Webinar: The Role of Physicians in Identifying Foodborne Illness Outbreaks

>>Welcome to the
webinar entitled the Role of Physicians in Identifying
Foodborne Illness Outbreaks, Early Diagnosis and Reporting
of Foodborne Illness, sponsored by the Georgia
Department of Agriculture and UGA Cooperative Extension. My name is Judy Harrison. I’m a Professor and
Extension Food Specialist with the University of
Georgia’s College of Family and Consumer Sciences. And joining me today
are Jessica Badour, Recall Outreach Specialist
with the Georgia Department of Agriculture’s
Food Safety Division, and Melissa Tobin-D’Angelo,
a Medical Epidemiologist with the Georgia
Department of Public Health, Division of Health Protection. The topics that we will cover
include the role of physicians in identifying foodborne
illness cases. We’ll talk about
the importance of foodborne illness,
the cost, and the burden of foodborne illness, and
what symptoms physicians can watch for. We’ll also cover how
physicians can help regulators identify food safety risks
and initiate food recalls. We’ll cover what food recalls
are, and how they work, and how physicians
can protect consumers. We’ll also examine resources
for physicians on food recalls and also handling food
safely in the home. Joining me first is Dr.
Melissa Tobin-D’Angelo, and we’ll discuss the
role of physicians in identifying foodborne
illness cases. Physicians can play
an important role in identifying foodborne
illness and keeping the
food supply safe. What is that role
for physicians?>>Well, the physician can
identify a potential food safety problem through
an encounter with a potential index patient of a foodborne illness
outbreak. The physician can facilitate
faster laboratory diagnosis of foodborne illness and then
has a role in notification of public health authorities
through disease reporting, and can also watch for
additional cases of illness. This can lead to
identification of a suspect food by
regulatory agencies and a recall initiative.>>Specifically, how does
this protect our food supply?>>Identifying illnesses
early can lead to expedited recognition
of problems with foods. This can help public
health authorities and regulators identify
foods that should be recalled from the marketplace, and can
help companies remove problem foods earlier from
the marketplace to prevent additional
illnesses.>>Let’s take a look
at the importance of foodborne illness,
the cost, and the burden of these illnesses
in the United States.>>First of all,
what are the agents that cause foodborne illness?>>Well, a number of
different bacteria cause foodborne illness. Some bacteria actually produce
toxins that result in illness. Viruses cause foodborne
illness, parasites, fungi, and chemical contaminants
can cause foodborne illness. In addition, allergens
for persons who are susceptible can
cause foodborne illness.>>So how costly
are these illnesses?>>Well, as you can
see from this chart, there are five main
foodborne illnesses that make up the most of the costs. The total is approximately
14.6 billion annually from 14 pathogens. The largest cost of
foodborne illness comes from salmonella infections. In addition, some of the
other bacterial pathogens, such as campylobacter
and listeria result in a high cost of illness. Finally, toxoplasma, a
parasite, and Norovirus, a virus, along with
some other causes of illnesses make up the rest.>>What makes foodborne
illness so costly? Where do these costs
stem from?>>Well, as you can see
at the top of this slide, patient care costs make
up some of the costs, so, physicians caring for
patients, hospital fees, and then loss of productivity,
staying home from work. Moving kind of around
the clock to the bottom, there are government
costs, such as the cost of the public health and
regulatory investigations, and the cost of
regulatory enforcement. And then finally moving
around to the top left corner, there is, there are industry
costs, such as having to destroy contaminated
foods, and needing to change their processes and potential legal
costs, and bankruptcy.>>What pathogens contribute to most domestically-acquired
cases of foodborne illness
in the U.S.?>>Well, it’s estimated
that the pathogens listed on this slide comprise
91 percent of the U.S. foodborne
illnesses. So at the very top
of the list, with more than 5 million
estimated illnesses is Norovirus, and that
comprises more than half. Next on the list
is salmonella. Followed by clostridium
perfringens, campylobacter, and staphylococcus aureus.>>Of the foodborne
pathogens, which result in the most hospitalizations?>>Now this list is in a
slightly different order than the list on
the previous slide, and there are some
additional pathogens listed, so salmonella is still very
high on the list with more than 19,000 estimated
hospitalizations. Norovirus is still
very high on the list, but it has gone a little lower
just because Norovirus tends to cause not as
severe illness as some of the bacterial infections. Campylobacter is next, and
we have two new pathogens on this hospitalization
list really just because of the severity of
illness that they cause, so, toxoplasma, and
then E.coli O157, abbreviated Shiga
toxin-producing E.coli or STEC.>>About 3,000 people in
the U.S. die each year from foodborne illness or
from complications associated with these illnesses, which pathogens cause more
deaths in this country?>>Well, here again, we see a
lot of the bacterial, viral, and parasitic pathogens
listed on the previous slides and the order does change
somewhat compared to burden and hospitalizations. As far as the proportion
of deaths attributable to salmonella, we see
about 28 percent followed by toxoplasma, listeria,
and Norovirus, and campylobacter are
still on this list.>>We hear more these days
about STECs, what organisms is that term referring to?>>Well, there are a
variety of different types of E.coli bacteria,
called serogroups, and O157:H7 is the most
commonly identified type of Shiga toxin-producing
E.coli in the United States, and the other numbers on the list are other
relatively common types. So all of these types of
E.coli can cause this toxin that results in illness,
sometimes severe.>>And why are they
called STECs?>>They produce a toxin
called Shiga toxin, and there are also a
variety of other names that people can use
this for type of E.coli, so you may see it referred to as verocytotoxin-producing
E. coli, or you, or you may hear about
enterohemorrhagic E.coli, or EHEC, and they all
mean the same thing.>>There are some
pathogens that may result in similar symptoms but
may have very different treatments, Shigella
for instance, compare Shigella
and E.coli for us.>>Well it’s very important
to be able to differentiate between Shigella and shiga
toxin-producing E.coli, and this chart outlines some of the similarities
and differences. They both cause
bloody diarrhea. A difference is
that antibiotics for treatment are often
indicated and recommended for Shigella infections,
however, for shiga toxin-producing
E.coli infections, in general, antibiotics are
not recommended. Now to another similarity, they are both very
common among children, and they both require
exclusion from child care settings. Finally, another difference between these two pathogens
are the, is the likelihood that they are transmitted
through food. So for Shigella,
only, only a third of Shigella infections are
estimated to be foodborne, whereas for shiga
toxin-producing E.coli, it can vary somewhat depending
on the sterile group, but well over 50
percent are foodborne.>>Some population
groups are more at risk for foodborne illness and
for serious complications, who are these high-risk
groups?>>Infants, young children,
older adults, pregnant women, in particular with listeria
infections or listerosis, and immunocompromised
individuals.>>Why is foodborne
illness important, and why should physicians
be concerned about it?>>Well foodborne
illness affects 1 in 6 Americans annually, resulting in 128,000
hospitalizations and 3,000 deaths. Serious complications and even
long-term health consequences can occur, kidney failure,
hemolytic uremic syndrome, or HUS, premature
delivery or stillbirth, reactive arthritis, and
neurological disorders.>>Let’s examine the symptoms that physicians
should watch for. What are some common symptoms
that a patient may exhibit when they have a
foodborne illness that physicians
need to watch for?>>Well, gastroenteritis
is what most of these pathogens cause. We define diarrhea as 3 or
more unformed stools a day, however, in infants
this really is going to be a judgment call. We can further characterize
the diarrhea to give us clues as to whether the
infection might be bacterial or parasitic by determining
whether the stools are bloody, watery, or occurring for
a prolonged time period. That usually means a bacterial
or if it is occurring over weeks and weeks,
a parasitic infection. In addition to the diarrhea,
we would see abdominal pain, cramping, nausea, vomiting,
in some instances fever, and weight loss depending
on the duration of symptoms.>>In addition to
those symptoms, there can be more serious
symptoms and complications, what are some of those?>>Well, renal or
hematologic manifestations, going back to hemolytic
uremic syndrome, and this can be
caused by a number of different bacterial
pathogens, but it’s most commonly caused by shiga toxin-producing
E.coli. We can see skin
manifestations with a number of these foodborne illnesses. There are some characteristic
bullous lesions that can be seen with
Vibrio vulnificus, Rose spots can be seen
with typhoid fever caused by salmonella typhi. Systemic illness can occur and
one may see signs of sepsis with some of the
bacterial infections that cause invasive disease. Hepatitis A is an
example of a virus that can result in jaundice. We see bone or joint
manifestations, reactive arthritis, which can,
again, be caused by a number of the bacterial
pathogens and along with some other
manifestations, it’s referred to as Reiter’s syndrome. Finally, neurological
manifestations can occur. If a patient has
double vision, respiratory depression,
cranial nerve palsies, and descending paralysis,
botulism is an important thing to worry about, and
meningitis is common with listeria infections.>>So a patient comes
in with these symptoms, let’s identify some of the
questions that physicians need to ask and how they can
report these illnesses. What are the questions that physicians
should ask patients?>>The physician should
find out specifics on what symptoms the
patient has been experiencing and for how long. The physician should
find out whether family or friends have
similar symptoms. Ask what the patient
does for a living and are there co-workers
with symptoms, have there been any recent
hospitalizations and why, what medications
are being taken, and when is the last time
the patient was sick? Is the patient sexually
active? Has the patient
traveled lately, especially internationally? Has the patient been
on any camping trips and had exposure
to untreated water? Does the patient have
contact with animals or pets? Contact with children
or contact with any nursing
home residents? The physician should ask about
selected high-risk foods. The physician should ask
whether the patient has ingested any raw or
poorly-cooked foods, such as raw oysters or sushi. Unpasteurized milk or
juices, home-canned foods, fresh produce, or soft cheeses
made from unpasteurized milk.>>If a foodborne
illness is suspected, what should a physician do?>>Well, the physician
could consider this patient as potentially an index case
for a foodborne outbreak. Collect a stool
specimen in order to characterize the illness
through laboratory testing, and to report the
results quickly to the local health
department. In some instances, the physician may notify
public health even before laboratory confirmation
occurs, such as if botulism
is suspected or hemolytic uremic syndrome. The bottom line is
to communicate early with public health
authorities.>>Joining me now
is Jessica Badour from the Georgia
Department of Agriculture. Jessica, let’s talk about the
role that physicians can play in helping regulators
identify food safety risk, which sometimes lead
to food recalls. How can identifying
an outbreak of foodborne illness lead to
a recall or an investigation?>>During normal surveillance,
when a larger number of people than expected appear to
have the same illness, in a given time and place,
they are then considered to be a cluster of illness. As more details come to light
and the investigation begins, if it turns out that those
ill people have something in common to explain why they
all got the same illness, such as a food product,
then the group of illnesses is referred
to as an actual outbreak. It’s important to remember
that not all clusters of illness are outbreaks. And recalls and
tracebacks can happen without reports
of actual illness.>>There are several steps in an investigation
of an outbreak. Take us through those steps.>>When you think about
an outbreak investigation, these are the primary steps that take place on
this slide here. Each will be happening
in various orders, and many of the components
can be occurring concurrently. It’s important to remember that an investigation
is not linear, and each specific
situation may be different. All the partners in foodborne
disease surveillance, illness and outbreak detection,
and response, are critical to protecting public health. Success requires an integrated
approach, so you have each of these pieces that come
together, and our partners in the medical field
would follow most closely into the areas of
surveillance, epidemiology, and lab analysis, because
in their first interactions with the patient, they are
actually fulfilling aspects of the investigation whether
they realize it or not. There’s an integral role that
medical professionals fulfill as an investigation develops, and pieces of information
begin to link together.>>What agencies are
involved at the federal level when there are outbreak
investigations?>>There are three
main players, the CDC, FDA, and USDA FSIS. The CDC is only involved
in multistate outbreaks, otherwise, the State
Department of Public Health is the
lead in this respect. They help to coordinate
between public health partners in determining the outbreak,
defining its size and extent, and working to help
identify the source. FDA becomes involved if
and when its determined that it’s likely a food
source tied to the outbreak. FDA regulates all
food products except for meat and poultry. USDA regulates livestock
meat, poultry, and processed egg products.>>And at the state and
local level, who is involved?>>Primarily, you have
your Georgia Department of Public Health and
the Georgia Department of Agriculture. Public health includes
various sections, including the Acute
Disease Epidemiology Section that Melissa is from, as
well as Environmental Health and a Public Health
Lab section. Then you have local health
departments and districts. The State Department of
Public Health collaborates with Georgia’s 159
county health departments, who inspect and
regulate Georgia food service establishments. Then there are also
18 regional districts that are responsible
for county coordination and outbreak detection
and investigation. On the ag side, the
Georgia Department of Agriculture’s Food Safety
Division administers rules and regulations for retail
and manufacturing firms in the business of
food production. This may include grocery
stores, dairy farms, eggs, seafood, and more, and they
are responsible for licensing and inspecting intrastate
foods or products made and sold exclusively
here in Georgia.>>So there are
multiple groups involved in an investigation. How do you piece
all this together?>>The three-legged stool for an investigation
is one easy way to look at the major players. You have your epidemiology,
your lab, and your environmental. Within the center of it all, communication links
the three pieces. Confirmation of a
foodborne illness starts the whole process. You get an epidemiological
sample that confirms a person is sick
with a particular pathogen. The next step is
to try and tie that to either a lab
sample of a food product, or an environmental
sample, such as water, soil, or swabs form within
a facility. If you can find a match
between the clinical specimens to a food and/or
environmental samples to support an association of the product causing
the outbreak, then you have effectively
found your source and you have these matching
lab tests to confirm it.>>Investigations can
begin in different ways, what is a traceback
investigation versus a traceforward
investigation?>>Traceability has
been a useful tool for many industries,
particularly when a product recall
becomes necessary. FDA’s early tracing activities
were primarily traceforward, tracing a product
from the source, or the manufacturer
to the consumer. A traceback is
working in the reverse with foodborne illness
outbreaks, starting from the
consumer’s point of purchase, or point of service, and going
backwards through distribution to find the common point
in the supply chain, such as the manufacturer
or the growing farm.>>Sometimes foodborne
illness outbreaks result in food recalls. Let’s take a closer
look at food recalls. What is a food recall?>>A food recall occurs when
there is reason to believe that a particular food
product could pose a high risk to consumers. If there have been
associated illnesses by the time the
recall happens, you’ve already established
that there is an outbreak and that the source may
have been identified so the investigation traces
forward from that source through each point of service
down to the consumer level where it was directly
purchased or consumed, such as at a grocery
store or at a restaurant. In general, recalls are
initiated by the food company that made the product. The manufacturer will
voluntarily recall their food products when a problem
has been identified, which basically means
they announce the problem and take the product
out of the marketplace. In some cases, food recalls
can be mandated by FDA or USDA in order to ensure
effective removal of contaminated products
from the marketplace. When this mandated
process happens, it can take a long time,
whereas on the state level, the Department of Agriculture
can issue a withhold from sale, which
basically means that the company cannot
distribute the product further, and we can
also request a voluntary destruction of the product.>>There are several things that can trigger food
recalls, what are those?>>Recalls can be
triggered by either one thing or various things that
may have happened. If there is the discovery
of a pathogen in a product that can make a consumer
sick, we’ll have a recall. There’s also industry
monitoring. Here in Georgia, food manufacturing
facilities conduct testing in finished products and
finished product ingredients, and they require to have these
tests done on a routine basis and report back any
positive results to the Department
of Agriculture. Consumers may call the
Department of Public Health, or the Georgia Department of
Agriculture with complaints. At the Department
of Agriculture, we have a compliance officer who oversees consumer
complaints, and we investigate those
complaints that we received through our headquarters or
our three district offices. Food may also be recalled
when there’s discovery of a mislabeling
or a misbranding, such as a potential allergen that has not been correctly
listed on the label.>>What are the goals
of a food recall?>>The goal of a recall is to have an immediate
intervention. Traceability tracks the
product from one firm to the next, determining
each distribution point, and working to prevent
further distribution. Public health interventions
can also occur which may include
a consumer warning or a recall notice
posted online and distributed to the media. Recall effectiveness checks
determine the companies who received product
were notified and reacted appropriately. The long-term findings of the product investigation
can also identify practices or conditions that we want to
avoid in the future in order to minimize the risk
of contamination and future foodborne
illness events. This may involve policy
changes or new rules and regulations and outreach
and education to industry and consumers, as well
as some heightened food surveillance activities.>>So how does this
all tie together?>>During the beginning stages of a foodborne illness
outbreak, there are two ways a
problem can be identified. One, a patient may see
a physician and complain of illness, or two, a consumer
may call public health or the Department of
Agriculture and complain about a product and any
associated symptoms. At that point in time,
they are always encouraged to visit a physician for official confirmation
of illness. Assuming that a
physician is able to collect a clinical sample, that sample should then
be tested for the presence of foodborne illness-causing
pathogens. If the sample is positive,
those results are given to public health, and
public health will follow-up to gather a food
history from the patient. If the food is linked to
a particular retail store or restaurant, the
investigation continues from regulatory
standpoints and can lead to additional actions,
such as a recall.>>Now let’s look at
what physicians can do to help protect consumers. How can physicians
contribute to this process?>>Medical professionals
are a crucial resource in providing this link in
confirming patient illnesses. On the federal level, FDA
and CDC work very closely in the early stages of an
outbreak investigation, and FDA is relying heavily on
public health in collaboration with their other partners on
the state and local levels to identify what food may
be causing the illness.>>Physicians can
play an important role in preventing foodborne
illnesses. What is that role?>>By diagnosing
illnesses appropriately and reporting potential
outbreaks and reportable diseases
quickly to the health department, in aids in linking
information together, and could be the one
missing piece of the puzzle. All it takes is one patient,
one confirmed illness here in Georgia, and that
confirmation could be the link in a multistate or
a national outbreak. It’s also important
for physicians to make their patients aware of the food safety
dangers that exist. Are they a high-risk patient? Somebody who is pregnant,
immunocompromised, or elderly? These factors play large roles
in a person’s susceptibility to potentially contracting
a foodborne illness and suffering extended
consequences. It’s important to talk
to these high-risk groups and discuss safer
practices when it comes to food handling
and consumption.>>Reporting is an
important part of prevention. How should physicians
report foodborne illness?>>The easiest way to
report potential outbreaks and reportable diseases
quickly to local health departments
is through the Department of Public Health’s website. The link provided on this
slide will take physicians directly to where they need to
go in order to quickly report.>>What advice can physicians
give patients who believe that a food product
has made them ill?>>Physicians should encourage
their patients to come in and be seen if they are
experiencing potential symptoms of foodborne illness. Again, especially if they
are in a high-risk category. Clinical samples should
be requested and tested. And just as a caveat,
it’s unusual, but sometimes can
happen during an outbreak investigation. If a patient still has
some of the product that they believe made them
ill, if it’s possible for them to separate and
label the product to avoid further consumption,
but still keep it, say in the fridge or freezer
that can sometimes be used to assist in an investigation. This only would happen if
there was no product left in the marketplace, and the
consumer sample is the only way to test the product. In that instance,
which again is rare, the consumer’s sample
may be collected by FDA for further analysis.>>When a food recall
is going on, what advice can physicians
give their patients to help them avoid problems?>>Recalls can be confusing. Often times they only
include very specific products within a given time frame. And recalls are
usually identified with specific expiration dates
and lots and product codes. If a patient believes they
have a recall product, they should check the product
labels themselves to see if the codes match anything within the recall
being issued. They should never
eat the product. They should follow
specific directions in the recall notice
or call the company for additional information,
or they could take it back to the store or call the store
where it was purchased from. And we always like to say,
when in doubt, throw it out.>>Let’s examine some of
the resources available for physicians to
get information about food recalls, and also about handling food
safely in the home. Where can physicians
and patients go to get more information?>>The CDC website has
a primer specifically for physicians pertaining to
the diagnosis and management of foodborne illness, with
additional information that expands on what was
covered in this presentation. That can be found
at the first link. For the latest on
recall information, the next three links
provide FDA and USDA recalls. The last link, for the
agr.georgia.gov website, those recalls impact
Georgia specifically. The final two links are
great for consumers to review for some additional
safe food-handling tips. The Partnership for Food
Safety Education’s website can be accessed at fightbac.org, and the UGA Extension Program
provides publications and tips for consumers on food safety
that are great resources.>>If you have questions
about food recalls or any of the information presented,
contact Jessica Badour with the Georgia
Department of Agriculture at Jessica.Badour
@agr.georgia.gov, or Judy Harrison with UGA
Extension at [email protected]

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