I miss Bill Keene: Museum catalogues food poisoning in Oregon, elsewhere

Lynne Terry of The Oregonian writes that an unusual museum stocked with food packages including everything from ground beef to alfalfa sprouts has gone live on the internet.

bill.keene.portland
The Outbreak Museum, physically located in Portland, showcases the culprits in food poisoning cases.

The museum was the brainchild of Oregon’s star epidemiologist William Keene, who died suddenly at the end of 2013. He cracked dozens, if not hundreds of outbreaks that sickened people from Portland, Oregon to Portland, Maine with food tainted by E. coli, salmonella, norovirus, campylobacter and listeria. He worked with manufacturers and health officials alike with one goal in mind: prevent consumers from getting sick.

He collected packages of tainted items in outbreaks he worked on and other public health officials sent him containers from their investigations. The museum includes items from the 1999 salmonella outbreak traced to alfalfa sprouts, the 2006 E. coli outbreak involving spinach and the 2012 E. coli outbreak traced to raw milk.

Dr. Paul Cieslak, medical director of Oregon’s immunization program, said the museum is designed to educate younger epidemiologists about the significance of past outbreaks and how they influenced public health decisions and epidemiological investigations.

“It’s mainly meant to be instructure,” Cieslak said.

The items are open to public health students and school groups by appointment. The website includes more extensive information on 12 outbreaks.

I believe the epidemiologists: Boise restaurant linked to Salmonella cases

Last week I spent some time with an old friend who owns a funeral home. Fifteen years ago we spent our time and extra money in the local pub drinking pints and talking trash. As we’ve gotten older our taste has changed; we discussed our chosen professions over a bottle of wine.

As we chatted food safety and death he wanted to know how the disease detectives connected the dots in an outbreak. I gave him a rudimentary explanation of PFGE, genome sequencing, Pulsenet and told him about Bill Keene’s contribution to foodborne epidemiology. He was genuinely interested in learning about how epi folks do their magic, or it may have been the wine.101821776

Here’s today’s example of a cluster of illnesses linked to a restaurant, without a smoking gun, that is garnering further investigation (via the Idaho Statesman).

Five people have reported getting sick from Salmonella poisoning since late February after eating at a Boise restaurant, according to the Central District Health Department.

The agency did not publicly name the eatery Monday, but the owner of Pho Tam on North Orchard Street confirmed to the Idaho Statesman that her Vietnamese restaurant is the one in question.

“I don’t know what happened,” owner Long Doan said. “We try to be careful.”

The most recent sickness took place in mid-March, but wasn’t reported to health officials until Thursday, Health Department spokeswoman Christine Myron said.

Health inspectors last week tested food at the restaurant and did not find any traces of Salmonella or other harmful bacteria, Myron said.

“The cultures that they grew did not come back with any Salmonella, so they’ve not determined a definite source for the Salmonella,” Myron said. “We don’t know exactly how it may have gotten into the food at this point.”

I trust the epi folks.

 

Problems public health investigators face: It’s a tough job (but we love ya for it)

In Ontario, Canada (that’s in Canada), enteric case investigators perform a number of functions when conducting telephone interviews including providing health education, collecting data for regulatory purposes ultimately to prevent further illness, enforcement, illness source attribution and outbreak detection. Information collected must be of high quality as it may be used to inform decisions about public health actions that could have significant consequences such as excluding a person from work, recalling a food item that is deemed to be a health hazard, and/or litigations. The purpose of this study was to describe, from the perspectives of expert investigators, barriers experienced and the techniques used to overcome these barriers during investigation of enteric disease cases (that’s Sider, right, exactly as shown).

doug.siderMethods

Twenty eight expert enteric investigators participated in one of four focus groups via teleconference. Expert investigators were identified based on their ability to 1) consistently obtain high quality data from cases 2) achieve a high rate of completion of case investigation questionnaires, 3) identify the most likely source of the disease-causing agent, and 4) identify any possible links between cases. Qualitative data analysis was used to identify themes pertaining to successful techniques used and barriers experienced in interviewing enteric cases.

Results

Numerous barriers and strategies were identified under the following categories: case investigation preparation and case communication, establishing rapport, source identification, education to prevent disease transmission, exclusion, and linking cases. Unique challenges experienced by interviewers were how to collect accurate exposure data and educate cases in the face of misconceptions about enteric illness, as well as how to address tensions created by their enforcement role. Various strategies were used by interviewers to build rapport and to enhance the quality of data collected.

Conclusions

To our knowledge, this is the first study to examine the perspectives of expert enteric disease case investigators on successful interview techniques and barriers experienced during enteric case investigation. A number of recommendations could improve the process of enteric case investigation in the Ontario context which include formal training and development of resource materials pertaining to interviewing, standardized interviewing tools, strategies to address cultural and language barriers, and the implementation of the single interviewer approach.

A focus group study of enteric disease case investigation: successful techniques utilized and barriers experienced from the perspective of expert disease investigators

BMC Public Health, Disease epidemiology- infectious, Volume 14, doi:10.1186/1471-2458-14-1302

Stanley Ing, Christina Lee, Dean Middleton, Rachel D Savage, Stephen Moore and Doug Sider

http://www.biomedcentral.com/1471-2458/14/1302

To the importer who says there’s no proven link, I say, epidemiology still works: 18 confirmed sick with hep A from frozen Chinese berries

As the number of confirmed hepatitis A cases in Australia from frozen berries grown in China rose to 18 over the weekend, as political rhetoric about imports and local food reached staggering new heights, the company continued to insist there’s no firm link between a national hepatitis A outbreak and its recalled berries.

epidemiology.WATER PUMP3_Page_4The company says its imported Chinese berries were recalled on health department advice despite a lack of proof from accredited laboratories of a link to the hepatitis A virus (HAV).

“At this point, we have not been provided any remaining consumer product to test from the 13 confirmed HAV cases to clinically verify there is indeed a link with the Nanna’s Mixed Berries,” managing director and chief executive Stephen Chaur said in a statement on Friday.

Mr Chaur said the company had rigorous testing that went beyond the Australian standards requirement that five per cent of imported fruit containers be tested.

“Patties Foods’ documented test regime is among the highest, testing 20 per cent of all the containers when they arrive in Australia,” he said.

But Mr Chaur said sample testing for microbial and viral markers had been increased to 100 per cent of imported frozen berries from all countries.

The company has checked quality control testing documents back to June 2014 and says they’re satisfied no biological indicators outside Australian guidelines have been detected.

Great. Prove it and make the data public.

Importance of epi: Outbreak of diarrheal illness caused by Shigella flexneri — American Samoa, May–June 2014

The U.S. Centers for Disease Control reports that on May 9, 2014, a physician at hospital A in American Samoa noticed an abnormally high number of children presenting to the emergency department with bloody diarrhea.

American Samoa.schoolBased on preliminary testing of stool specimens, Entamoeba histolytica infection was suspected as a possible cause. Shigella was also suspected in a subset of samples. On May 22, the American Samoa Department of Health requested assistance from CDC with the outbreak investigation. The goals of the investigation were to establish the presence of an outbreak, characterize its epidemiology and etiology, and recommend control measures. The CDC field team reviewed the emergency department log book for cases of diarrheal illness during April 15–June 13, 2014. During this period, 280 cases of diarrheal illness were recorded, with a peak occurring on May 10. Twice as many cases occurred during this period in 2014 compared with the same period in 2011, the most recent year for which comparable surveillance data were available. Cases were widely distributed across the island. The highest number of cases occurred in children aged 0–9 years. Across age groups, cases were similarly distributed among males and females. These patterns are not consistent with the epidemiology of disease caused by E. histolytica, which tends to cause more cases in males of all ages.

Hypothesis-generating interviews with families of 13 patients did not reveal any common water, food, sewage, or event exposures. Eight participants reported having ill household contacts, with family contacts often becoming ill within 1–3 days after the participant’s illness onset. Six stool specimens were sent to CDC. All were negative for ameba, including E. histolytica, by multiple laboratory methods. All six specimens were also negative for Cryptosporidium and Giardia by a polymerase chain reaction test. However, an invasion plasmid antigen H (ipaH) gene sequence, a genetic marker of Shigella, was identified in four specimens. Additionally, seven Shigella isolates sent to the Hawaii Department of Health and CDC were identified as Shigella flexneri serotype 7 (proposed; also referred to as provisional 88-893 or 1c), and five shared an indistinguishable pulsed-field gel electrophoresis pattern.

american.samoa.peopleShigella causes an estimated 500,000 cases of shigellosis per year in the United States (1). Most persons infected with Shigella develop diarrhea (sometimes bloody), fever, and stomach cramps 1–2 days after they are exposed to the bacteria. The illness usually resolves in 5–7 days. Careful and frequent hand washing and strict adherence to standard food and water safety precautions are the best defense against shigellosis (2).

Together, epidemiologic and laboratory data suggest this was a shigellosis outbreak with person-to-person transmission. This investigation highlights the importance of building epidemiologic and laboratory capacity for enteric illnesses and enhancing basic hand hygiene and prevention strategies in U.S. territories.

Lesson in epidemiology (not): Wisconsin farmer says raw milk may not have made Durand football team ill

Now that the Reed ranch has been named and shamed as the source of the raw milk linked to at least 38 illnesses of Campylobacter jejuni related to players and staff of the Durand High School football team, the owner is speaking out.

raw.milk.death.1917Diana Reed, whose farm provided the milk said, “Some people got sick who did not drink the milk,” she said Saturday.

State health officials also tested manure of the cows at the Reed ranch and concluded some of the cows contained the strain of Campylobacter that sickened the students.

On Friday, state health officials identified the Reed farm as the source of the milk following an open records inquiry by the Milwaukee Journal Sentinel.

But Reed said there could have been other sources of the bug.

“I discussed it with the epidemiologist in Madison. He gave me some statistics — 56 people ate chicken, 38 got sick; 43 people chose to drink milk and 33 got sick,” she said. “They interviewed everyone who was there.”

That leaves five people who did not drink milk, but who still had Campylobacter.

Epidemiology, just trying to do this jigsaw puzzle: Outbreak of E. coli O157:H7 associated with lettuce served at fast food chains in the Maritimes and Ontario, Canada, Dec 2012

Background: Identification and control of multi-jurisdictional foodborne illness outbreaks can be complex because of their multidisciplinary nature and the number of investigative partners involved.

spongebob.oil.colbert.may3.10Objective: To describe the multi-jurisdictional outbreak response to an E. coli O157:H7 outbreak in Canada that highlights the importance of early notification and collaboration and the value of centralized interviewing.

Methods: Investigators from local, provincial and federal jurisdictions, using a national outbreak response protocol to clarify roles and responsibilities and facilitate collaboration, conducted a rapid investigation that included centralized re-interview of cases, descriptive methods, binomial probability, and traceback findings to identify the source of the outbreak.

Results: There were 31 laboratory confirmed cases identified in New Brunswick, Nova Scotia, and Ontario. Thirteen cases (42%) were hospitalized and one case (3%) developed hemolytic uremic syndrome; there were no deaths. Due to early notification a coordinated investigation was initiated before laboratory subtyping was available. Re-interview of cases identified 10 cases who had not initially reported exposure to the source of the outbreak. Less than one week after the Outbreak Investigation Coordinating Committee was formed, consumption of shredded lettuce from a fast food chain was identified as the likely source of the illnesses and the implicated importer/processor initiated a precautionary recall the same day.

Conclusion: This outbreak investigation highlights the importance of early notification, prompt re-interviewing and collaboration to rapidly identify the source of an outbreak.

Canada Communicable Disease Report CCDR

Tataryn J, Morton V, Cutler J, McDonald L, Whitfield Y, Billard B, Gad RR and Hexemer A

http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/14vol40/dr-rm40s-1/dr-rm40s-1-ecoli-eng.php

Use of social media to identify foodborne illness — Chicago, Illinois, 2013–2014

An estimated 55 million to 105 million persons in the United States experience acute gastroenteritis caused by foodborne illness each year, resulting in costs of $2–$4 billion annually (1).

social.media.likeMany persons do not seek treatment, resulting in underreporting of the actual number of cases and cost of the illnesses (2). To prevent foodborne illness, local health departments nationwide license and inspect restaurants (3) and track and respond to foodborne illness complaints. New technology might allow health departments to engage with the public to improve foodborne illness surveillance (4). For example, the New York City Department of Health and Mental Hygiene examined restaurant reviews from an online review website to identify foodborne illness complaints (5). On March 23, 2013, the Chicago Department of Public Health (CDPH) and its civic partners launched FoodBorne Chicago (6), a website (https://www.foodbornechicago.orgExternal Web Site Icon) aimed at improving food safety in Chicago by identifying and responding to complaints on Twitter about possible foodborne illnesses. In 10 months, project staff members responded to 270 Twitter messages (tweets) and provided links to the FoodBorne Chicago complaint form.

A total of 193 complaints of possible foodborne illness were submitted through FoodBorne Chicago, and 133 restaurants in the city were inspected. Inspection reports indicated 21 (15.8%) restaurants failed inspection, and 33 (24.8%) passed with conditions indicating critical or serious violations. Eight tweets and 19 complaint forms to FoodBorne Chicago described seeking medical treatment. Collaboration between public health professionals and the public via social media might improve foodborne illness surveillance and response. CDPH is working to disseminate FoodBorne Chicago via freely available open source software

FoodBorne Chicago tracked Twitter messages using a supervised learning algorithm (7). The algorithm parsed tweets originating from Chicago that included “food poisoning” to identify specific instances of persons with complaints of foodborne illness. The geographic boundaries used by the algorithm also included some neighboring Chicago suburbs. However, follow-up inspections were conducted only at restaurant locations within the city limits. Tweets identified by the algorithm were reviewed by project staff members for indications of foodborne illness (e.g., stomach cramps, diarrhea, or vomiting) from food prepared outside the home. Project staff members provided feedback on whether each tweet fit the criteria, enabling the tweet identification algorithm to learn and become more effective over time.

communication.context.13For tweets meeting the criteria, project staff members used Twitter to reply. For example, Tweet: “Guess who’s got food poisoning? This girl!” Reply: “That doesn’t sound good. Help us prevent this and report where you ate here (link to Foodborne Chicago and a web form to report the illness).” The information in submitted forms went directly into the Chicago 311 system that handles all requests for nonemergency city services. Descriptive statistics were used to evaluate FoodBorne Chicago over its first 10 months of use and to compare the results of complaint-based health inspections of food establishments resulting from FoodBorne Chicago use with health inspections of food establishments based on complaints not submitted through FoodBorne Chicago. The comparisons did not include reinspections or routine inspections not based on a complaint.

During March 2013–January 2014, FoodBorne Chicago identified 2,241 “food poisoning” tweets originating from Chicago and neighboring suburbs. From these, project staff members identified 270 tweets describing specific instances of persons with complaints of foodborne illness. Eight of the 270 tweets (3.0%) mentioned a visit to a doctor or an emergency department. A total of 193 complaints of food poisoning were submitted through the FoodBorne Chicago web form. However, project staff members were not able to track how many of the 193 came from persons led to the form via Twitter and how many came from persons who visited the FoodBorne Chicago site on their own.

Of the 193 FoodBorne Chicago complaints, 19 (9.8%) persons indicated they sought medical care. The complaints identified 179 Chicago restaurant locations; at 133 (74.3%) locations, CDPH inspectors conducted unannounced health inspections. These 133 inspections amounted to 6.9% of the 1,941 health inspections of food establishments prompted by complaints during the study period. Of the 133 FoodBorne Chicago–prompted health inspections, 122 (91.7%) inspection reports identified at least one health violation, compared with 91.8% of inspection reports following complaints filed outside of FoodBorne Chicago during the same period.

Of the 133 FoodBorne Chicago–prompted health inspections 27 (20.3%) identified at least one critical violation, compared with 16.4% of the 1,808 inspections not prompted by FoodBorne Chicago. Critical violations indicate an “immediate health hazard” resulting in a high risk for foodborne illness. Critical violations must be fixed while the inspector is present or the restaurant fails inspection, has its license suspended, and is closed.* Twenty-nine restaurants (21.8%) reported via FoodBorne Chicago had at least one serious violation compared with 27.8% of restaurants not reported via FoodBorne Chicago. Serious violations indicate a “potential health hazard” that must be corrected within a timeframe determined by the health inspector, typically 5 days. If the serious violation is not fixed on re-inspection, the license is suspended, and the business is closed. Overall, at least one critical or serious violation was found in 37.6% of inspections prompted by FoodBorne Chicago and 37.2% of inspections from other complaints during the same period.

Some differences were noted in the distribution of specific violations between FoodBorne Chicago inspections and other complaint inspections. For example, 13.5% of FoodBorne Chicago inspections resulted in (critical) violation 3 (i.e., food not stored at appropriate temperatures), compared with 8.2% of other complaint inspections (Table). In addition, 14.3% of other complaint inspections reported (serious) violation 18 (i.e., food not protected from contamination), compared with 6% of FoodBorne inspections.

A total of 21 (15.8%) of the 133 restaurants reported through FoodBorne Chicago failed inspection and were closed; an additional 33 restaurants (24.8%) passed with conditions, indicating that serious or critical violations were identified and corrected during inspection or within a specified timeframe. Of the inspected restaurants with complaints not reported through FoodBorne Chicago, 25.8% failed and 14.2% passed with conditions. During the study period, among all restaurants inspected, FoodBorne Chicago–prompted inspections accounted for 4.3% of failed inspections and 11.4% of pass with conditions inspections.

Centers for Disease Control and Prevention

Jenine K. Harris, PhD, Raed Mansour, MS, Bechara Choucair, MD, Joe Olson, Cory Nissen, MS, Jay Bhatt, DO

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6332a1.htm?s_cid=mm6332a1_x

Smartphones lead to smarter outbreak investigations: Clostridium perfringens, London, March 2013

On 22 March 2013, 150 of 1,255 students (13–17 years) and staff at a school in London reported gastrointestinal symptoms; onset peaked 8 to 12 hours after a lunch served in the school on 21 March. We performed a retrospective cohort study of all students and staff. We defined cases as school attenders on 20 and 21 March with onset of gastrointestinal symptoms between 20 and 23 March.

carpet-vomit-stainsWe tested food, environmental and stool samples of cases for common pathogens and bacterial toxins. We administered an online questionnaire via email, encouraging the use of smartphones to respond, to measure risk of illness for food items eaten at school on 20 and 21 March. Survey response was 45%. Adjusted risk ratios were generated in a multivariable analysis. Those who ate chicken balti on 21 March were 19.3 times more likely to become ill (95% confidence interval: 7.3–50.9). Clostridium perfringens was detected in all 19 stool samples collected. Within eight school hours of its launch, 412 of 561 (73%) responders had completed the survey. Hygienic standards in the kitchen were satisfactory. The investigation was done rapidly due to smartphone technology and we recommend considering this technology in future outbreaks.

Euro Surveill. 2014;19(19)

Simone B, Atchison C, Ruiz B, Greenop P, Dave J, Ready D, Maguire H, Walsh B, Anderson S.

Food Safety Talk episode 52: A Keene epidemiologist

Food Safety Talk, a bi-weekly podcast for food safety nerds, by food safety nerds.  The podcast is hosted by Ben Chapman and barfblog contributor Don Schaffner, Extension Specialist in Food Science and Professor at Rutgers University.  Every two weeks or so, Ben and Don get together virtually and talk for about an hour.  They talk about what’s on their minds or in the news regarding food safety, and popular culture. They strive to be relevant, funny and informative — sometimes they succeed. You can download the audio recordings right from the website, or subscribe using iTunes.bill.keene_.portland

The guys started the show dreaming about a Red Mac Pro. They then turned to the passing of Bill Keene. Bill has been mentioned in various FST episodes and was a well respected epidemiologist as seen in the articles by the Oregonian and Doug Powell. The guys then turned to their beverages, Coffee Club, Napoleon Dynamite, Homeland, and Car Talk. Ben shared his preference for Aussie Rule football and Arcade Fire’s album Reflektor. The conversation then turned to Don’s limited iPhone music library, Privateering and Dire Straights, which reminded Ben of Money for Nothing and WWE Wrestling (not WWF Wrestling). To finish they talked about Christmas music, Bad Religion’s Christmas Songs, Coulton and Roderick’s One Christmas at a Time and Horrible Christmas songs.

Ben confused IAFP’s History with Bug Trivia and shared Julian Cox’s information about the 1960’s, and this evolved into a broader discussion about the IAFP and its membership.

The discussion then turned back to Bill Keene and some of the outbreaks he had been involved in. This included a Salmonella Panama outbreak (not to be confused with Van Halen’s Panama), which was the first outbreak that was solved through the innovative use of supermarket loyalty cards and that Bill and others were sued for (the lawsuit was eventually dropped.. The guys then discussed outbreak investigation in some detail and that public health officials are damned if they do and damned if they don’t name commodities and suppliers. There is of course always a risk of getting the epidemiology wrong, as was the case with Salmonella Saintpaul in peppers. Finally, Bill’s investigation of a Norovirus outbreak reminded Ben of a recent Norovirus outbreak in Las Vegas.

Then Ben commented on an exchange with Chris Gunter, who was presenting on traceability for small producers at the 2013 Strawberry Expo. Chris’ presentation is based on the investigation of an E. coli O157 outbreak related to strawberries, in which Bill Keene played a part.

In the after dark, the guys reflected on mortality and that we should all Enjoy Every Sandwich. And because they love him,  Rob Ford got a mention again and again.