CDC UPDATE Conference for Food Protection Executive Board Meeting Park City, Utah AUGUST 11 - 12, 2015 Vince Radke, MPH, RS, CP-FS, DAAS, CPH National Center for Environmental Health Centers for Disease Control and Prevention The findings and conclusions in this report are those of the author and do necessarily represent the official position of the Centers for Disease Control and Prevention. U. S. Department of Health and Human Services Centers for Disease Control and Prevention

Foodborne Illness Sickness 48 Million People Death 3,000 People DANGER (Review slide). Each year roughly 1 in 6 Americans (or 48 million people) gets sick, 128,000 are hospitalized, and 3,000 die from foodborne. Hospitalization 128,000 People http://www.cdc.gov/foodborneburden/estimates-overview.html

Foodborne Illness is common and costly Reducing foodborne illness by just 10% would keep 5 million people a year from getting sick Salmonella infections alone are responsible for $365 million in direct medical costs annually Total economic burden $77.7 billion “That's an unacceptable price to pay for contaminations that are mostly preventable.” – Kathleen Sebelius, Secretary of Health and Human Services

What about vulnerable groups? Burden of foodborne illness who does it hit the hardest

Providing technical assistance and training on foodborne illness surveillance and outbreak investigations

FoodCORE: Turning Innovation into Action Foodborne Diseases Centers for Outbreak Response Enhancement Performance metrics for process evaluation Problem solving Improved surveillance AND stronger public health response Integrated Food Safety Center of Excellence (CoE) and FoodCORE Center NOT FOR DISSEMINATION! -- CURRENT AS OF 03-15-2012 - Please Contact FoodCORE@cdc.gov for additional information

PulseNet Slides- Besser 60,000-70,000 isolates/yr

Performance Metrics: Improved Surveillance

Whole Genome-based Enteric Disease Surveillance: What we hope to Achieve More outbreaks detected and solved more quickly, with fewer cases New vehicles identified, informing new prevention strategies Better use of epidemiology / laboratory resources

Listeria Outbreaks Solved and Incidence, 1983-2014 (per million pop) No. outbreaks Era Outbreaks per year Median cases per outbreak Pre-PulseNet 0.3 69 Early PulseNet 2.3 11 Listeria Initiative 2.9 5.5 WGS 9 4 Data are preliminary and subject to change

Antibiotic Resistance (AR) Antimicrobial Resistance (AR) 2 million antibiotic resistant illnesses per year in the US 410,000 illnesses (~ 1 in 5) caused by Salmonella or Campylobacter 23,000 deaths CDC’s Role: Preventing Infections, preventing the spread of resistance, tracking, improving antibiotic prescribing/stewardship, developing new drugs and diagnostic test

National Outbreak Reporting System (NORS) INFORMATION GAPS ? Captures outbreak data on agents, foods, and settings responsible for illness

State and local partners EHS-Net A collaborative program working to understand the environmental causes of foodborne illness outbreaks Federal, state, and local environmental health/food safety specialists epidemiologists CDC State and local partners CA MN NY NYC RI TN FDA USDA EHS-Net 14 14

Foodborne Illness Outbreak Investigation Components Epidemiological Determine the who, what when, where of an outbreak Laboratory Identify or confirm the agent causing the outbreak Environmental Assess how and why the agent got into the environment and spread Recommend steps to stop outbreaks and prevent future ones Outbreak investigations typically involve epidemiology, laboratory, and environmental health (EH) staff—the three legs of the stool—as well as partners in risk communication, public health, industry, and other disciplines. Outbreak investigations are also opportunities for different authorities and professionals to work together as a team.  They may reveal points at which the public health systems that detect and respond to outbreaks can be improved. Outbreak investigations and additional research should result in better industry practices, better regulations and enforcement by the regulatory agencies, and better consumer understanding, all of which should reduce the number of foodborne illnesses that occur.

Environmental antecedents Environmental Assessment as part of Foodborne Illness Outbreak Investigations Outbreak E. coli Outbreak caused by salads eaten at Restaurant A Contributing factor Cross contamination Worker used same utensils on raw ground beef and salads Environmental antecedents Worker in a hurry Worker had not been trained on avoiding cross contamination Follow slide

Preliminary Results, 2009-2013 National Voluntary Environmental Assessment Information System Pilot* 320 outbreaks were reported Averaged 64 outbreaks reported each year 84% of outbreaks involved restaurants Other locations included a caterer, bakery and monastery Contributing factors reported in 70% of outbreaks As we go through these data please remember they represent EHS-Net pilot data that was collected during the development of the NVEAIS data collection instrument. They are only presented today as examples of the type of information we will be able to report as programs begin to register and report data into NVEAIS beginning this year, 2014. (REVIEW SLIDE) (Notes to Presenter if asked: From our initial look at the data Norovirus appears to be the most common outbreak pathogen reported.) Contributing factors were reported in 70% of the outbreaks reported to NVEAIS. NORs reports contributing factors in approximately 40-45% of outbreaks. We hoped that if EH programs were reporting data based on their environmental assessments that more outbreaks would have CFs identified. *All data in this and the remainder of presentation represents examples of the type of information NVEAIS can provide NVEAIS is changing its name to NEARS, National Environmental Assessment Reporting System

C – represents contamination factors; P – represents proliferation factors; S – represents survival factors. In our pilot data analysis C10, Bare-hand contact by a food handler/worker/preparer who is suspected to be infectious (e.g., with ready-to-eat-food) is the most often cited contributing factor; followed by C12, contamination by an infectious food work other than by bare hand contact; and C11, glove hand contamination by an infectious food worker. We were not surprised by this as the majority of outbreaks in our datasets are norovirus. In the next few slides we will begin to look at various antecedents like, establishment busyness, worker to manager ratio and other potential underlying factors that may be linked to these types of outbreaks.

Note 1: 7:1 and greater category (max = 39:1, average = 12 Note 1: 7:1 and greater category (max = 39:1, average = 12.73:1, SD = 6.12, n = 70). We also believe that the ratio of food workers to managers may also be an important environmental antecedent. The outbreaks characterized in our 2009-2013 data set shows the highest percentage of the outbreaks reported had 7 food workers to 1 manager.

Restaurant Food Safety Studies: Recent Findings Chicken Leafy greens Ground beef Ill workers Food cooling Kitchen manager certification Goals of these studies are to describe restaurant food safety policies and practices and to find links between restaurant/worker characteristics and food safety policies and practices Data collection: - Involves -Interviews with restaurant managers and workers -Observations of -food prep/safety practices -kitchen environment -Is conducted by EHS-Net site environmental health specialists -Occurs in 300-400 randomly selected restaurants in selected jurisdictions in EHS- Net sites 20

Restaurant Food Safety Studies- 2013 Chicken cross contamination prevention and cooking practices Less than half of kitchen managers knew the temperature to which chicken should be cooked Handling practices of fresh leafy greens Most restaurants met FDA guidelines for keeping purchase records for shipments of leafy greens Ground beef handling and cooking practices Chain restaurants and restaurants with food-safety certified managers had safer ground beef practices Food worker experiences with and beliefs about working while ill Workers concerned about leaving coworkers short-staffed were more likely to say they had worked with vomiting or diarrhea In 2013, we published 4 articles in the Journal of Food Protection. Here you see the topics and a main finding from each article. (Review slide) 21

Restaurant Food Safety Studies- 2014 The relationship between food cooling practices and estimated food cooling rates Of three food cooling practices, active monitoring of cooling time/temperature cooled food most quickly Managerial practices regarding workers working while ill Most restaurants have ill worker policies, but many of them are inadequate Restaurant manager and worker food safety certification and knowledge Factors linked with managers and workers passing a food safety test included: certification, English as a primary language, working in chain and large restaurants, having more job-related experience and duties We currently have 3 articles in press, again you see their topics, and a main finding. (Review slide) 22

EHS-Net 2010-2015: California Project Findings Outcome CA EHS-Net conducted an observation study to describe mobile food unit (i.e., food trucks) food safety practices. Findings 95% of studied food trucks had at least one critical foodborne illness risk factor (e.g., unsafe temperatures, poor personal hygiene). Outcome Several environmental health jurisdictions in CA have restructured their mobile food truck inspection programs to address the gaps identified by CA’s study. 23

New Tool- E-Learning on Environmental Assessments of Foodborne Illness Outbreaks Through our EHS-Net work, it became clear to us that food safety program staff needed more training on how to conduct outbreak investigations in a way that would identify environmental causes of outbreaks. They needed training on how to conduct environmental assessments. In turn, this training would lead to higher quality data reported into NVEAIS. Thus, we developed this training, called e-learning on environmental assessments of foodborne illness outbreaks. http://www.cdc.gov/nceh/ehs/eLearn/EA_FIO/index.htm 24

New Foodborne illness outbreak surveillance system WHAT New Foodborne illness outbreak surveillance system National Environmental Assessment Reporting System (NEARS) (formerly NVEAIS) Collects data from environmental assessments conducted during foodborne illness outbreaks 25

National Voluntary Environmental Assessment Information System (NVEAIS) Now NEARS GAPS NEARS FILLS ! The National Voluntary Environmental Assessment Information System (NVEAIS) is a surveillance system targeted to jurisdictions that inspect and regulate restaurants and other food venues such as banquet facilities, schools, and other retail food service locations. The system provides an avenue to capture environmental assessment data that describes foodborne outbreaks associated with restaurants and other retail food service venues. These data will help identify factors that food safety programs can routinely monitor to prevent or reduce the risk for foodborne outbreaks associated with food service establishments. Identifies and monitors contributing factors and their environmental antecedents

CDC Needs Your Help! Consider using our environmental assessment training and reporting environmental assessment data to NEARS Things to think about… Do you think knowing how and why outbreaks appear to occur would be helpful? Would more training on how to conduct environmental assessments as part of foodborne outbreak investigations be helpful? Would a characterization of your program involvement in investigating foodborne outbreaks be helpful? Would more details than we now have about outbreak food vehicles be helpful? Review Slide Winning the battle on food safety will not be easy. It is hard to add another activity to an already strapped program like reporting EA data to NVEAIS. This indeed would likely involve another activity for a food program. However, having a robust national description of the environmental aspects of foodborne outbreaks for the establishments that represent half of the foodborne outbreaks reported in this country can make the difference between doing the same things over and over expecting different results and having information to develop new policies and practices and evaluate them. Are you up for the challenge?

Thank you! vradke@cdc.gov U. S. Department of Health and Human Services Centers for Disease Control and Prevention