Literature DB >> 23344696

Surveillance for foodborne disease outbreaks--United States, 2009-2010.

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Abstract

Known pathogens cause an estimated 9.4 million foodborne illnesses annually in the United States. CDC collects data on foodborne disease outbreaks submitted by all states, the District of Columbia, and Puerto Rico through CDC's Foodborne Disease Outbreak Surveillance System. Data reported for each outbreak include the number of illnesses, hospitalizations, and deaths; the etiologic agent; the implicated food vehicle; and other factors involved in food preparation and consumption. During 2009-2010, a total of 1,527 foodborne disease outbreaks (675 in 2009 and 852 in 2010) were reported, resulting in 29,444 cases of illness, 1,184 hospitalizations, and 23 deaths. Among the 790 outbreaks with a single laboratory-confirmed etiologic agent, norovirus was the most commonly reported, accounting for 42% of outbreaks. Salmonella was second, accounting for 30% of outbreaks. Among the 299 outbreaks attributed to a food composed of ingredients from one of 17 predefined, mutually exclusive food commodities, those most often implicated were beef (13%), dairy (12%), fish (12%), and poultry (11%). The commodities in the 299 outbreaks associated with the most illnesses were eggs (27% of illnesses), beef (11%), and poultry (10%). Public health, regulatory, and food industry professionals can use this information when creating targeted control strategies along the farm-to-table continuum for specific agents, specific foods, and specific pairs of agents and foods. This information also supports efforts to promote safe food-handling practices among food workers and the public.

Entities:  

Mesh:

Year:  2013        PMID: 23344696      PMCID: PMC4604871     

Source DB:  PubMed          Journal:  MMWR Morb Mortal Wkly Rep        ISSN: 0149-2195            Impact factor:   17.586


Known pathogens cause an estimated 9.4 million foodborne illnesses annually in the United States (1). CDC collects data on foodborne disease outbreaks submitted by all states, the District of Columbia, and Puerto Rico through CDC’s Foodborne Disease Outbreak Surveillance System. Data reported for each outbreak include the number of illnesses, hospitalizations, and deaths; the etiologic agent; the implicated food vehicle; and other factors involved in food preparation and consumption. During 2009–2010, a total of 1,527 foodborne disease outbreaks (675 in 2009 and 852 in 2010) were reported, resulting in 29,444 cases of illness, 1,184 hospitalizations, and 23 deaths. Among the 790 outbreaks with a single laboratory-confirmed etiologic agent, norovirus was the most commonly reported, accounting for 42% of outbreaks. Salmonella was second, accounting for 30% of outbreaks. Among the 299 outbreaks attributed to a food composed of ingredients from one of 17 predefined, mutually exclusive food commodities (2), those most often implicated were beef (13%), dairy (12%), fish (12%), and poultry (11%). The commodities in the 299 outbreaks associated with the most illnesses were eggs (27% of illnesses), beef (11%), and poultry (10%). Public health, regulatory, and food industry professionals can use this information when creating targeted control strategies along the farm-to-table continuum for specific agents, specific foods, and specific pairs of agents and foods. This information also supports efforts to promote safe food-handling practices among food workers and the public. CDC defines a foodborne disease outbreak as the occurrence of two or more similar illnesses resulting from ingestion of a common food. State, local, tribal, and territorial health department officials voluntarily submit reports of outbreaks investigated by their agency to the Foodborne Disease Outbreak Surveillance System on a standard, Internet-based form.* This report analyzes outbreaks that were reported by August 2, 2012, in which the first illness occurred during 2009–2010. Data reported for each outbreak include the number of illnesses, hospitalizations, and deaths; the etiologic agent (confirmed or suspected†); the implicated food vehicle; factors contributing to food contamination; and the settings of food preparation and consumption. Foods were assigned to one of 17 commodities§ if a single contaminated ingredient was identified or if all ingredients belonged to that commodity (2). Outbreaks identifying foods that could not be assigned to one of the 17 commodities, or for which the report contained insufficient information for commodity assignment, were not attributed to any commodity. Population-based outbreak reporting rates were calculated for each state using U.S. Census estimates of the 2009 and 2010 state populations.¶ Public health officials from all 50 states, the District of Columbia, and Puerto Rico reported 1,527 outbreaks, including 675 in 2009 and 852 in 2010. For the period 2009–2010, the median average annual rate of foodborne outbreaks among states was 3.2 per 1 million population (Figure).
FIGURE

Average annual rate of reported foodborne disease outbreaks per 1 million population* and number of outbreaks,† by state and major etiology group§ — Foodborne Disease Outbreak Surveillance System, United States, 2009–2010

* Cutpoints for outbreak rate categories determined using Jenks Natural Breaks Optimization in ArcGIS. Legend differs for each major etiology.

† Number of reported outbreaks in each state. In addition to the 50 states, Puerto Rico reported 10 outbreaks, and the District of Columbia reported four outbreaks.

§ Analysis restricted to outbreaks with a single confirmed or suspected etiology.

¶ Includes 38 multistate outbreaks (i.e., outbreaks in which exposure to the etiologic agent occurred in more than one state) assigned as an outbreak to each state involved. Multistate outbreaks involved a median of seven (range: 2–45) states.

A single confirmed or suspected etiologic agent was identified in 1,022 (67%) outbreaks (790 confirmed and 232 suspected) (Table 1). Among the 790 outbreaks with a single confirmed etiologic agent, bacteria caused 413 (52%) outbreaks, viruses caused 336 (42%), chemicals and toxins caused 39 (5%), and parasites caused 2 (0.2%). Norovirus was the most common cause of outbreaks and illnesses, accounting for 331 (42%) of the confirmed, single-etiology outbreaks and 7,332 (37%) illnesses. Salmonella was next, causing 234 (30%) of confirmed, single-etiology outbreaks and 7,039 (36%) illnesses. Among the 225 confirmed Salmonella outbreaks with a serotype reported, Enteritidis was the most common serotype with 76 outbreaks (34%). Shiga toxin–producing Escherichia coli (STEC) caused 58 confirmed, single-etiology outbreaks, of which 53 were caused by serogroup O157.
TABLE 1

Number and percentage of reported foodborne disease outbreaks, outbreak-associated illnesses, and hospitalizations, by etiology (confirmed or suspected)* — Foodborne Disease Outbreak Surveillance System, 2009–2010

EtiologyOutbreaksIllnessesHospitalizations



20092010Total 2009 and 201020092010Total 2009 and 201020092010Total 2009 and 2010









CESECESENo.(%)CESECESENo.(%)CESECESENo(%)
Bacterial
Salmonella11341215243(24)2,924302,2741,8617,089(24)28642912583(49)
Clostridium perfringens197171457(6)9648661,0623333,225(11)00909(1)
Escherichia coli, Shiga toxin–producing (STEC)§34124160(6)43922037651(2)1132723190(16)
Campylobacter13221440(4)292825941600(2)1019222(2)
Bacillus**567725(2)1794117829427(2)012030
Staphylococcus enterotoxin††475319(2)952911810252(1)000000
Shigella§§30508(1)12303850508(2)3016019(2)
Clostridium botulinum102030204060202040
 Other bacterial020020017400174(1)000000
Listeria¶¶20709(1)1003904905035040(3)
Vibrio parahaemolyticus20237(1)18078330102030
Vibrio other001010004040002020
Enterococcus faecalis10001013000130000000
Escherichia coli, Enteropathogenic001010007070004040
Escherichia coli, Enterotoxigenic200130660019850000000
Brucella sp.100010400040100010
Total 200 29 213 38 480 (47) 5,129 1,150 4,540 2,308 13,127 (45) 421 8 444 7 880 (74)
Chemical and toxin
 Scombroid toxin/Histamine7011018(2)320440760000000
 Ciguatoxin1005015(1)36025061030306(1)
 Other chemical1101306302110000110
 Mycotoxins100120200680000000
 Paralytic shellfish poison001010003030002020
 Pesticides10102039030420101020
 Plant/Herbal toxins100010600060100010
 Other natural toxins000110000220000000
Total 21 1 18 3 43 (4) 121 3 75 10 209 (1) 5 0 6 1 12 (1)
Parasitic
Cyclospora100010800080000000
Giardia lamblia001010005050001010
Total 1 0 1 0 2 0 8 0 5 0 13 0 0 0 1 0 1 0
Viral
 Norovirus1296620294491(48)2948968438414379737(33)28135117109(9)
 Hepatitis A202040400704701405019(2)
 Rotavirus01001002800280010010
 Other viral00101000130130000000
Total 131 67 205 94 497 (49) 2,988 996 4,404 1,437 9,825 (33) 42 14 56 17 129 (11)
Known etiology *** 353974371351,022(66)8,2462,1499,0243,75523,174(78)46822507251022(86)
Unknown etiology ††† 02120263475(31)03,01302,4415,454(19)03406599(8)
Multiple etiologies 11214330(2)2876440857816(3)29132163(5)
Total (all etiologies) §§§ 364 311 451 401 1,527 (99) 8,533 5,226 9,432 6,253 29,444 (100) 497 57 539 91 1,184 (100)

Abbreviations: CE = confirmed etiology; SE = suspected etiology.

If at least one etiology was laboratory-confirmed, the outbreak was considered to have a confirmed etiology. If no etiology was laboratory-confirmed, but an etiology was reported based on clinical or epidemiologic features, the outbreak was considered to have a suspected etiology.

Salmonella serotypes causing more than five outbreaks are Enteriditis (76 outbreaks), Newport (29), Typhimurium (27), Heidelberg (15), Montevideo (nine), Javiana (eight), Oranienburg (seven), Saintpaul (six) and Infantis (six).

STEC O111 (one confirmed outbreak), STEC O121:H19 (one confirmed outbreak), O145 (one confirmed outbreak) STEC O157:H7 (53 confirmed outbreaks), O26 (one confirmed outbreak), O26:H11 (one confirmed outbreak).

Campylobacter jejuni (31 confirmed outbreaks, four suspected outbreaks), Campylobacter unknown (three confirmed outbreaks, two suspected outbreaks).

Bacillus cereus (12 confirmed outbreaks, 12 suspected outbreaks), Bacillus unknown (one suspected outbreak).

Staphylococcus aureus (nine confirmed outbreaks, 10 suspected outbreaks).

Shigella sonnei (eight confirmed outbreaks).

Listeria monocytogenes (nine confirmed outbreaks).

The denominator for the total etiology percentages is the known etiology total. The denominator for the known etiology, unknown etiology, and multiple etiologies percentages is the total (all etiologies).

An etiologic agent was not confirmed or suspected based on clinical, laboratory, or epidemiologic information.

Because of rounding, numbers might not add up to the etiology category total or the known etiology total.

Of the 29,444 outbreak-related illnesses, 1,184 (4%) resulted in hospitalization. Salmonella caused the most outbreak-related hospitalizations with 583 (49%), followed by STEC with 190 (16%) and norovirus with 109 (9%). Outbreaks caused by Listeria resulted in the highest proportion of persons hospitalized (82%), followed by Clostridium botulinum (67%), and paralytic shellfish poisoning outbreaks (67%). Among the 23 deaths, 22 were attributed to bacterial etiologies (nine to Listeria monocytogenes, five Salmonella, four STEC O157, three Clostridium perfringens, and one Shigella), and one to norovirus. A food vehicle was reported for 653 (43%) outbreaks; in 299 (46%) of these outbreaks the vehicle could be assigned to one of the 17 predefined commodities (Table 2). The commodities most commonly implicated were beef, with 39 outbreaks (13%), followed by dairy and fish with 37 (13%) each, and poultry with 33 (11%). Among the 36 dairy-associated outbreaks for which pasteurization information was reported, 26 (81%) involved unpasteurized products. The commodities associated with the most outbreak-related illnesses were eggs with 2,231 illnesses (27%), beef with 928 (11%), and poultry with 826 (10%). The pathogen-commodity pairs responsible for the most outbreaks were Campylobacter in unpasteurized dairy (17 outbreaks), Salmonella in eggs and STEC O157 in beef (15 each), ciguatoxin in fish (12), and scombroid toxin (histamine fish poisoning) in fish (10). The pathogen-commodity pairs responsible for the most outbreak-related illnesses were Salmonella in eggs (2,231 illnesses), Salmonella in sprouts (493), and Salmonella in vine-stalk vegetables** (422). The pathogen-commodity pairs responsible for the most hospitalizations were Salmonella in vine-stalk vegetables (88 hospitalizations), STEC O157 in beef (46), and Salmonella in sprouts (41). The pathogen-commodity pairs responsible for the most deaths were STEC O157 in beef (three deaths), and Salmonella in pork and Listeria in dairy (two each).
TABLE 2

Number of reported foodborne disease outbreaks and outbreak-associated illnesses, by etiology (confirmed or suspected)* and food commodity status — United States, 2009–2010

EtiologyNo. of outbreaks (No. of illnesses)

Attributed to a single commodityAttributed to food vehicle containing >1 commodityAttributed to unknown commodityTotal
Bacterial
Salmonella71(4,210)44(914)128(1,965) 243 (7,089)
Clostridium perfringens24(853)23(1,078)10(1,294) 57 (3,225)
Escherichia coli, Shiga toxin–producing (STEC)§29(363)12(145)19(143) 60 (651)
Campylobacter22(380)2(30)16(190) 40 (600)
Bacillus**12(206)9(201)4(20) 25 (427)
Staphylococcus enterotoxin††3(22)12(219)4(11) 19 (252)
Shigella§§1(96)2(329)5(83) 8 (508)
Clostridium botulinum3(6)0000 3 (6)
 Other bacterial001(167)1(7) 2 (174)
Listeria¶¶5(25)2(10)2(14) 9 (49)
Vibrio parahaemolyticus6(30)001(3) 7 (33)
Vibrio other1(4)0000 1 (4)
Enterococcus faecalis001(13)00 1 (13)
Escherichia coli, Enteropathogenic00001(7) 1 (7)
Escherichia coli, Enterotoxigenic002(77)1(8) 3 (85)
Brucella sp.1(4)0000 1 (4)
Total 178 (6,199) 110 (3,183) 192 (3,745) 480 (13,127)
Chemical and toxin
 Scombroid toxin/Histamine12(55)4(13)2(8) 18 (76)
 Ciguatoxin12(49)003(12) 15 (61)
 Other chemical1(2)1(6)1(3) 3 (11)
 Mycotoxins1(6)1(2)00 2 (8)
 Paralytic shellfish poison1(3)0000 1 (3)
 Pesticides002(42)00 2 (42)
 Plant/Herbal toxins1(6)0000 1 (6)
 Other natural toxins1(2)0000 1 (2)
Total 29 (123) 8 (63) 6 (23) 43 (209)
Parasitic
Cyclospora1(8)0000 1 (8)
Giardia lamblia00001(5) 1 (5)
Total 1 (8) 0 0 1 (5) 2 (13)
Viral
 Norovirus40(778)135(3,254)316(5,705) 491 (9,737)
 Hepatitis A1(5)1(2)2(40) 4 (47)
 Rotavirus00001(28) 1 (28)
 Other viral00001(13) 1 (13)
Total 41 (783) 136 (3,256) 320 (5,786) 497 (9,825)
Known etiology *** 249(7,113)254(6,502)519(9,559) 1,022 (23,174)
Unknown etiology ††† 41(815)74(982)360(3657) 475 (5454)
Multiple etiologies 9(264)8(232)13(320) 30 (816)
Total (all etiologies) §§§ 299 (8,192) 336 (7,716) 892 (13,536) 1,527 (29,444)

If at least one etiology was laboratory-confirmed, the outbreak was considered to have a confirmed etiology. If no etiology was lab-confirmed, but an etiology was reported based on clinical or epidemiologic features, the outbreak was considered to have a suspected etiology.

Salmonella serotypes causing more than five outbreaks are Enteriditis (76 outbreaks), Newport (29), Typhimurium (27), Heidelberg (15), Montevideo (nine), Javiana (eight), Oranienburg (seven), Saintpaul (six) and Infantis (six).

STEC O111 (one confirmed outbreak), STEC O121:H19 (one confirmed outbreak), O145 (one confirmed outbreak) STEC O157:H7 (53 confirmed outbreaks), O26 (one confirmed outbreak), O26:H11 (1 confirmed outbreak).

Campylobacter jejuni (31 confirmed outbreaks, four suspected outbreaks), Campylobacter unknown (three confirmed outbreaks, two suspected outbreaks).

Bacillus cereus (12 confirmed outbreaks, 12 suspected outbreaks), Bacillus unknown (one suspected outbreak).

Staphylococcus aureus (nine confirmed outbreaks, 10 suspected outbreaks).

Shigella sonnei (eight confirmed outbreaks).

Listeria monocytogenes (nine confirmed outbreaks).

The denominator for the total etiology percentages is the known etiology total. The denominator for the known etiology, unknown etiology, and multiple etiologies percentages is total (all etiologies).

An etiologic agent was not confirmed or suspected based on clinical, laboratory, or epidemiologic information.

Because of rounding, numbers might not add up to the etiology category total or the known etiology total.

Thirty-eight multistate outbreaks were reported (16 in 2009 and 22 in 2010). Twenty-one were caused by Salmonella, 15 by STEC (13 O157, one O145, and one O26), and two by Listeria. The etiologic agent was isolated from an implicated food in 11 multistate outbreaks. Five of the multistate outbreaks were caused by Salmonella (in alfalfa sprouts [two outbreaks], ground turkey, shell eggs, and a frozen entrée [one each]). Six were caused by STEC (in ground beef [two outbreaks], unpasteurized Gouda cheese, multiple unpasteurized cheeses, hazelnuts, and cookie dough [one each]). Among the 766 outbreaks with a known single setting where food was consumed, 48% were caused by food consumed in a restaurant or deli, and 21% were caused by food consumed in a private home. Forty-three outbreaks resulted in product recalls.†† The recalled foods were ground beef (eight outbreaks), sprouts (seven), cheese and cheese-containing products (six), oysters (five), raw milk (three), eggs (three), and salami (ground pepper), bison, sirloin steak, unpasteurized apple cider, cookie dough, frozen mamey fruit, hazelnuts, Romaine lettuce, ground turkey burger, tuna steak, and a frozen entrée (one each).

Editorial Note

In 2009, the Foodborne Disease Outbreak Surveillance System transitioned to the use of a new reporting form and online data entry interface, the National Outbreak Reporting System (NORS). NORS receives reports of outbreaks of enteric disease transmitted through water, person-to-person contact, contact with animals, environmental contamination, and indeterminate means, as well as through food. Before 2009, only foodborne and waterborne outbreaks were reported to CDC. Following the transition to the new system, the number of foodborne disease outbreaks reported in 2009 and 2010 declined 32% compared with the mean of the preceding 5 years (4). The decline in foodborne disease outbreak reporting was largely observed among norovirus outbreaks. Norovirus can be transmitted through a variety of routes, including direct contact between persons, through contact with contaminated surfaces, and ingestion of contaminated food or water (5,6). Distinguishing among these modes of transmission in an outbreak can be challenging; some outbreaks involve multiple transmission routes. The advent of NORS, which for the first time enables electronic reporting of nonfoodborne norovirus outbreaks, might have led to more appropriate classification of outbreaks previously reported as foodborne, resulting in fewer reports of foodborne norovirus outbreaks. Other possible explanations for the fewer foodborne disease outbreaks in 2009 and 2010 include resource limitations and competing priorities (e.g., the influenza A [H1N1] virus pandemic in 2009) for state epidemiologic and laboratory resources (7,8). What is already known about this topic? Surveillance for foodborne disease outbreaks can identify opportunities to prevent foodborne diseases, which cause millions of illnesses in the United States each year. What is added by this report? Among the 1,527 foodborne disease outbreaks reported in 2009 and 2010, most outbreak-associated illnesses were caused by norovirus or Salmonella. Among outbreaks in which both an etiologic agent and single-commodity food vehicle were identified, most outbreaks were attributed to Campylobacter in unpasteurized dairy products, Salmonella in eggs, and Shiga toxin–producing Escherichia coli O157 in beef. The pathogen-commodity pairs responsible for the most outbreak-related illnesses were Salmonella in eggs (2,231 illnesses), in sprouts (493), and in vine-stalk vegetables (422). What are the implications for public health practice? Public health, regulatory, and food industry professionals can use this information when creating targeted control strategies along the farm-to-table continuum for specific agents and foods, and specific pairs of agents and foods. This information also supports efforts to promote safe food-handling practices among food workers and the public. For STEC O157 and Salmonella serotype Enteritidis, the number of outbreaks reported was not lower than previous years. For STEC O157, the 33 outbreaks in 2009 and 20 in 2010 exceeded the Healthy People 2010 yearly target of 11, and for Salmonella serotype Enteritidis, the 39 outbreaks in 2009 and 37 outbreaks in 2010 exceeded the Healthy People 2010 yearly target of 22 (9). During 2009–2010, beef, dairy, fish, and poultry were associated with the largest number of foodborne disease outbreaks. During the preceding 11 years, beef, fish, and poultry were consistently among the commodities most commonly associated with outbreaks (4). The large number of outbreaks caused by unpasteurized dairy products is consistent with findings that more outbreaks occur in states that permit the sale of unpasteurized dairy products (10); 60% of states permit sales of raw milk in some form, according to a 2011 survey by the National Association of State Departments of Agriculture.§§ The findings in this report are subject to at least four limitations. First, only a small proportion of foodborne illnesses reported each year are identified as associated with outbreaks. The extent to which the distributions of food vehicles and settings implicated in foodborne disease outbreaks reflect the same vehicles and settings as sporadic foodborne illnesses is unknown (4). Similarly, not all outbreaks are identified, investigated, or reported. Second, many reported outbreaks had an unknown etiology, an unknown food vehicle, or both, and conclusions drawn from outbreaks with a confirmed or suspected etiology or food vehicle might not apply to outbreaks with an unknown etiology or food vehicle. Even when a food is identified, the point of contamination is not always known or reported. Third, CDC’s outbreak surveillance system is dynamic; agencies can submit new reports and can change or delete previous reports as new information becomes available. Therefore, the results of this analysis might differ from those published earlier or from future reports. Finally, because of changes in the surveillance system implemented in 2009, comparisons with preceding years should be made with caution. Public health, regulatory, and food industry professionals use foodborne disease outbreak surveillance data to target prevention efforts related to pathogens and foods that cause foodborne disease outbreaks. Additional information on outbreaks and the Foodborne Outbreak Online Database are available at http://www.cdc.gov/outbreaknet/surveillance_data.html.
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Authors: 
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5.  Outbreaks associated with cantaloupe, watermelon, and honeydew in the United States, 1973-2011.

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