Collaborative Efforts of Federal, State, and Local Public Health Partners in Foodborne Illness Investigations United States Public Health Commissioned Corps Scientific and Training Symposium Environmental Health PAC Category Day LCDR Latasha A. Allen, MSPH June 21, 2012

Learning Objectives Identify the mission of the U.S. Department of Agriculture Food Safety and Inspection Service (FSIS) List the three Teams within the Applied Epidemiology Division (AED) and explain how this multi-disciplinary collaboration fulfills the Agency mission Explain how federal, state, and local agencies collaborate during a foodborne illness investigation using a listeriosis outbreak as a case study and list at least three types of information that FSIS needs during an investigation This presentation will provide an overview of the role of the multi-disciplinary Investigations Team within the Applied Epidemiology Division, Office of Public Health Science in performing its role in foodborne illness investigations. The presentation also will stress the importance of collaboration among federal, state, and local public health partners to ensure that illnesses are investigated and controlled in a timely and efficient manner. In the Winter of 2010, an investigation of a cluster of eight listeriosis cases in Southern Louisiana resulted in a recall of hog head cheese. This investigation of Listeria monocytogenes infections will be used as a case study to highlight the collaborative efforts between federal and state agencies. In addition, this outbreak investigation exemplifies the importance of the agency's regulatory role in protecting public health by preventing foodborne illness.

AGENDA Discuss the Food Safety and Inspection Service and the Applied Epidemiology Division within the Office of Public Health Science Discuss the Investigations Team in operational flow during outbreaks Case Study - Hog Head Cheese in Southern Louisiana

Usda Food Safety and Inspection Service Applied Epidemiology Division Usda Food Safety and Inspection Service

What is the Food Safety and Inspection Service? “One Team, One Purpose . We are one team, with only one purpose. And that is to protect public health. FSIS employees take pride in the fact that their jobs help prevent foodborne illness.” –FSIS Strategic Plan FSIS is a public health and regulatory agency operating within USDA. The Agency ensures the commercial supply of meat, poultry, and processed egg products is safe, wholesome, and correctly labeled and packaged. There are four primary laws that provide FSIS the authority to issue regulations. These include the: Federal Meat Inspection Act (FMIA), Poultry Products Inspection Act (PPIA), Egg Products Inspection Act (EPIA), Humane Methods of Slaughter Act (HMSA) FSIS is comprised of a wide range of talented employees dedicated to protecting public health by ensuring that these food products are safe to eat. There are four primary laws that provide FSIS the authority to issue regulations regarding the inspection of meat, poultry, and processed egg products. These include the Federal Meat Inspection Act (FMIA), Poultry Products Inspection Act (PPIA), Egg Products Inspection Act (EPIA), and Humane Methods of Slaughter Act (HMSA) FSIS also works diligently with our partners—including other Federal, State, and local governments; industry; and consumers — to prevent foodborne illness and promote food safety. Nearly 8,000 FSIS full-time and other inspection personnel are stationed across the United States in approximately 6,200 federally inspected meat, poultry, and processed egg products plants. FSIS employees verify that the processing of tens of billions of pounds of red meat and poultry and billions of pounds of liquid egg products comply with statutory requirements. FSIS conducts assessments (e.g., Food Safety Assessments or FSAs) and promotes the implementation of plans to defend against intentional contamination (i.e., Food Defense Plans) at food establishments across the country. Together, these statutes authorize FSIS to inspect all meat, poultry, and processed egg products, as well as certain exotic species (such as buffalo, etc.), and provide FSIS the authority to ensure equivalence of to foreign country systems for imports and reinspect imported products. The HMSA specifically requires that the handling and slaughtering of livestock be carried out by humane methods. (From the FSIS Strategic Plan 2011-2016) http://www.fsis.usda.gov/Regulations_&_Policies/Equivalence_Process_Overview/index.asp http://www.fsis.usda.gov/PDF/At_Least_Equal_to_Guidelines.pdf

FSIS Vision and Mission Vision: A trusted public health regulatory agency committed to preventing foodborne illness Mission: Protect consumers by ensuring that meat, poultry, and processed egg products are safe, wholesome, and correctly labeled and packaged

Applied Epidemiology Division The Applied Epidemiology Division (AED) within the Office of Public Health Science (OPHS) consists of three Teams: Surveillance Team: Enable FSIS to detect and respond to foodborne hazards through the application of surveillance, epidemiology, and food safety science; Investigations Team: Collaborate with public health partners to investigate foodborne illnesses possibly associated with FSIS-regulated products; Prevention and Control Team: Support the FSIS mission through the application of epidemiology to prevent and control foodborne illness. Multi-disciplinary collaboration among veterinarians, medical doctors, epidemiologists, environmental health scientists The Surveillance Team: Detect and initiate response to hazardous product in commerce by evaluating reports from consumers, PulseNet, the media, and other sources. Support FSIS’s mission by producing and promoting high-quality science that elucidates emerging trends and risks Establish and maintain strong relationships with partners both internal and external to FSIS to facilitate surveillance reporting. Optimize signal detection and Agency responsiveness through efficient business processes, data use, and data management. The Investigations Team collaborate with federal, state, and local public health partners to investigate foodborne illnesses possibly associated with FSIS-regulated products The P&C Team applies the work of the surveillance and investigations teams to the evaluation of the public health impact of food hazards. In addition, the P&C Team evaluates the implications of zoonotic conditions for FSIS to help the agency identify and manage food safety risks.

AED Functions of Surveillance, Investigation, and Control Investigations Outbreak investigation and coordination, develops risk hypotheses and gathers novel data to determine hazard, source, and possible risks. Prevention and Control Tests risk hypotheses for risk identification and uses epidemiologic data to develop future prevention and control measures. Surveillance Performs systematic monitoring for indications of growing food borne hazards or outbreaks, characterize incidence and prevalence of risks and develops techniques to detect incidents earlier. FSIS Consumer Complaints (CCMS) Non-CCMS Surveillance

The Investigations Team

Investigations Team The Team supports FSIS to: Trace foods implicated in foodborne illness back to their producing establishments Facilitate collection and sampling of foods implicated in foodborne illness to identify pathogens that may be causing human illness Assist FSIS recall activity and health hazard evaluations Serve as a liaison to state and local public health agencies on foodborne disease investigations and food safety issues The Investigations Team includes Public Health and Epidemiology Liaisons (PHELs) who work with public health partners to investigate foodborne illness possibly associated with FSIS-regulated products. PHELs are the points of contact linking public health partners to FSIS experts on a multitude of food safety and security issues.

Collaboration with Partners during Foodborne Illness Investigations Centers for Disease Control and Prevention (CDC) Consistent communication and information sharing during outbreak investigations to receive epidemiologic information from states Food and Drug Administration (FDA) Collaboration of foodborne illness investigations involving both FSIS- and FDA-regulated products State and Local Departments of Health and Agriculture Provide epidemiological data through interviews of case-patients Collaborate traceback activities FSIS laboratories verify product testing conducted by state laboratories to determine if FSIS can accept non-FSIS laboratory results

Data Operational Flow during an Outbreak Diagram shows the flow of information during an outbreak. Discuss how data is received from various public health partners and shared to efficiently investigate a cluster of illnesses that may possibly be associated with FSIS regulated products.

Data Needs during a Foodborne Illness Investigation   Clinical information Laboratory Information Exposure Information Illness onset date and incubation period Isolate information Food history Symptoms Pulsed-Field Gel Electrophoresis (PFGE) Food preparation review Number of suspected and confirmed cases Other tests of clinical and food specimens Other possible sources of exposure While needs vary with each investigation, the type of information FSIS routinely needs to make these determinations includes. Isolate information- date received, uploaded, confirmed, etc. Other tests, MLVA, MLGT, etc. Other sources of exposure- ruminant animal, pet, other wildlife, travel, etc.

Data Needs during a Foodborne Illness Investigation Who? What? When? Where? FSIS establishment number Product name and type Production date code or lot number Point of purchase Copy of label Product weight and units per case Sell by/use by date Complete name and address of store Amount of product purchased Purchase date Product Traceback Investigations: What We Need to Know FSIS can assist public health partners in the traceback of product thought to be associated with foodborne illness. In order to trace a product back to the producing establishment, FSIS needs specific information. While this information may not always be available, FSIS can best work with our public health partners when product information is as complete as possible. Information that will aid in product traceback includes: Who? FSIS establishment number (e.g. inside USDA seal or on package closure);Copy of the label What? Product name and type (e.g. “90 percent lean ground beef”); product weight and units per case; amount of product purchased When? Production date code or lot number; Sell by/use by date ;Purchase date Where? Point of purchase, including name and complete address Additional Question asked: Does the consumer have purchase receipts or other purchase information (e.g. club cards)? Is there any leftover product held by consumer? Are there other sources of the same product?

Listeriosis in Southern Louisiana Case study

Case Study: Listeriosis in Southern Louisiana January 2010, an investigation of a cluster of eight listeriosis cases in Southern Louisiana resulted in a recall of hog head cheese This investigation of Listeria monocytogenes infections will be used as a case study to highlight the collaborative efforts between federal and state agencies This outbreak investigation exemplifies the importance of collaboration during a foodborne illness investigation

What is Hog Head Cheese??? Louisiana, Mississippi, and other portions of the Deep South, United States The highly seasoned hog's head cheese is very popular as a cold cut or appetizer. A pig's foot provides the gelatin that sets the cheese, and vinegar is typically added to give a sour taste. It is a popular Cajun food and is often encountered seasoned with green onions. In Mississippi, Alabama, and other southern states, it is encountered in a spicy form known as souse or less spicy hog's head cheese. (Wikipedia) But there are variations of this ‘cold cut’ Worldwide and goes by many different names from pig souse (uses various parts of the pig including the foot) in the Caribbean to Presskopf in Germany.

Collaboration Intra-agency Collaboration Microbiology Division (MD)- Microbiological Investigations Branch (MIB) Office of Field Operations (OFO) Office of Public Affairs and Consumer Education (OPACE) Inter-agency Collaboration Louisiana Office of Public Health (OPH) Louisiana Department of Agriculture and Forestry (LDAF) CDC Initial notification of this cluster was from our Microbiological Investigations Branch with in the Office of Public Health Science Microbiology Division (there were human isolates that matched by PFGE to USDA product and environmental isolates) -> post this notification AED contacted the Louisiana Office of Public Health to request epidemiologic, product, and purchase information for the matching human cases. -> then AED was notified by the Office of Field Operations that those specific products could not be linked to cases because the product was not distributed to that state. -> Then CDC notified AED of cases within the cluster who reported consumption of hog head cheese during their food history interviews!!! BINGO OPACE-The Office of Public Affairs and Consumer Education (OPACE) ensures that all segments of the farm-to-table chain receive valuable food safety information.

Timeline of Investigation, Louisiana, 2010 This is to show the collaboration between public health agencies during this investigation. Briefly discuss what’s shown on the slide. MMWR/April 8,2011/Vol.60/No. 13

For Further information MMWR Publication - Outbreak of Invasive Listeriosis Associated with the Consumption of Hog Head Cheese --- Louisiana, 2010 Weekly April 8, 2011 / 60(13);401-405 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6013a2.htm USDA FSIS – http://www.fsis.usda.gov/ CDC – Outbreak Response Team - http://www.cdc.gov/outbreaknet/outbreaks.html U. S. Food and Drug Administration - http://www.fda.gov/ FoodSafety.gov – www.foodsafety.gov http://www.fsis.usda.gov/Food_Safety_Education/Ask_Karen/index.asp Ask Karen- (mobile) m.askkaren.gov USDA FSIS Twitter- twitter.com/usdafoodsafety FSIS Multi-Media Site: http://www.fsis.usda.gov/News_&_Events/multimedia/index.asp

Acknowledgements USDA FSIS Office of Public Health Science Applied Epidemiology Division Microbiology Division Outbreaks Section of Eastern Laboratories Office of Field Operations Office of Public Affairs and Consumer Education Centers for Disease Control and Prevention Louisiana Office of Public Health Louisiana Department of Agriculture and Forestry