1 Surveillance and Response to Foodborne Disease Association of Local Public Health Associations Dr. Paul Sockett November 2004

2 Sources of Infectious Disease Information? Public Health Laboratories Public Health agencies Media National Surveillance Networks Infectious Disease Networks Public Health Community Hospitals International Surveillance Networks

3 Determine magnitude and monitor trends Identify outbreaks and take action Identify high risk populations, foods, behaviours… Evaluate health impact of food safety programs Information for policy and other prevention strategies, risk assessment and priority setting (public & private sectors) - - Surveillance Aims…….

4 The “Activity” level of the surveillance program is influenced by perceived need on the one hand and on the type, availability and sensitivity/specificity of data on the other NDSS PassiveActive/Reactive NESP Enteric Surveillance Alert Reporting (CEOSC/PulseNet) Syndromic reporting (ASAP) ID Surveillance – Approaches Passive Active Enhanced Active Near Real-time Observation of Long-term and Short-term trends Detection of recent events leading to planned control and Prevention programs Detection of current events leading to immediate intervention Surveillance for disease in non-human species Detection of Environmental/agricultural change which could impact/indicate future human health threats Anticipatory? Population-based Sentinel studies (NSAGI)

5 Nationally Notifiable Diseases Botulism* Salmonella (also Typhoid) Campylobacter Shigella Verotoxigenic Escherichia coli Vibrio (Cholera) Cryptosporidium Cyclospora Giardia Hepatitis A* * Not reported through NESP Others Reported through NESP YersiniaRotavirus NorovirusEntamoeba Nationally Notifiable Diseases in Canada

6 A surveillance program which integrates national data on enteric pathogens for outbreak detection and response National Enteric Surveillance Program (NESP) Pulsenet Canada Provincial-Territorial Laboratories Outbreak Investigations FWZID + NLEP Weekly NESP Reports Annual descriptive report Facilitates analysis for outbreak detection

7 NESP - Major Disease Groups Organism Salmonella Campylobacter Shigella E. coli Vibrio Yersinia Parasites Viruses Total

8 NATIONAL ENTERIC SURVEILLANCE PROGRAM ANNUAL SUMMARY REPORT Isolates Reported by Major Disease Group

9 Outbreaks Reported to the NESP in 2003 OrganismNo. of Outbreaks *No. of Cases * Salmonella S. Typhimurium S. Enteritidis S. Heidelberg S. Newport S. Thompson S. Oranienburg S. Hartford S. ssp. 1 4,5,12:b:- Others (10 serotypes) 33 (10.6%) (23.6%) Campylobacter jejuni2 (0.6%)5 (0.5%) E. coli (4.2%)95 (8.8%) Shigella S. sonnei S. dysenteriae 10 (3.2%) (4.8%) 49 3 Yersinia enterocolitica1 (0.3%)2 (0.2%) Cryptosporidium1 (0.3%)4 (0.4%) Viruses Norovirus Rotavirus 250 (80.6%) 241* (61.7%) 643* 20* Totals310*1075* *Numbers based mostly on partial information received via the NESP reports

10 Canadian Enteric Outbreak Surveillance Centre CEOSC Alerts Sources of Alerts Provincial/territorial Public Health Federal Public Health Local/ Regional Public Health CEOSC Alerts

11 nphi C Enteric Alerts (regional Health Authority coverage) – as of Sept 2003 CNPHI - ALERTS

12 How its working….. Alert posted… S.Enteritidis PT5b & Cuba 5 provinces identify cases Cases travelled to same region in Cuba Cuban government informed Local investigators identify source; institute control measures

13 PulseNet Canada? A co-ordinated network of laboratories for rapid exchange of molecular typing information. – 2000: Consultation meeting with partners –2000-1: Sharing and standardized methods –2001: established listserv for exchanging information Allow future real time surveillance Employs single IT platform: Bionumerics

14 Pulse Net National and International Harmonization Standardized database allow interchange with –PulseNet US : established in 1995 for E. coli –PulseNet Europe: 2003 –PulseNet Central Asia: 2003 –PulseNet South America: 2004

15 Community surveillance of gastroenteritis based on over-the-counter sales of anti-diarrheal and anti-nausea medications A. S. A.P. Alternative Surveillance Alert Project To reduce impact of a severe and sudden introduction of an infectious agent in the community by facilitating rapid outbreak detection Applications to other disease syndromes, including respiratory, dermatological, etc…

16 Key Components Automated data download/exchange system Establish a relevant baseline of unit sales for each pharmacy Create an automatic analytic system to detect trends that deviate from this baseline ALERT!

17 Information Sources (Foodborne Diseases) International Global Public Health Intelligence Network (GPHIN) PROMED EnterNet (Europe plus) WHO Outbreak Verification List PulseNet

18 European Enteric Disease Network (Enter Net) Established international network EU and non EU European countries & linked to: –Canada and USA –Australia and New Zealand –Japan Focused on Surveillance and Epidemiological research (Salmonella and VTEC) Regular sharing of standardised data and alert mechanism

19 Canadian Integrated Surveillance Salmonella, Campylobacter, pathogenic E. coli and Shigella from 1996 to 1999 report Available electronically at:

20 Health Canada Food Safety Program Integrated Surveillance Report Salmonella, Campylobacter, pathogenic E. coli,Shigella: Multiple data sources relating to human and animal disease Focus: disease trends over time comparison of geographic distributions comparison of data from different sources comparison of disease trends in humans and animal species

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23 VTEC - Cases and Incidence Rates Reported to the NDRS, PPHB, Health Canada

24 VTEC Cases by Month, 1997 to 2001, NNDS

25 VTEC Outbreaks by Month

26 VTEC Outbreaks by Type TypeTotal (n=114) Household51 Community27 Daycare / School / Camp18 Event*6 Institution (Hospital)5 (2) Restaurant5 Unknown2 * e.g. church supper, BBQ, etc.

27 VTEC Outbreaks by Source SourceTotal (n=114) Food Beef Deli Meats Turkey Not specified Water Municipal Surface Salads (+ sandwiches)3 (1) Person to Person3 Apple Cider/Juice2 Bean Sprouts1 Petting Zoo1 Goat’s Milk1 Cheese1 Unknown79

28 Health Canada Food Safety Programs Surveillance – Future Focus Further development of electronic networks for sharing data Rapid detection of issues, and response Analysis of data from multiple “risk” sources Integration of risk assessment and policy needs with surveillance objectives Enhancing skills in outbreak response Development of decisions tools (guidelines, data, analysis)