It has excellent sanitation: Winter’s coming so people stop going to the heated pool

I miss the hot tub we had in Kansas.

Yet in the U.S., thousands of public pools, hot tubs are closed each year due to serious violations.

caddyshack.pool.poop-1The U.S. Centers for Disease Control and Prevention reports that inspections of public pools and other aquatic venues enforce standards that can prevent illness, drowning, and pool-chemical–associated injuries such as poisoning or burns.

“No one should get sick or hurt when visiting a public pool, hot tub, or water playground,” said Beth Bell, M.D., M.P.H., director of CDC’s National Center for Emerging and Zoonotic Infectious Diseases. “That’s why public health and aquatics professionals work together to improve the operation and maintenance of these public places so people will be healthy and safe when they swim.”

Inspection data were collected in 2013 in the five states with the most public pools and hot tubs: Arizona, California, Florida, New York and Texas. Researchers reviewed data on 84,187 routine inspections of 48,632 public aquatic venues, including pools, hot tubs, water playgrounds and other places where people swim in treated water.

Among the key findings:

Most inspections of public aquatic venues (almost 80 percent) identified at least one violation.

1 in 8 inspections resulted in immediate closure because of serious health and safety violations.

1 in 5 kiddie/wading pools were closed—the highest proportion of closures among all inspected venues.

The most common violations reported were related to improper pH (15 percent), safety equipment (13 percent), and disinfectant concentration (12 percent).

“Environmental health practitioners, or public health inspectors, play a very important role in protecting public health. However, almost one third of local health departments do not regulate, inspect, or license public pools, hot tubs, and water playgrounds,” said Michele Hlavsa, R.N., M.P.H., chief of CDC’s Healthy Swimming Program. “We should all check for inspection results online or on site before using public pools, hot tubs, or water playgrounds and do our own inspection before getting into the water.”

When visiting public or private pools, swimmers and parents of young swimmers can complete their own inspection using a short and easy checklist that will identify some of the most common health and safety problems:

Use a test strip (available at most superstores or pool-supply stores) to determine if the pH and free chlorine or bromine concentration are correct. CDC recommends:

diaper.poolFree chlorine concentration of at least 1 ppm in pools and at least 3 ppm in hot tubs/spas.

Free bromine concentration of at least 3 ppm in pools and at least 4 ppm in hot tubs/spas.

pH of 7.2–7.8.

Make sure the drain at the bottom of the deep end is visible. Clear water allows lifeguards and other swimmers to see swimmers underwater who might need help.

Check that drain covers appear to be secured and in good repair. Swimmers can get trapped underwater by a loose or broken drain cover.

Confirm that a lifeguard is on duty at public venues. If not, check whether safety equipment like a rescue ring with rope or pole is available.

If you find problems, do not get into the water and tell the person in charge so the problems can be fixed. For more information and other healthy and safe swimming steps, visit www.cdc.gov/healthywater/swimming.

Before CDC-led development of the Model Aquatic Health Code, there were no national standards for the design, construction, operation, and maintenance practices to prevent illness and injury at public treated recreational water venues. Now, local and state authorities can voluntarily adopt these science- and best practices–based guidelines to make swimming and other activities at public pools and other aquatic venues healthier and safer. The second edition of the code will be released during the 2016 swim season. For more information about the Model Aquatic Health Code, visitwww.cdc.gov/mahc.


hot.tubProblem/Condition: Aquatic facility–associated illness and injury in the United States include disease outbreaks of infectious or chemical etiology, drowning, and pool chemical–associated health events (e.g., respiratory distress or burns). These conditions affect persons of all ages, particularly young children, and can lead to disability or even death. A total of 650 aquatic facility–associated outbreaks have been reported to CDC for 1978–2012. During 1999–2010, drownings resulted in approximately 4,000 deaths each year in the United States. Drowning is the leading cause of injury deaths in children aged 1–4 years, and approximately half of fatal drownings in this age group occur in swimming pools. During 2003–2012, pool chemical–associated health events resulted in an estimated 3,000–5,000 visits to U.S. emergency departments each year, and approximately half of the patients were aged <18 years. In August 2014, CDC released the Model Aquatic Health Code (MAHC), national guidance that can be adopted voluntarily by state and local jurisdictions to minimize the risk for illness and injury at public aquatic facilities.

Reporting Period Covered: 2013.

Description of System: The Network for Aquatic Facility Inspection Surveillance (NAFIS) was established by CDC in 2013. NAFIS receives aquatic facility inspection data collected by environmental health practitioners when assessing the operation and maintenance of public aquatic facilities. This report presents inspection data that were reported by 16 public health agencies in five states (Arizona, California, Florida, New York, and Texas) and focuses on 15 MAHC elements deemed critical to minimizing the risk for illness and injury associated with aquatic facilities (e.g., disinfection to prevent transmission of infectious pathogens, safety equipment to rescue distressed bathers, and pool chemical safety). Although these data (the first and most recent that are available) are not nationally representative, 15.7% of the estimated 309,000 U.S. public aquatic venues are located in the 16 reporting jurisdictions.

Results: During 2013, environmental health practitioners in the 16 reporting NAFIS jurisdictions conducted 84,187 routine inspections of 48,632 public aquatic venues. Of the 84,187 routine inspection records for individual aquatic venues, 78.5% (66,098) included data on immediate closure; 12.3% (8,118) of routine inspections resulted in immediate closure because of at least one identified violation that represented a serious threat to public health. Disinfectant concentration violations were identified during 11.9% (7,662/64,580) of routine inspections, representing risk for aquatic facility–associated outbreaks of infectious etiology. Safety equipment violations were identified during 12.7% (7,845/61,648) of routine inspections, representing risk for drowning. Pool chemical safety violations were identified during 4.6% (471/10,264) of routine inspections, representing risk for pool chemical–associated health events.

Interpretation: Routine inspections frequently resulted in immediate closure and identified violations of inspection items corresponding to 15 MAHC elements critical to protecting public health, highlighting the need to improve operation and maintenance of U.S. public aquatic facilities. These findings also underscore the public health function that code enforcement, conducted by environmental health practitioners, has in preventing illness and injury at public aquatic facilities.

Public Health Action: Findings from the routine analyses of aquatic facility inspection data can inform program planning, implementation, and evaluation. At the state and local level, these inspection data can be used to identify aquatic facilities and venues in need of more frequent inspections and to select topics to cover in training for aquatic facility operators. At the national level, these data can be used to evaluate whether the adoption of MAHC elements minimizes the risk for aquatic facility–associated illness and injury. These findings also can be used to prioritize revisions or updates to the MAHC. To optimize the collection and analysis of aquatic facility inspection data and thus application of findings, environmental health practitioners and epidemiologists need to collaborate extensively to identify public aquatic facility code elements deemed critical to protecting public health and determine the best way to assess and document compliance during inspections.

Immediate Closures and Violations Identified During Routine Inspections of Public Aquatic Facilities — Network for Aquatic Facility Inspection Surveillance, Five States, 2013

Surveillance Summaries / May 20, 2016 / 65(5);1–26

Michele C. Hlavsa, MPH; Taryn R. Gerth, MPH; Sarah A. Collier, MPH; Elizabeth L. Dunbar, MPH; Gouthami Rao, MPH; Gregory Epperson; Becky Bramlett; David F. Ludwig, MPH; Diana Gomez, MPH; Monty M. Stansbury; Freeman Miller; Jeffrey Warren; Jim Nichol; Harry Bowman; Bao-An Huynh, MPH; Kara M. Loewe; Bob Vincent; Amanda L. Tarrier, MPH; Timothy Shay; Robert Wright; Allison C. Brown, PhD; Jasen M. Kunz, MPH; Kathleen E. Fullerton, MPH; James R. Cope, PhD; Michael J. Beach, PhD

http://www.cdc.gov/mmwr/volumes/65/ss/ss6505a1.htm?s_cid=ss6505a1_e

Who ya gonna call? MicrobeNet, CDC’s disease identification tool

MicrobeNet, an innovative online tool designed by the U.S. Centers for Disease Control and Prevention (CDC) has, since 2013, has helped laboratorians and doctors get the information they need to accurately diagnose causes of disease faster and save lives.

ghostbusters-imageMicrobeNet provides laboratorians with unprecedented access to CDC’s virtual microbe library of more than 2,400 rare and emerging infectious bacteria and fungi at no cost. The recent multi-state outbreak of Elizabethkingia in Wisconsin, Illinois and Michigan underscores the need for a tool like MicrobeNet in diagnostic laboratories. Hospitals and health departments using MicrobeNet can identify rare bacteria like Elizabethkingia quicker, and know they’re comparing their results to the most comprehensive and accurate disease database available.

In partnership with Bruker Corp., CDC has recently added a new module to MicrobeNet that allows labs to search the protein signatures of the bacteria and compare them to the rare pathogens in CDC’s MicrobeNet library by using Bruker’s MALDI Biotyper systems. Using MALDI to test is extremely fast and cheaper to run than many other types of testing, making the technology increasingly popular among labs. The new MicrobeNet module will be immediately available to laboratorians and clinicians using the Bruker system in labs nationwide. Until the addition of the MALDI library, MicrobeNet offered two ways to search pathogens: by DNA sequence or biochemical tests (chemical reactions caused by the bacteria).

MicrobeNet can dramatically improve the health of people in the United States and around the world by cutting the time for testing from about a week to a few hours.

“MicrobeNet has the potential to revolutionize public health,” said John R. McQuiston, PhD, team lead for CDC’s Special Bacteriology Reference Laboratory and CDC’s lead for MicrobeNet. “This system helps public health labs and hospitals quickly identify some of the most difficult pathogens to grow and detect. In turn, MicrobeNet will help treat patients faster and allow health departments to respond to public health emergencies more effectively.”

Traditionally, clinicians or laboratorians who needed to identify a rare bacteria or fungi or to confirm an infectious disease diagnosis with one of these organisms needed to send a sample to CDC and await test results. With MicrobeNet, they can access the information they need immediately.

One of MicrobeNet’s greatest advantages lies in allowing two-way communications between users and CDC staff who are experts in the diseases that users are searching. MicrobeNet allows state public health experts to monitor disease trends in their state in real time and recognize when those trends might indicate an outbreak. It also provides public health agencies with a valuable snapshot of nationwide disease trends and will help CDC identify multistate outbreaks and provide information to public health partners in the affected states.

In addition to being faster, using the MALDI module in MicrobeNet offers dramatic cost savings for clinical and public health laboratories because they no longer will need to develop their own pathogen libraries. These laboratories will also have the assurance that their information has been confirmed by CDC experts. In addition, for many germs, MicrobeNet provides doctors with information about which antibiotics the bacteria are resistant to. By quickly identifying the species of bacteria, lab staff can pass this critical information to the doctors who can use it to help make a diagnosis and select the right treatment, thus reducing the risk of their patients developing drug-resistant infections.

MicrobeNet was launched in 2013 by the Division of High-Consequence Pathogens and Pathology’s Special Bacteriology Reference Laboratory as a way to help state public health laboratories and other diagnostic labs rapidly identify rare and emerging infections, with the goal of saving time, money, and lives. MicrobeNet initially had a DNA sequence search module. Since then, MicrobeNet has added a phenotypic and biochemical search tool and, through a partnership with ThermoFisher, a DNA sequence editing tool, MicrobeBridge. CDC has also entered pages of information, including contact information for the subject matter expert for every species.

Funded in part by CDC’s Advanced Molecular Detection initiative, MicrobeNet currently includes information about more than 2,400 bacteria and fungi, including images and information about growing these organisms. Every month, CDC adds information on as many as 100 new species to MicrobeNet to aid in detection, diagnosis, and planning treatment for sick patients.

For more information on MicrobeNet, please visit: http://www.cdc.gov/microbenet/. Labs wishing to join MicrobeNet can request an account by visiting https://microbenet.cdc.gov or emailing MicrobeNet@cdc.gov.

Stop kissing small turtles: 133 sick from four multistate outbreaks of human Salmonella

Since 2015, the U.S. Centers for Disease Control, multiple states, U.S Fish and Wildlife Service, the U.S. Department of Agriculture’s Animal and Plant Health Inspection Service (USDA-APHIS), and the U.S. Food and Drug Administration (FDA) Center for Veterinary Medicine have investigated four separate multistate outbreaks of human Salmonella infections linked to contact with small turtles.

turtle.kissIn the four outbreaks, a total of 133 people infected with the outbreak strains of Salmonella were reported from 26 states between January 16, 2015 and April 8, 2016:

  • 38 ill people were hospitalized, and no deaths were reported;
  • 41% of ill people were children 5 years of age or younger; and,
  • epidemiologic and laboratory findings linked the four outbreaks of human Salmonella infections to contact with small turtles or their environments, such as water from a turtle habitat.

Since 1975, the FDA has banned the sale and distribution of turtles with a shell length of less than 4 inches in size as pets because they are often linked to Salmonella infections, especially in young children.

Small turtles should not be purchased as pets or given as gifts.

All turtles, regardless of size, can carry Salmonella bacteria even if they look healthy and clean. These outbreaks are a reminder to follow simple steps to enjoy pet reptiles and keep your family healthy.

It’s not simple or so many people wouldn’t get sick – so many little kids.

The outbreak is expected to continue at a low level for the next several months since consumers might be unaware of the risk of Salmonella infection from small turtles. If properly cared for, turtles have a long life expectancy.

Change the law, name the supplier: Salmonella in seed transfers to sprouts in Kansas and sickens 26

They’re probably still eating sprout-laden sandwiches at science-based faculty meetings at Kansas State University.

jimmy.john's.sproutsFollowing an initial announcement of eight people sick with Salmonella from sprouts in Kansas and Missouri – followed by surveillance silence – the U.S. Centers for Disease Control now reports that 26 people were infected with the outbreak strains of Salmonella Muenchen (25 people), or Salmonella Kentucky (1 person), as reported from 12 states. Eight people were hospitalized and no deaths were reported.

In February 2016, state and local health and regulatory officials in several states traced back the source of the sprouts from multiple restaurant locations where ill people ate them, and identified Sweetwater Farms of Inman, Kansas, as a supplier of alfalfa sprouts to all of these locations. The FDA collected and tested irrigation water and alfalfa sprout samples from Sweetwater Farms LLC and found Salmonella Kentucky and Salmonella Cubana. Salmonella Muenchen was not isolated.

On February 19, 2016, FDA and other federal, state, and local agencies briefed Sweetwater Farms LLC on their findings, and the firm voluntarily recalled alfalfa sprouts grown from a specific seed lot.

On February 26, 2016, Sweetwater Farms informed the FDA that it would recall all of its sprout products from the market.

After the recalls by Sweetwater Farms were completed, Salmonella Muenchen illnesses were still reported by people who reported eating alfalfa sprouts before they got sick. FDA traceback investigations indicated that several sprouters other than Sweetwater Farms produced the alfalfa sprouts these ill people ate. All of these sprouters, as well as Sweetwater Farms, used the same seed lot.

FDA tested samples of seeds from this lot and isolated Salmonella Cubana with the same DNA fingerprint of the Salmonella Cubana isolated in irrigation water from Sweetwater Farms. FDA contacted the seed supplier, who then called for the return of the contaminated seed lot from growers. The seed supplier is not named here because FDA is prohibited by law from releasing certain information about supply chains, which may constitute confidential commercial information. However, FDA has been able to confirm that all domestic sprouters who received contaminated seeds either returned or destroyed the seeds, and the shelf life of all sprouts grown from this seed lot has expired. Therefore, no sprouts from the contaminated seed lot are expected to be on the market.

sprout.santa.barf.xmasOn May 13, 2016, CDC reports that this outbreak appears to be over. FDA has provided the sprouters with information on reducing microbial food safety hazards for sprouted seeds and complying with new standards for growing, harvesting, packing, and holding of produce for human consumption under the Produce Safety Rule, which beings to go into effect for sprouters in January 2017 with additional time for small and very small operations. In particular, covered sprouters will now be required to comply with sprout-specific requirements such as treating seeds to reduce the presence of microorganisms of public health significance, testing the growing environment for Listeria as well as testing each production batch of spent sprout irrigation water or sprouts for E. coli O157:H7, Salmonella species and, under certain conditions, other pathogens. In addition, sprouters would be expected to comply with all other applicable requirements of the Produce Safety Rule, such as requirements related to worker health and hygiene, agricultural water and buildings, tools and equipment.

An updated table of raw sprout related outbreaks is available at: http://barfblog.com/wp-content/uploads/2016/04/Sprout-associated-outbreaks-4-27-16.xlsx

Everything you always wanted to know about sex (but were afraid to ask)

After a 10-year hiatus, I’m playing regular hockey again. And, to sharpen my goalie reflexes, I’m playing squash again (the two medical types I ran into today both asked, independently, what part of your body do you want to injure first?).  Better eyesight would help both.

850full-everything-you-always-wanted-to-know-about-sex-*-but-were-afraid-to-ask-screenshotBut what I really need is cardio, and I can’t imagine anything more boring than running. Bicycling is an occupational hazard in Brisbane, but I went for a ride today into town and back, because, driving in downtown Brisbane is just silly.

But I still need that cardio.

The U.S. Centers for Disease Control has a better solution: sex.

The percentage of U.S. adults who met the 2008 federal physical activity guidelines for Americans increased from 15.1% in 2000 to 21.5% in 2014. Most of the increase occurred from 2006 to 2010 for men and from 2007 to 2011 for women. During all years, men were more likely than women to meet the physical activity guidelines. In 2014, 25.5% of men and 17.7% of women met the guidelines.

*Based on self-reports of frequency and duration of light-moderate and vigorous leisure-time aerobic physical activity and frequency of leisure-time strengthening activity at levels consistent with federal physical activity guidelines for adults (http://health.gov/paguidelines/guidelines/).

†Estimates are based on household interviews of a sample of the non-institutionalized U.S. civilian population aged ≥18 years and are derived from the National Health Interview Survey sample adult component.

I love this exercise stuff.

QuickStats: Percentage of U.S. adults who met the 2008 federal physical activity guidelines for aerobic and strengthening activity,* by sex — National Health Interview Survey,† 2000–2014

Morbidity and Mortality Weekly Report; May 13, 2016; 65(18);485

http://www.cdc.gov/mmwr/volumes/65/wr/mm6518a9.htm?s_cid=mm6518a9_e

sex.aerobic.may.16

252 sick: Noro cruise docks in Maine

Federal health officials say the first cruise ship to dock in Portland, Maine, this season is under surveillance for norovirus.

chapman.vomitThe Centers for Disease Control and Prevention says 27 percent of the passengers aboard the Balmoral — operated by the Fred Olsen Cruises — have gotten sick since the cruise began April 16.

The ship and all aboard have since left Portland, according to police Lieutenant Robert Doherty.

The CDC reports that 252 of the 919 passengers on the Balmoral have fallen ill, as well as eight crew members.

Fred Olsen Cruises did not immediately return a call seeking comment.

So far this year, there have been 10 outbreaks of norovirus on cruise ships, according to the CDC.

Really? CDC campaign reminds docs, nurses that “Clean Hands Count”

Today (yesterday), World Hand Hygiene Day, the U.S. Centers for Disease Control is launching the new “Clean Hands Count” campaign urging healthcare professionals, patients, and patients’ loved ones to prevent healthcare-associated infections by keeping their hands clean.

handwash_south_park(2)Although hand contact is known to be a major way germs spread in medical facilities, studies show that some healthcare professionals don’t follow CDC hand hygiene recommendations. On average, healthcare professionals clean their hands less than half of the times they should.

“Patients depend on their medical team to help them get well, and the first step is making sure healthcare professionals aren’t exposing them to new infections,” said CDC Director Tom Frieden, M.D., M.P.H. “Clean hands really do count and in some cases can be a matter of life and death.”

Part of the new campaign promotes healthcare provider adherence to CDC hand hygiene recommendations by addressing some of the myths and misperceptions about hand hygiene. For example, some people wrongly believe that using alcohol-based hand sanitizer contributes to antibiotic resistance and that it is more damaging to hands than washing with soap and water. Alcohol-based hand sanitizer kills germs quickly and in a different way than antibiotics, so it does not cause antibiotic resistance, and it causes less skin irritation than frequent use of soap and water.

The initiative also encourages patients and their loved ones to ask their healthcare team to clean their hands if they don’t see them do so before providing care.

“We know that patients can feel hesitant to speak up, but they are important members of the health care team and should expect clean hands from providers,” said Arjun Srinivasan, M.D., CDC’s associate director for healthcare-associated infection prevention programs. “We know that healthcare providers want the best for their patients, so we want to remind them that the simple step of cleaning their hands protects their patients.”

That’s right, it’s up to the dying and preoccupied family to ensure medical types wash their damn hands.

visit: www.cdc.gov/handhygiene.

4 dead, 33 ill from Listeria in lettuce: Of course Dole knew

Beginning August 2, 1998, over 80 Americans fell ill, 15 were killed, and at least six women miscarried due to listerosis. On Dec. 19, 1998, the outbreak strain was found in an open package of hot dogs partially consumed by a victim. The manufacturer of the hot dogs, Sara Lee subsidiary Bil Mar Foods, Inc., quickly issued a recall of what would become 35 million pounds of hot dogs and other packaged meats produced at the company’s only plant in Michigan. By Christmas, testing of unopened packages of hot dogs from Bil Mar detected the same genetically unique L. monocytegenes bacteria, and production at the plant was halted.

four.monkeysA decade later, the deaths of two Toronto nursing home residents in the summer of 2008 were attributed to listeriosis infections. These illnesses eventually prompted an August 17, 2008 advisory to consumers by the Canadian Food Inspection Agency (CFIA) and Maple Leaf Foods, Inc. to avoid serving or consuming certain brands of deli meat as the products could be contaminated with L. monocytogenes. When genetic testing determined a match between contaminated meat products and listeriosis patients, all products manufactured at a Toronto Maple Leaf Foods plant were recalled and the facility closed. An investigation by the company determined that organic material trapped deep inside the plant’s meat slicing equipment harbored L. monocytogenes, despite routine sanitization that met specifications of the equipment manufacturer. In total, 57 cases of listeriosis as well as 22 deaths were definitively connected to the consumption of the plant’s contaminated deli meats.

As far back as 2013, Blue Bell ice cream was finding Listeria in places like floors, catwalks and cleaning tubs. Blue Bell had positive listeria findings from at least 11 swabs of plant surfaces between March 2013 and November 2014. Each time, it vigorously cleaned the area, and moved on without testing the equipment that touches the ice cream. At the same time, Blue Bell had problems with the layout of its plants, with condensation dripping all over the place. After federal officials linked an illness outbreak to Blue Bell in 2015, they tested the company’s food processing equipment and found LM. Three people died and 10 were sickened.

In all three Listeria outbreaks, the companies had data that showed an increase in Listeria-positive samples.

But rather than pay attention, they ignored the safety.

Those who study engineering failures –the BP oil well in the Gulf, the space shuttle Challenger, Bhopal – say the same thing: human behavior can mess things up.

listeria4In most cases, an attitude prevails that is, “things didn’t go bad yesterday, so the chances are, things won’t go bad today.”

And those in charge begin to ignore the safety systems.

Or hope the problem will just go away.

Kellogg’s was taking Salmonella-contaminated peanut paste based on paperwork in 2009? Pay attention, Nestle did.

In 2009, the operator of a yakiniku barbecue restaurant chain linked to four deaths and 70 illnesses from E. coli O111 in raw beef in Japan admitted it had not tested raw meat served at its outlets for bacteria, as required by the health ministry.

“We’d never had a positive result [from a bacteria test], not once. So we assumed our meat would always be bacteria-free.”

Chipotle Mexican Grill was aware of a norovirus outbreak among people who had eaten in one of its restaurants in Simi Valley, Calif., but did not tell public health officials there until after it had closed and cleaned the restaurant. More than 200 people were sickened.

So it’s no surprise that officials at Dole’s Springfield, Ohio plant, which bags lettuce and other supposedly healthy meals, knew about Listeria in its facility for 18 months before shutting down and issuing a recall.

Four people have died and 33 sickened in Canada and the U.S. from Listeria in the Dole products.

Kudos to Bill Marler and his Food Safety News, as well as Food Poisoning Bulletin, for filing the Freedom of Information request on U.S. Food and Drug Administration inspections at the Dole plant and putting together a preliminary picture of who knew what when.

Inspection reports (483) obtained by Food Safety News revealed the timeline of positive Listeria results and inaction. Dole Fresh Vegetables Inc. finally suspended production at its salad plant in Springfield, OH, on Jan. 21 this year after a random test by state officials showed a bagged salad contained Listeria monocytogenes.

Dole restarted production at the plant in Springfield, OH, on April 21. Company officials won’t say what was done to clean the plant or how they plan to prevent future contamination there.

powell_soli_AUG2Inspectors from FDA checked the production plant three times in January and twice in February after genetic fingerprinting showed the undeniable link between the sick people and salads from the facility. They collected swab samples, unfinished product samples, testing records and other documents and information.

According to the FDA’s inspection reports, in July 2014 Dole did swab tests of surfaces in the Springfield plant. The tests returned positive results for Listeria, but the facility kept producing salads, shipping them to dozens of states and at least five Canadian provinces.

At least five more times in 2014 and three times in late 2015 Dole’s internal tests showed Listeria contamination, but Dole kept the salad lines kept rolling until January this year.

The FDA inspection report states that Dole’s vice president for quality assurance and food safety, as well as the company’s quality assurance manager, were aware internal tests on Jan. 5 and 7 this year showed Listeria on equipment and other surfaces in the plant. But Dole continued to produce and ship salads.

The plant kept operating until Jan. 21. The following day Dole posted a recall notice with the FDA and the Canadian Food Inspection Agency (CFIA) for salads produced at the Springfield facility. Dole branded salads and house brands for Walmart, Kroger, Loblaws and Aldi were included in the recall.

Marler, a prominent food safety lawyer who represents one of the victims in a lawsuit against Dole told Stephanie Strom of the N.Y. Times, “If the government inspectors hadn’t showed up, who knows when or if they were going to tell anyone.”

“They’d been having positive tests for listeria for some time,” said William Goldfield, a spokesman for Dole. “We understand these recent news reports may raise questions among our consumers and customers. They should be assured, however, that we have worked in conjunction with the F.D.A. to address those observations and ensure that Dole products are safe.”

Lauren Sucher, a spokeswoman at the F.D.A., said that companies must notify the agency when they find a food has a “reasonable probability” of causing serious adverse health consequences.

But, Ms. Sucher said, not all strains of listeria cause disease. “When listeria is found in the manufacturing environment, rather than on the food itself, it is not uncommon for a company to immediately take corrective action rather than test further to see if the strain of listeria poses a threat,” she wrote in an email.

Food companies that find listeria during periodic testing are not required to run further tests to determine whether the pathogen is of a toxic variety.

In Dole’s case, it was swabbing various locations in its plant in Springfield, Ohio, not necessarily testing the finished products, according to the F.D.A. inspection. Rather, Canadian public health officials investigating an outbreak of listeriosis dating to summer 2015, tested bagged Dole salads and found four varieties that were contaminated.

CDC: Faster tests, but lousy tracking

Changes in the tests that diagnose foodborne illness are helping identify infections faster but could soon pose challenges to finding outbreaks and monitoring progress toward preventing foodborne disease, according to a report published today in CDC’s Morbidity and Mortality Week Report.

vomit.2Culture-independent diagnostic tests (CIDTs) help doctors diagnose infections quickly because they provide results in hours instead of the days needed for traditional culture methods, which require growing bacteria to determine the cause of illness. But without a bacterial culture, public health officials cannot get the detailed information about the bacteria needed to help find outbreaks, check for antibiotic resistance, and track foodborne disease trends.

In 2015, the percentage of foodborne infections diagnosed only by CIDT was about double compared with the percentage in 2012-2014.

“Foodborne infections continue to be an important public health problem in the United States,” said Robert Tauxe, M.D., M.P.H, director of CDC’s Division of Foodborne, Waterborne and Environmental Diseases. “We are working with partners to make sure we still get important information about harmful bacteria despite the increasing use of diagnostic tests that don’t require a culture.”

The increased use of CIDT could affect public health officials’ ability to monitor trends and detect outbreaks. In the short term, clinical laboratories should work with their public health laboratories to make sure a culture is done whenever a CIDT indicates that someone with diarrheal illness has a bacterial infection. For a long-term solution, CDC is working with partners to develop advanced testing methods that, without culture, will give health care providers information to diagnose illness and also give the detailed information that public health officials need to detect and investigate outbreaks.

Limited progress in reducing foodborne illness

The report included the most recent data from CDC’s Foodborne Diseases Active Surveillance Network, or FoodNet. It summarizes preliminary 2015 data on nine germs spread commonly through food. Overall, progress in reducing rates of foodborne illnesses has been limited since 2012, according to the report. The most frequent causes of infection in 2015 were Salmonella and Campylobacter, which is consistent with previous years.

Other key findings from the FoodNet report include:

The incidence of Salmonella Typhimurium infection, often linked to poultry and beef, decreased 15 percent from 2012-2014 levels.

This decline may be due in part to tighter regulatory standards and vaccination of chicken flocks against Salmonella.

The incidence of some infections increased:

Reported Cryptosporidium infections increased 57 percent since 2012-2014, likely due to increased testing for this pathogen.

Reported non-O157 Shiga toxin-producing Escherichia coli (STEC) infections increased 40 percent since 2012-2014. Quicker and easier testing likely accounted for some or all of this increase.

FoodNet has been monitoring illness trends since 1996. FoodNet provides a foundation for food safety policy and prevention efforts because surveillance data can tell us where prevention efforts are needed to reduce foodborne illnesses.

CDC is working with federal, state, and local partners, and the food industry to improve food safety. New regulations and continuing industry efforts are focusing on challenging areas. USDA has made improvements in its poultry inspection and testing models and has tightened standards for both Salmonella and Campylobacter in poultry.

“In 2013, we launched a series of targeted efforts to address Salmonella in meat and poultry products, known as the Salmonella Action Plan, and recent data show that since then the incidence of Salmonella Typhimurium infection has dropped by 15 percent,” said USDA Deputy Undersecretary for Food Safety, Al Almanza. “However our work is not done. The newly published performance standards for poultry parts will lead to further Salmonella reductions and fewer foodborne illnesses.”

In 2015, FDA published new rules to improve the safety of the food supply including produce, processed foods, and imported foods.

Dr. Kathleen Gensheimer, MD, MPH, director of the FDA’s Coordinated Outbreak Response and Evaluation team and Chief Medical Officer, Foods and Veterinary Medicine Program, said, “We want to respond quickly to foodborne illness, but our true goal is to move forward with preventive measures that will be implemented from farm to table. In addition to collaboration with other government agencies at the local, state and federal level, the rules we are implementing under the FDA Food Safety Modernization Act will help the food industry minimize the risk of contamination to our food supply.”

For more information on avoiding illnesses from food, please visit www.foodsafety.gov.

About FoodNet

FoodNet collects information to track rates and determine trends in laboratory-confirmed illnesses caused by nine germs transmitted commonly by food: Campylobacter, Cryptosporidium, Cyclospora, Listeria, Salmonella, Shiga toxin-producing O157 and non-O157, Shigella, Vibrio, and Yersinia. Annual data are compared with data from the previous three years (2012-2014). Since 2010, FoodNet has been tracking the increasing use of CIDTs used by clinical laboratories for diagnosis of bacterial enteric infection.

FoodNet is a collaboration among CDC, 10 state health departments, the USDA’s Food Safety and Inspection Service, and the FDA. FoodNet covers 48 million people, encompassing about 15 percent of the United States population. The sites are the states of Connecticut, Georgia, Maryland, Minnesota, New Mexico, Oregon, and Tennessee, and selected counties in California, Colorado, and New York.

 

FoodNet: An electronic success story

I started the Food Safety Network (FSnet) in Jan. 1993.

hqdefaultLots of people have stolen or borrowed the idea since, but they don’t have a good origin story.

Posers.

They’re just copycats.

I was a lost genetics graduate student/journalist who happened along to Mansel who let me do what I wanted to do to get a PhD.

And I am forever grateful to him for that.

Back then, the U.S. Centers for Disease Control Morbidity and Mortality Weekly would take about six months to arrive by mail.

I started doing things electronically, because I had e-mail at the University of Waterloo previously.

It would be another three years until Al Gore invented the Internet.

Now, it’s been 20 years since the inauguration of FoodNet.

That the CDC annual data has become so common and is no longer worthy of mention in what remains of the media is an outstanding scientific and policy accomplishment.

The heros of wars – as we gear up for ANZAC Day here in Australia – are usually the grunts and the public folks who toil in obscurity.

I retrieved my grandfather’s medals from WW1 and II when we gathered our final belongings from Kansas last month, not because I thought he was a great person – he wasn’t – but he served, and so much of public health is about serving.

hqdefault-1Out of all my professoring moments, the ones that stick with me are positively influencing students – who knew Chapman would stand out, I thought he was Stork in Animal House when I met him – and the folks who serve: public health, military, whatever.

I don’t want to deal with your bureaucracy, but I can respect what you do.

It’s all about service.

To evaluate progress toward prevention of enteric and foodborne illnesses in the United States, the Foodborne Diseases Active Surveillance Network (FoodNet) monitors the incidence of laboratory-confirmed infections caused by nine pathogens transmitted commonly through food in 10 U.S. sites.* This report summarizes preliminary 2015 data and describes trends since 2012.

In 2015, FoodNet reported 20,107 confirmed cases (defined as culture-confirmed bacterial infections and laboratory-confirmed parasitic infections), 4,531 hospitalizations, and 77 deaths. FoodNet also received reports of 3,112 positive culture-independent diagnostic tests (CIDTs) without culture-confirmation, a number that has markedly increased since 2012 (1). Diagnostic testing practices for enteric pathogens are rapidly moving away from culture-based methods. The continued shift from culture-based methods to CIDTs that do not produce the isolates needed to distinguish between strains and subtypes affects the interpretation of public health surveillance data and ability to monitor progress toward prevention efforts. Expanded case definitions and strategies for obtaining bacterial isolates are crucial during this transition period.

FoodNet is a collaboration among CDC, 10 state health departments, the U.S. Department of Agriculture’s Food Safety and Inspection Service (USDA-FSIS), and the Food and Drug Administration (FDA).

FoodNet conducts active, population-based surveillance for laboratory-confirmed infections caused by Campylobacter, Cryptosporidium, Cyclospora, Listeria, Salmonella, Shiga toxin–producing Escherichia coli (STEC), Shigella, Vibrio, and Yersinia in 10 sites covering approximately 15% of the U.S. population (an estimated 49 million persons in 2014). Confirmed infections are defined as culture-confirmed bacterial infections and laboratory-confirmed parasitic infections (e.g., identified by enzyme immunoassay). Positive CIDT results are defined as the detection of antigen or nucleic acid sequences of the pathogen, or for STEC, Shiga toxin or the genes that encode a Shiga toxin, in a stool specimen or enrichment broth using a CIDT.† Positive CIDT results that were confirmed by culture are included only among the confirmed infections. For this analysis, the term “positive CIDT report” refers to positive CIDT results that were not confirmed by culture (either because the specimen was not cultured at the clinical or public health laboratory or because a culture did not yield the pathogen). Hospitalizations occurring within 7 days of specimen collection are recorded. The patient’s vital status at hospital discharge, or 7 days after specimen collection if the patient was not hospitalized, is also captured. Hospitalizations and deaths that occur within 7 days of specimen collection are attributed to the infection.

Incidence of confirmed infections is reported for all FoodNet pathogens and calculated by dividing the number of confirmed infections in 2015 by U.S. Census estimates of the surveillance area population for 2014. A second incidence measurement, calculated by adding positive CIDT reports to confirmed infections, is also reported for Campylobacter, Salmonella, Shigella, and STEC.§ A negative binomial model with 95% confidence intervals (CIs) was used to estimate changes in incidence of infections in 2015 compared with 2012–2014. To describe changes in testing practices, percentage difference in number of positive CIDT reports was calculated for 2015 compared with 2012–2014, by pathogen.

Surveillance for physician-diagnosed postdiarrheal hemolytic uremic syndrome (HUS), a complication of STEC infection, is conducted through a network of nephrologists and infection preventionists and by hospital discharge data review. This report includes HUS data for persons aged <18 years for 2014, the most recent year for which data are available, and compares 2014 incidence with 2011–2013 incidence.

Cases of Infection, Incidence, and Trends

In 2015, FoodNet identified 20,107 confirmed cases of infection, 4,531 hospitalizations, and 77 deaths (Table 1). The number and incidence of confirmed infections per 100,000 population were reported for Salmonella (n = 7,728 [incidence = 15.89]), Campylobacter (6,309 [12.97]), Shigella (2,688 [5.53]), Cryptosporidium (1,612 [3.31]), STEC non-O157 (796 [1.64]), STEC O157 (463 [0.95]), Vibrio (192 [0.39]), Yersinia (139 [0.29]), Listeria (116 [0.24]), and Cyclospora (64 [0.13]). Among confirmed infections, the vast majority were diagnosed only by culture; the exception is STEC, for which most were identified by a CIDT (Table 2).

Among 6,827 (88%) serotyped Salmonella isolates, the top serotypes were Enteritidis, 1,358 (20%); Newport, 816 (12%); and Typhimurium, 739 (11%). Among 175 (91%) speciated Vibrio isolates, 113 (65%) were V. parahaemolyticus, 27 (15%) were V. alginolyticus, and 12 (7%) were V. vulnificus. Among 606 (76%) serogrouped STEC non-O157 isolates, the top serogroups were O26 (32%), O103 (27%), and O111 (18%).

Compared with incidence in 2012–2014, the 2015 incidence of confirmed infections was significantly higher for STEC non-O157 (40% increase; CI = 21%–62%), and Cryptosporidium (57% increase; CI = 20%–106%). No significant changes were observed in 2015 for other pathogens compared with the previous 3-year averages. Among the top three most commonly identified Salmonella serotypes, the incidence in 2015 compared with 2012–2014 was significantly lower for Typhimurium (15% decrease; CI = 4%–25%) and unchanged for Enteritidis and Newport.

FoodNet identified 55 cases of postdiarrheal HUS in children (0.50 cases per 100,000) in 2014; 30 (55%) occurred among children aged <5 years (1.01 cases per 100,000). Compared with 2011–2013, the incidence was significantly lower for all children (27% decrease; CI = 1%–46%) but no change for children aged <5 years was observed.

FoodNet also received 3,112 positive CIDT reports. The number of positive CIDT reports, by pathogen, were Campylobacter (2,021), Shigella (454), Salmonella (361), and STEC (254). These numbers represent an increase in positive CIDT reports in 2015 of 92% for Campylobacter, 284% for Shigella, 247% for Salmonella, and 120% for STEC, when compared with the 2012–2014 averages; the overall increase in CIDT reports for these four pathogens was 122%. Adding positive CIDT reports to confirmed cases resulted in the following incidence rates per 100,000 population: 17.12 for Campylobacter, 16.63 for Salmonella, 6.46 for Shigella, and 3.12 for STEC (Figure). Compared with 2012–2014, the 2015 incidence of confirmed infections plus positive CIDT reports was significantly higher for STEC but not for any other pathogen.

Discussion

Use of CIDTs is finding cases that were not being previously diagnosed. Among confirmed cases, the incidence of Cryptosporidium and STEC non-O157 infections in 2015 was significantly higher than the average for the previous 3 years. The increase in incidence of STEC non-O157 infections is attributable, in part or in full, to increases in diagnostic testing (2). The proportion of laboratories testing for STEC non-O157 increased to 74% in 2015, compared with 55% in 2012 (FoodNet, unpublished data). The increase in Cryptosporidium follows the pattern observed in national data since 2005 and is likely also driven by increases in diagnostic testing (3,4).

The incidence of Salmonella serotype Typhimurium infections continues to decline, and it has dropped to the third most commonly reported serotype. The use of a live attenuated Typhimurium vaccine in poultry (5), in addition to more stringent performance standards for Salmonella contamination of poultry carcasses (6) might have contributed to this decline. The significant decrease in HUS incidence in 2014 compared with the preceding 3 years (2011–2013) mirrors significant decreases in STEC O157 incidence observed during the same period (7). Efforts are still needed to decrease contamination of produce, beef, and other foods to achieve the Healthy People 2020 goal for STEC O157 of 0.6 cases per 100,000 population.¶

The percentage of infections diagnosed only by CIDTs markedly increased in 2015. Diagnostic testing practices for enteric pathogens are rapidly moving away from culture-based methods, and the impact of this change varies by pathogen. Although CIDTs are still most commonly being used for Campylobacter and STEC, the highest percentage increase in use compared with the previous 3-year average was observed for Shigella and Salmonella, most likely due to laboratories using the newly available DNA-based syndrome panels (FoodNet, unpublished data)

In FoodNet, current methods to assess trends in the incidence of illness caused by bacterial pathogens are based only on culture-confirmed infections. The ability to assess and interpret change is impeded as the number of positive CIDT reports continues to rise because of important limitations in the understanding of CIDTs and possible changes in clinician and laboratory practices surrounding them. For example, analyses need to consider the likelihood of false-positive CIDTs and of CIDTs that are more sensitive than routine culture methods; such characteristics vary among CIDTs. The availability of CIDTs might also increase testing for some pathogens. Surveillance systems need to adapt to these changes by expanding case definitions to include positive CIDT reports. Isolates are still needed for antimicrobial susceptibility testing, serotyping, subtyping, and whole genome sequencing (1); these data are critical for monitoring trends, detecting clusters of illness, and investigating outbreaks. For Salmonella, with serotypes diverse in reservoirs and sources, the inability to distinguish serotypes will prevent tracking of important changes in incidence by serotype, and markedly limit detection and investigation of outbreaks. For STEC, because identification of serogroups requires culture, it is not known which STEC-positive CIDT reports represent O157 versus non-O157.

The findings in this report are subject to at least five limitations. First, increasing use of CIDTs by clinical laboratories might affect the number of culture-confirmed infections reported; use of CIDTs might result in an increase (as seen for STEC non-O157 infections) or decrease (as fewer cases might be diagnosed by traditional methods) in reported incidence. Second, the sensitivity and specificity of CIDTs vary by test type, brand, and other factors; some CIDT reports could be false positives (1). Third, health care–seeking behaviors, access to health services, and other characteristics of the population in the surveillance area might affect the generalizability of the findings. Fourth, the proportion of illnesses transmitted by non-food routes differs by pathogen; data provided in this report are not limited to infections from food.** Finally, changes in incidence between periods can reflect year-to-year variation during those periods rather than sustained trends, and the number of infections and patterns observed might change as final data become available.

The use of CIDTs in clinical laboratories has many advantages. Illnesses can be diagnosed much faster than when culture is required. Also, some CIDTs are becoming available to detect infections caused by pathogens not routinely sought by standard laboratory methods. One of these is enterotoxigenic E. coli, an important cause of travelers’ diarrhea (8).

More work is needed to extend the benefits of CIDT to the public health sector. During this initial period when clinical laboratories are transitioning to the use of CIDTs, reflex culturing†† of specimens with positive CIDT reports should be considered for bacterial pathogens to obtain isolates needed for public health practice. For the future, expedited research and development are needed to create methods to detect the genetic sequences of pathogens directly and rapidly from stool specimens, which has the potential to benefit both clinical and public health practice, because subtype, resistance profile, and other features can be obtained from the genetic sequence.

Infection with Pathogens Transmitted Commonly Through Food and the Effect of Increasing Use of Culture-Independent Diagnostic Tests on Surveillance — Foodborne Diseases Active Surveillance Network, 10 U.S. Sites, 2012–2015

Weekly / April 15, 2016 / 65(14);368–371

Jennifer Y. Huang, MPH; Olga L. Henao, PhD; Patricia M. Griffin, MD; Duc J. Vugia, MD; Alicia B. Cronquist, MPH; Sharon Hurd, MPH; Melissa Tobin-D’Angelo, MD; Patricia Ryan, MD; Kirk Smith, DVM; Sarah Lathrop, PhD; Shelley Zansky, PhD; Paul R. Cieslak, MD; John Dunn, DVM; Kristin G. Holt, DVM; Beverly J. Wolpert, PhD1; Mary E. Patrick, MPH

http://www.cdc.gov/mmwr/volumes/65/wr/mm6514a2.htm?s_cid=mm6514a2_x