- numbers of farms and livestock operations, processors, packers, shippers, and retail outlets comprise the current global food system, upon which the U.S.
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19 WORKSHOP OVERVIEW FIGURE WO-7 Global supply chain complexity: Origin and contents of a generic "megaburger." SOURCE: Shaun Kennedy, Director, National Center for Food Protection and Defense, University of Minnesota, as cited by Hueston (2011)
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. Figure WO-8.eps Hueston insisted that there is no single global food system but rather a multitude of interdependent food systems driven by the diverse needs of different countries and populations.
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(Dr. Tauxe's contribution to the workshop summary report can be found in Appendix A, pages 307-331.)
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He envisioned a new model of partnership that engages the food industry through a flexible and realistic regulatory system. "Voluntary compliance [with food safety standards]
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. Recent Food-Borne Disease Outbreaks: Patterns of Emergence and Lessons Learned Even in the industrialized world, food-borne illness is a relatively common phenomenon.
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Campylobacter spp. are part of the normal intestinal flora of a wide variety of healthy domestic and wild animalsa and are often found associated with bodies of water such as water troughs and streams.
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Escherichia coli Escherichia coli comprise a large and diverse group of bacteria. Although most strains of E
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FIGURE WO-2-3 This colorized scanning electron micrograph (SEM) depicts a Figure WO-2-3.eps number of Escherichia coli bacteria of the strain O157:H7 (Magnification 6,836x)
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The virus's abilities to withstand a wide range of temperatures (from freezing to 60°C) and to persist on environmental surfaces and food items contribute to rapid dissemination, particularly via secondary spread (via food handlers or to family members)
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. FIGURE WO-2-5 Transmission electron micrograph of norovirus virions.
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bitmap SOURCE: National Institute of Allergy and Infectious Diseases, National Institutes of Health. Toxoplasma gondii Toxoplasma gondii is one of the world's most common parasites (Figure WO-2-7)
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For some countries, this figure is as high as 95 percent. Figure WO-2-7.eps FIGURE WO-2-7 Colored transmission electron micrograph (TEM)
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Figure WO-9.eps bitmap -- all newistype added evolving threat to Be that as it may, food-borne disease a persistent and global health. These diseases occur daily, in all countries -- from the least to the most developed -- and are caused by consumption of foods and food components contaminated with a variety of microorganisms.
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. Several workshop presentations described the unfolding investigation, and analysis, of recent food-borne disease events that have informed a One Health view of food-borne disease emergence.
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. WO 10 The foods implicated in outbreaks 2003-2008: Illnesses in 1,565 outbreaks caused by single food, and reported to CDC Poultry Pork Leafy greens Fruits Beef Nuts Dairy National Foodborne Outbreak Surveillance System FIGURE WO-11 Foods implicated in outbreaks.
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"What is that long-term effect? I don't think we know." Many recent disease outbreaks reflect the changing nature of food-borne threats to health.
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Large-scale, centralized, food-processing operations followed by broad product distribution pathways create additional vulnerabilities in the food supply (ERS, 2005; Maki, 2009)
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Escherichia coli Escherichia coli is a large and diverse group of bacteria that are present in the environment and as commensala organisms in a wide range of animals, including humans (Garcia et al., 2010)
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. Based on isolates from contaminated produce from sick consumers, investigators matched the outbreak strain to environmental samples from a single field in central California.
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. Investigators initially identified fresh produce -- including leafy greens, toma toes, and cucumbers as likely sources of the outbreak (Frank et al., 2011b)
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. Listeria monocytogenes Listeria monocytogenes is a bacterium that is widely distributed in nature.
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. j Listeria monocytogenes may grow in biofilms that protect them against environmental stress and can be isolated from surfaces after cleaning and disinfection (Ghandi and Chikindas, 2007)
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; Division of Foodborne, Water borne, and Environmental Diseases (DFWED) cant contribution of this highly infectious RNA virus to the burden of food-borne i llness -- particularly as the cause of numerous outbreaks of food-borne disease in community settings such as nursing homes, hospitals, the military, and cruise ships (Estes et al., 2006; Glass et al., 2009)
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Organized much like large, floating hotels, cruise ships provide ideal conditions for the introduction and the rapid, global spread of norovirus infection. Thousands of passengers from different geographic areas are transported in close quarters to multiple destinations around the world.
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. Infection can thus be introduced to the cruise ship environment in a variety of ways: by passengers or crew infected before embarkation; with food items con taminated before loading; by persistently contaminated environmental surfaces; or after ships dock in countries where sanitation might be inadequate -- either through contaminated food or water, or via passengers that have been infected while ashore (Hall et al., 2005)
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The objectives of USDA VetNet are to determine PFGE (Pulse Field Gel Electrophoresis) patterns of Salmonella isolates submitted to the National Antimicrobial Resistance Monitoring System (NARMS)
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coli O157:H7 in meat, speaker Cathie Woteki, Chief Scientist and Under Secretary for Research, Education, and Economics at the USDA, attributed the subsequent decline in such illnesses in part to the introduction of Hazard Analysis and Critical Control Point (HACCP) systems21 and their implementation by the ground beef industry.
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(Dr. Burger's contribution to the workshop summary report can be found in Appendix A, pages 115-130.)
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"To inform reliably, to the best of present knowledge, without losing credibility and convincing the people that it's appropriate, this was a challenge, which one should really be aware of in advance of such crisis situations." Cohort studies of groups of people who became ill (such as a team from a Swedish company who stayed a short time in Germany, so it could easily be determined where they stayed and what they ate) helped identify sources of contaminated food items, Burger recalled.
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(Dr. Doyle's contribution to the workshop summary report can be found in Appendix A, pages 140-175.)
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However, he added, "there are still one or two cases per month, always secondary cases connected to previous cases." Nipah Virus in Malaysia and Bangladesh The emergence of Nipah virus (NiV) in Malaysia and Bangladesh provides particularly deadly examples of the many routes of zoonotic disease transmission that are associated with the food system.
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(Dr. Luby's contribution to the workshop summary report can be found in Appendix A, pages 271-298.)
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Several days before the outbreak, the family sent date palm sap to nearby relatives; three people in that household were also among the cases in that outbreak. "As we sorted this out, we said, we're epidemiologists, so we're going to put this in an epidemiology journal and we're going to talk about food-borne transmission of Nipah virus," Luby recalled -- but their conclusion was questioned by microbiologists, who noted that the virus had never been found in food, and wanted Date Palm Sap Collection • Late November through March – Sap harvesters cut a tap into the tree • In the evening they place a clay pot under the tap • Each morning the pot is removed – Most sap is made into molasses – Some sold fresh early in the morning • A local delicacy FIGURE WO-15 Date palm sap collection.
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The experiment to monitor the nightly visitations of bats to drink date palm sap is presented in Figure WO-16. This discovery prompted Forum member Gerald Keusch, of Boston University, to remark on the growing recognition of the role of bats as carriers of infectious diseases, and to suggest that epidemiological surveillance should be conducted on bats to identify prospective human pathogens.
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. Other outbreaks arose when bats transmitted the virus to domestic animals (as occurred in Malaysia; in this case, the vehicle was sometimes date palm sap fed to animals)
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We work to identify risk factors, to mount interventions, to evaluate those interventions, even when those evaluations are not quite as resoundingly successful as we would like." Challenges in Food-Borne Pathogen Detection One workshop participant noted in discussion, that in the case of both the German EHEC outbreak and the Nipah virus epidemic in Bangladesh, investigators were unable to isolate the pathogen from the suspected food source. This observation led to a discussion of sampling and testing strategies for food-borne pathogens.
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This implies a greater need for interdisciplinary collaboration, he continued. "I see it as not just an internal bioinformatics microbiological issue, but more broadly, whether we can tell coherent stories." Tauxe noted that the CDC has used molecular subtyping of food-borne pathogens for many years as part of public health surveillance of food-borne diseases to detect and investigate outbreaks that would otherwise be missed.
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food supply offers countless opportunities for intentional contamination, many of which would be difficult to trace back to their "origin" because of the intricacies of food production and distribution networks. Both Tauxe and Doyle discussed the nature, scope, and environmental sources of plant food-borne disease.
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Protozoan parasites, including Cryptosporidium and Giardia, have been found in high concentrations in irrigation water in Mexico and the United States. Doyle observed that global trade in produce means that local water problems can result in food-borne disease anywhere in the world.
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"This general phenomenon has been demonstrated for a variety of fruits." Active internalization of pathogens into plants can also occur, Tauxe continued. For example, he noted, an electron micrographic study of Salmonella distribution on fresh lettuce leaves shows that the bacterial cells are distributed randomly over the leaf surface during the night, while in daylight, they are concentrated near the stomata, where metabolic products of photosynthesis are released (Kroupitski et al., 2009)
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(Dr. Koopmans' contribution to the workshop summary report can be found in Appendix A, pages 225-251.)
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Food-borne viral disease outbreaks that are recognized as such represent the "tip of the iceberg," she asserted. "Not only do we need to have people with [gastrointestinal]
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She urged increased international efforts to exchange molecular and epidemiological information to enable the sequencebased linking of clusters of viral enteric disease, and thereby to track global food-borne outbreaks -- outbreaks that threaten to produce more virulent viruses through recombination. Ultimately, Koopmans added, "I think we need to start moving away from individual surveillance systems for individual pathogens and really think through what the fecal flows and the produce flows are, what smart sampling is, and .
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(Dr. Wegener's contribution to the workshop summary report can be found in Appendix A, pages 331-349.)
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. DANMAP monitors antimicrobial resistance, through systematic sampling and testing of bacterial isolates, from humans, food, and food animals.
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"If they don't do that, they may get a visit from the district veterinarian's office," Wegener explained; however, there are no defined consequences for ignoring the "yellow card." Nevertheless, he said, this measure has been associated with a 20 percent reduction in antibiotic use since it was instituted in 2010. Efforts are under way to implement integrative surveillance of AMR and antimicrobial usage throughout Europe and also at the global level, through the WHO's Advisory Group on Integrated Surveillance of Antimicrobial Resistance, 24 he reported.
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The effects of this change on both human and animal health have yet to be determined. The Danish food animals consume less than 20 percent of the amount of antimicrobials used by U.S.
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It is more based on a culture of agreeing to a common problem and then trying to agree to a solution and then moving along." Although Wegener stated that these decisions were made primarily to satisfy risk-averse Danish consumers, Hueston observed that Denmark "made a decision decades ago to focus on their export market, as they should." Daszak added that Denmark's policies had allowed it to gain a market-share advantage -- a strategy that would not be as effective in the United States, which does not export the majority of the meat it produces. Within the United States, much of the discussion of the use of antibiotics in animals has been limited to two alternatives -- bans or unrestricted use -- despite the fact that a myriad of options exist for managing the associated risk, Hueston asserted.
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Returning to the emergence of Nipah virus in Malaysia, Daszak described how he and his colleagues used a One Health approach to analyze the livestock production system and surrounding ecosystem in order to understand how the outbreak happened. After unraveling the story of the virus-carrying bats messily eating mangoes among the pigsties, the researchers attempted to determine why the outbreak occurred when and where it did.
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. Daszak and coworkers attempted to build on this work to understand the role of farm size and connectivity as risk factors for avian influenza transmission.
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Identifying food-borne disease hotspots Daszak and colleagues developed a database of every infectious disease that has emerged over the past five decades in order to develop more generalized rules for predicting where infectious diseases are likely to emerge (Jones et al., 2008)
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70 IMPROVING FOOD SAFETY THROUGH A ONE HEALTH APPROACH Food-borne EID Hotspots map Rela ve risk of food-borne EID events, based on Jones et al.
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Before wildlifeassociated emerging infectious diseases such as SARS, monkeypox, or avian influenza commanded headlines, EcoHealth Alliance was examining connections between wildlife and infectious diseases in such settings as logging camps and bush meat markets, he said. People in logging camps, with populations numbering into the thousands, are essentially hunter-gatherers who must obtain all of their food from the surrounding forest.
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, determining routes of transmission, identifying animal species most likely to transmit infectious diseases, and conducting Internet surveillance for outbreak cues. PREDICT is also building surveillance capacity in hotspots for disease emergence to increase the possibility of early detection and effective containment.
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(Dr. Wolfe's contribution to the workshop summary report can be found in Appendix A, pages 349-362.)
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" Wolfe proceeded to describe several innovative approaches to detecting the emergence of infectious diseases, focusing on food-borne viral outbreaks. Viruses frequently jump from wild animals to domesticated animals and human hosts, but only by degrees, and often unsuccessfully -- as illustrated in Figure WO-24 -- a phenomenon he referred to as "viral chatter." Only occasionally do viruses become exclusively adapted to a human host, he said, but until recently, these relatively rare events have commanded researchers' attention and have prevented them from understanding -- and therefore predicting -- how infectious diseases emerge.
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. In addition to revealing new levels of HTLV diversity and suggesting that human exposure to non-human primates contributes to HTLV emergence, these findings also indicate that crossspecies transmission is not the rate-limiting step in pandemic retrovirus emergence; rather, they show that it may be possible to predict and prevent disease emergence by surveillance of populations exposed to animal reservoirs, as well as through interventions to reduce human exposure to non-human primates.
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(Dr. Lipkin's contribution to the workshop summary report can be found in Appendix A, pages 251-271.)
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illustrative examples, gleaned from his own experience, of the application of a range of molecular methods for pathogen discovery, described in Box WO-4, to the investigation of infectious outbreaks that appear to be caused by novel infectious agents. In one case, when Lipkin and colleagues used MassTag PCR (see Box WO-4)
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. These findings illustrate the potential pitfalls in prematurely narrowing an outbreak investigation to one pathogen, or even a single class of pathogens, he observed.
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SOURCE: Excerpted from Microbiology and Molecular Biology Reviews, 2010, 363-377, doi: 10.1128/MMBR.00007-10 and reproduced with permission from the American Society for Microbiology. and likely to become increasingly so, which begs the question of how best to analyze the volumes of data these methods generate, Lipkin stated.
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However, because the disease did not spread beyond these workers, it seemed unlikely to be infectious; eventually, it was confirmed that the workers were suffering from a previously described autoimmune reaction, not an infectious disease, he reported. Another episode of pathogen "de-discovery," described in detail in a recent review by Lipkin, involved evidence that contributed to discrediting a proposed causal relationship between the measles, mumps, and rubella (MMR)
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One Health Approaches to Food System Biosecurity The number of food-borne disease outbreaks is increasing in frequency, yet the myriad approaches to food safety used around the world make it difficult to implement a unified, risk-based approach to managing and controlling these hazards (Coker et al., 2011; Karesh et al., 2005)
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One Health in Australia: The Biosecurity Continuum While acknowledging that common factors drive the emergence of infectious diseases, including those that are food-borne, speaker Martyn Jeggo, director of the Commonwealth Scientific and Industrial Research Organisation (CSIRO) 29 Austra 29 CSIRO is Australia's national science agency.
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Few diseases affect bitmap any one group, and the complex rela exclusively tions between host populations set the scene for disease emergence. Examples of emerging infectious diseases that overlap these categories are canine distemper (domestic animals to wildlife)
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We've now got a strong dialogue going on, with industry prepared to seriously invest in this area." However, he added, partnership with industry "comes with the underlying understanding that industry will also want to be involved in at least influencing the decision-making process." Australia recognizes that the One Health approach is essential to managing both food safety and infectious disease risks, Jeggo concluded. "It is clear to all of us that if we work together across that continuum of wildlife, animal health, and human health, we should deliver better outcomes," he said, but he noted that actual evidence for that conclusion is lacking -- and that it is necessary to support further efforts.
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Addressing AMR (an issue previously discussed in the subsection titled Antimicrobial-Resistant Pathogens) is a focus of Canada's One Health approach to food safety, and surveillance is the keystone of these efforts, Engelhardt said.
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. A One Health approach to food safety emphasizes the sharing of relevant information among disparate organizations, unifying organizational mandates among human, animal, and environmental health professionals, and integrating local national and international surveillance networks.
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Yet, no single multilateral organization or government agency has a mandate to pursue policies or collect data related to disease spread based on a One Health approach (Karesh et al., 2005)
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Calling the One Health perspective "indispensable to the goal of preventing food-borne illness," he stressed that One Health is central to FDA's overall approach to improving food safety, not just to implementation of the FSMA. For example, he said, the Office of Foods, which he directs, was created to integrate the work of FDA's Center for Food Safety and Applied Nutrition (CFSAN)
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Several major food retailers and fast food chains have already made the decision not to buy meat from animals treated with medically significant antibiotics, he noted. FDA's voluntary antibiotic phase-out strategy was informed by discussion with drug companies, the veterinary community, and the animal production industry, Taylor said.
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However, he also noted that FDA was taking several steps to encourage collaboration, such as research under way with the CDC on ways to identify specific foods and pathogen-food combinations as causes of food-borne disease outbreaks. The FMSA stipulates that the CDC's conduct of food chain surveillance should fulfill the needs of consumers, FDA and other state and local regulatory agencies, and the food industry, Taylor continued.
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. Research agenda The overarching challenge in improving food safety through One Health is to bring interdisciplinary science to bear to implement interventions of proven benefit, Taylor observed.
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She characterized the USDA as an organization where expertise in animal health and science, human food safety and nutrition, wildlife ecology, plant and crop science, and economics come together in one place: fertile ground for establishing a One Health approach, which has evolved out of the department's efforts to plan for pandemic influenza. "This comprehensive approach is going to improve global capabilities to detect, prevent, prepare for, and respond to emerging diseases, pandemic threats, and other issues in the human, animal, and ecosystem interface," she stated.
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One Health in Practice: Regulations, Research, and Industrial Applications Several speakers attested to the influence of the One Health paradigm in shaping regulations, research agendas, and industry practices to improve food safety. Each of the presentations summarized below identified ways in which government agencies, food companies, and sectors of the food industry have looked across the food chain to identify opportunities to minimize risk of food-borne disease.
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, as well as increased bureaucracy among the agencies responsible for monitoring food safety and responding to outbreaks. Ensuring that all parts of the global food supply system function properly is critical to keeping the food supply safe.
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(Mr. Robach's contribution to the workshop summary report can be found in Appendix A, pages 298-307.)
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business initiatives, including the Global Food Safety Initiative, a multi stakeholder group that has developed guidance and benchmarks for food safety systems based on Codex.
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The One Health approach at Cargill hinges on global partnerships, Robach observed. "We work closely not only with our supply chain and our competitors in the industry, but also with our customers and with the regulatory agencies," he said, adding that the company also works closely and shares information with the CDC.
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"While we are very good at getting rid of 90 to 99 percent of the contamination that could be on fresh produce, there is always going to be some residual number of organisms that are able to hide away," he said. "Therefore, we strive at every point in the supply chain to prevent contamination from occurring, and we're not always successful." When prevention fails and a produce-associated outbreak of food-borne disease occurs, it is frequently difficult to discern its cause -- and therefore to avoid a recurrence, Gombas observed.
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We don't need more basic research on potential pathogens, potential risk factors because we've got plenty enough right now that we don't have answers for." David Acheson, of Levitt Partners, LLC, agreed that specific measurements of risk factors are necessary to improving food safety. For example, he noted, it was once assumed that a person would need to consume approximately 1 million Salmonella bacteria to become ill -- until precise measurements were made, which reduced the "dose" to only 25 organisms.
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In addition, greater fidelity of epidemiology, aided by improvements in genetic testing, enable quicker and more accurate outbreak investigations. Nevertheless, the increasing importation of food presents obvious challenges to maintaining a safe domestic food supply -- a task rendered even more difficult by shifting expectations among consumers, Acheson observed.
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food supply is also limited by consumer aversion to technological solutions such as irradiation, he observed; conference participants pointed out additional drawbacks to food irradiation, including cost (in the case of leafy greens, according to Gombas) and aesthetics (in the case of ground beef, which -- according to Robach -- has been said to [smell]
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The Future of One Health As the workshop drew to a close, King presented a summary of strategic actions identified by individual workshop participants that could advance the cause of improving food safety with One Health beyond mere awareness of its promise, and into action. These steps include the following: • presenting a sufficiently compelling case for the One Health paradigm that is expressed in training and education programs;
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WORKSHOP OVERVIEW REFERENCES Aarestrup, F
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coli via contaminated food. Presentation given at the December 13-14, 2011, public workshop Improving Food Safety Through One Health, Forum on Microbial Threats, Institute of Medicine, Washington, DC.
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2011k. National Center for Emerging and Zoonotic Infectious Diseases.
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Report Brief. Clinical Infectious Diseases.
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Emerging Infectious Diseases 13(11)
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Presentation given at the December 13-14, 2011, public workshop Improving Food Safety Through One Health, Forum on Microbial Threats, Institute of Medicine, Washington, DC. Hutchison, M
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Presentation given at the December 13-14, 2011, public workshop Improving Food Safety Through One Health, Forum on Microbial Threats, Institute of Medicine, Washington, DC.
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Clinical Infectious Diseases 41(9)
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Presentation given at the December 13-14, 2011, public workshop Improving Food Safety Through One Health, Forum on Microbial Threats, Institute of Medicine, Washington, DC. Robert Koch Institute.
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Presenta tion given at the December 13-14, 2011, public workshop Improving Food Safety Through One Health, Forum on Microbial Threats, Institute of Medicine, Washington, DC. Tauxe, R
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Presentation given at the December 13-14, 2011, public workshop Improving Food Safety Through One Health, Forum on Microbial Threats, Institute of Medicine, Washington, DC. Weinstein, K
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