1. "Food & the Environment" Berkeley, California September 22-26, 2002 Food Safety & Modern Food Production

2. Conclusions Foodborne illnesses are still common. Are these warning signs…YES... …that the system is breaking down? No How well does our food safety & regulation system work? How well do you want it to work?

3. Food Safety & Regulation System “Diagnosis” Ù CDC, State, Local Health departments Ù Disease Surveillance Ù Disease Investigation, l Including outbreaks Ù Recommendations “Write the Rx” “Manage the Patient” Ù FDA/USDA/States/ Industry Ù Food Policy Ù Inspection & Enforcement

4. Causes of Death, United States, 1900 PERCENT

5. Causes of Death, United States, 1992

6. 0 200 400 600 800 1000 19001920194019601980 Year Mortality Rate per 100,000 0 20 40 60 80 197019801990 Armstrong et al, JAMA 1999 Infectious Disease Mortality, United States, 1900-1996

7. “The future of infectious diseases will be very dull. ” “The future of infectious diseases will be very dull. (1972)” Macfarlane Burnet, 1960 Nobel Prize Winner In Medicine It is “time to close the book” on the problem of infectious diseases. It is “time to close the book” on the problem of infectious diseases. (1969) Jesse Steinfeld, MD, U.S. Surgeon General, 1969-73 Told students that there were “no new diseases to be discovered. ” Told students that there were “no new diseases to be discovered. (1976)” Lewis Thomas, Dean Yale Medical School

8. Examples of Pathogenic Microbes Identified Since 1973 1973 Rotavirus 1977 Ebola virus 1977 Legionella pneumophila 1980 Human T-lymphotrophic 1981 Toxin-producing Staph aureus 1982 Escherichia coli O157:H7 1982 Borrelia burgdorferi 1983 HIV 1983 Helicobacter pylori 1989 Hepatitis C Virus 1992 Vibrio cholerae O139 1993 Hantavirus Virus 1994 Cryptosporidium 1995 Ehrlichiosis 1996 nvCJD Prion 1997 HVN1 Virus Influenza 1999 Nipah Virus Source: US Institute of Medicine, 1997; WHO, 1999.

9. Emergence of non-typhoid Salmonella: Reported infections USA, 1920-1997 Years CDC, National surveillance data 0 5 10 15 20 25 30 35 40 45 50 19201930194019501960197019801990 Incidence per 100,000 population Typhoid

10. Emergence of Foodborne Pathogens 1900 BotulismBotulism BrucellosisBrucellosis CholeraCholera HepatitisHepatitis Scarlet fever (streptococcus)Scarlet fever (streptococcus) Staphylococcal food poisoningStaphylococcal food poisoning TuberculosisTuberculosis Typhoid feverTyphoid fever 1942 Staphylococcus aureus Staphylococcus aureus Salmonella Salmonella Clostridium botulinum Clostridium botulinum Streptococci Streptococci 1975-1995 Norwalk-like virusesNorwalk-like viruses Campylobacter jenjuniCampylobacter jenjuni Salmonella EnteritidisSalmonella Enteritidis Shiga toxin-producing E. coli O157:H7, O111:NM, O104:H21Shiga toxin-producing E. coli O157:H7, O111:NM, O104:H21 Listeria monocytogenesListeria monocytogenes Clostridium botulinum (infant)Clostridium botulinum (infant) Vibrio cholerae 0139Vibrio cholerae 0139 Vibrio vulnificusVibrio vulnificus Yersinia enterocoliticaYersinia enterocolitica Arcobacter butzleriArcobacter butzleri Hepatitis EHepatitis E Cryptosporidium parvumCryptosporidium parvum Giardia lambliaGiardia lamblia Cyclospora cayetanensisCyclospora cayetanensis Toxoplasma gondiiToxoplasma gondii BSE prionBSE prion Nitzchia pungens (dinoflagellate)Nitzchia pungens (dinoflagellate)

11. Factors influencing emergence Host factors Microbe factors Environment factors

12. Host factors Increased numbers of susceptible persons Aging, HIV infection, immunosuppressive drugs,… Changing eating habits Dietary, "fast food“, eating out,… Improved surveillance & detection

13. Microbe factors Evolution of new pathogens –Norwalk-like virus – low dose, no immunity –E. coli O157:H7 - Acid tolerant –Listeria & Yersinia - Refrigeration tolerant –Antibiotic resistance Microbes appear 3.5 Billion years ago Man appears 130,000 years ago in Africa

14. Environment factors Changes in food production...e.g., botulism Globalization of food supply Centralized production CAFOs & Manure glut

15. Food industry Changes in food preservation – decreased use of secondary barriers e.g. botulism from chopped garlic, soup, and cheese sauce New products & new processes – Sprouts – Hazelnut yogurt: change from sugar to aspartame in hazelnut yogurt ------> botulism Factors influencing emergence CENTERS FOR DISEASE CONTROL AND PREVENTION

16. Imported Food Consumption on the Rise Source: USDA Agricultural Research Service

17. Source: USDA Economic Research Service Source of Fresh & Frozen Imported Produce, 1997 by Dollar Value Source: USDA Economic Research Service

18. Top Twenty in 2000 Line Entries of foods, food related products, dietary supplements and cosmetics 1. Canada6. Italy11. South Korea16. The Philippines 2. Mexico7. UK12. Spain17. Indonesia 3. France8. Netherlands13. Chile18. Ecuador 4. China9. Germany14. Taiwan19. Ireland 5. Japan10.Thailand15. India20. Costa Rica

19. Recent Outbreaks from Imported Foods Cyclospora raspberriesGuatemala'96 & '97 Hepatitis A strawberriesMexico'97 lettuceMexico'88 cheeseMexico'96 Salmonella sp.cheeseMexico'96 alfalfa sproutsNetherlands'95 snack foodIsrael'94 cantaloupeMexico'89 & '91 Shigella sp.green onionsMexico'94 Vibrio choleraecoconut milkThailand'91 crab meatEcuador'91

20. Mass production & distribution U.S. Broiler Production & Number of Farms, 1975-95

22. 215 (65%) of 331 tested patient isolates from 23 states matched by PFGE 675 cases were reported to PHLIS 432 cases (64%) over expected baseline Mass production & distributionMass production & distribution

23. Examples of large, multi-state outbreaks 1985Salmonella in whole & low fat milk>16,000 cases in 6 states 1985Salmonella in whole & low fat milk>16,000 cases in 6 states 1993 E. coli 0157 in hamburger >700 cases, 4 died in four states. 1993 E. coli 0157 in hamburger >700 cases, 4 died in four states. 1994 Salmonella in ice cream ~ 224,000 ill in 41 states 1994 Salmonella in ice cream ~ 224,000 ill in 41 states 1995 S. Stanley in Alfalfa sprouts 242 ill in 17 states 1995 S. Stanley in Alfalfa sprouts 242 ill in 17 states 1996 Cyclospora & imported raspberries>1000 ill, 22 hospitalizations 1996 Cyclospora & imported raspberries>1000 ill, 22 hospitalizations 1997 E. coli 0157 & alfalfa sprouts 108 ill in 2 states 1997 E. coli 0157 & alfalfa sprouts 108 ill in 2 states 1998 Listeria in hotdogs >100 ill, 21 deaths in 21 states 1998 Listeria in hotdogs >100 ill, 21 deaths in 21 states 1999 Salmonella & Orange Juice 360 ill in 16 states and Canada 1999 Salmonella & Orange Juice 360 ill in 16 states and Canada 2000 Norwalk-like virus & pasta salad333 ill in 13 states 2000 Norwalk-like virus & pasta salad333 ill in 13 states

24. Number of multi-state outbreaks, 1990-1999 Source: Foodborne Outbreak Reporting System http://www.cdc.gov/ncidod/dbmd/outbreak/us_outb.htm

25. Concentrated Animal Feeding Operations (CAFOs)

26. US Manure Estimates, 1997* AnimalSolid Waste (tons / year) Cattle1,229,190,000 Hogs112,652,300 Chickens14,394,000 Turkeys5,425,000 Total: ~1.37 billion tons of manure * Democratic Staff Report, US Senate Agriculture Committee (1998) “Animal Waste Pollution in America, An Emerging National Problem”

27. The Manure Glut Ù 5 tons of animal manure/person/year Ù 130 times greater than amount of human waste Ù What’s in manure? Bacteria, viruses, protozoa Bacteria, viruses, protozoa Chemicals (nitrates, aerosols, antibiotics) Chemicals (nitrates, aerosols, antibiotics) Other (algae) Other (algae)

28. Potential Exposure Leakage from storage lagoons Surface water Ground water Application to fields Runoff into ground water or surface water Direct effect on crops

29. E. coli O157 Scotland (JE Coia et al, J. Infect 36:317, 1998) Handling / preparing raw food (40%) Gardening / garden play (36%) Lived on / visited farm (20%) Lived on / visited farm (20%) Direct / indirect contact with manure (17%) Direct / indirect contact with manure (17%) Private H 2 0 supply (12%) Private H 2 0 supply (12%) Recent high coliform counts in H 2 0 supplies (12%) Recent high coliform counts in H 2 0 supplies (12%) USA FoodNet Case-control studies: pink hamburger farm animals

30. Uses of antimicrobial agents in agriculture Uses of antimicrobial agents in agriculture Food animals –Therapy of infection –Disease prevention –Growth promotion Orchards –Sprayed in orchards for treatment/prevention –streptomycin and oxytetracycline

31. Resistant Campylobacteriosis in Humans due to Fluoroquinolone Use in Chickens* *Quinolone-Resistant Campylobacter jejuni Infections in Minnesota, 1992–1998 Smith K. E., et al, N Engl J Med 1999; 340:1525-1532, May 20, 1999.

32. Is the system breaking down?

33. Burden of Foodborne Disease, 21st Century Estimated 76 million cases resulting in 323,000 hospitalization & 5000 deaths each year in the U.S. 1 in 4 Americans will develop a foodborne illness 1 in 1000 will be hospitalized Cost: an estimated $6.5 billion per year ~CDC Annual budget

34. Infections Associated with Food, 1900 vs 2000 1900s – Botulism – Brucellosis – Cholera – Hepatitis – Scarlet fever (streptococcus) – Staphylococcal – Tuberculosis – Typhoid fever 2000 – Norwalk-like viruses – Campylobacter – Salmonella – Clostridium perfringens – Giardia lamblia – Staphylococcal – Toxoplasma gondii – Shigella – Yersinia enterocolitica – E coli O157:H7

35. 0 0 2,000,000 4,000,000 6,000,000 8,000,000 10,000,000 Norwalk-like virus Campylobacter Salmonella C. perfringens Giardia S. aureus Most common causes of foodborne Illness Most common causes of foodborne Illness Mead et al, 1999

36. Deaths due to Foodborne Illness Salmonella Listeria Toxoplasmosis Norwalk-like Campylobacter E. coli 0157 Other 31.0% 28.0% 21.0% 7.0% 5.0% 3.0% 5.0%

37. Reported non-typhoid Salmonella infections USA, 1920-1997 Years

38. 2001 FoodNet Data 23 percent overall drop in 7 bacterial foodborne illnesses since 1996.  27% Campylobacter  15% Salmonella  35% Listeria  49% Yersinia "Preliminary FoodNet Data on the Incidence of Foodborne Illnesses -- Selected Sites, United States, 2001" Morbidity & Mortality Weekly Report (April 19, 2002) http://www.cdc.gov/mmwr/. http://www.cdc.gov/mmwr/

39. How well does our food safety & regulation system work? How well do you want it to work?

40. Reported to CDC Laboratory confirmed case Laboratory confirmed case Lab test for organism Specimen obtained Person seeks care Person becomes ill Exposure in the general population Reported to health department Tip of the iceberg

41. Number of Foodborne Outbreaks by Etiology,1999

42. Est. Foodborne Illnesses (thousands) by etiology, Mead et al, 1999

43. Average Annual # of FB Outbreaks by State, 1988 - 92 VT= 1 NH= 2 MA= 13 RI = 0 CT = 3 NJ = 19 DE = 2 MD=16 DC = 1

44. Thank you

45. Outbreaks/1,000,000 pop 0 1-4 5-9 10+ Wide variation by Health District in outbreak detection, Georgia, 2000

46. How well does our food safety & regulation system work? We are not losing the “war.” Microbes rapidly adapt through biologic evolution, transfer of genes. Microbes appear 3.5 Billion years ago Homo sapien adapt through cultural evolution, transfer of information. The World is counting on you to pass down the lessons of civilization to this and future generations Once you start, you can’t stop

47. How well does our food safety & regulation system work? “Meat and Poultry: Better USDA Oversight and Enforcement of Safety Rules Needed to Reduce Risk of Foodborne Illnesses.” GAO-02-902GAO-02-902 August 30, 2002 http://www.gao.gov/new.items/d02902.pdf

48. Foodborne syndromes Diarrhea, nausea, vomiting (Norwalk Virus, Campylobacter, Salmonella et al) Renal failure: E. coli 0157:H7 Arthritis: Salmonella, Shigella, Yersinia Paralysis: Clostridium botulinum, Campylobacter Miscarriage: Listeria Birth defects: Toxoplasma gondii

49. Addressing Food Hazards Heating (1.9 million years Homo erectus) Drying (e.g., noodles 300 BC China; 1st Century AD Rome) Freezing Chemical preservatives (salting, spice, smoking) Fermentation (e.g., beer Mesopotamia & Egypt) “Bottling” Nicolas Appert, 1790s Canning Peter Durand, 1810

50. Addressing Food Hazards in the 20th century Disease monitoring, Outbreak detection & investigation (1911?) Inspection & regulation (Meat Inspection Act, 1906) Water chlorination ( Jersey City, NJ, 1908) Pasteurization, (by law, Chicago, 1908) Safe canning (1920’s) Refrigeration; hygienic processing; additives & preservatives Public Information & Education Medical advances: antibiotics, vaccines

51. FoodNet Case-control: Foreign travel Undercooked poultry Turkey or chicken cooked outside the home Other meat cooked outside the home Raw milk Raw seafood Living on or visiting a farm Living on or visiting a farm Contact with farm animals Contact with farm animals Contact with puppies * C. Friedman et al, Intl Conf Emerging Infect. Diseases, 2000 Campylobacter*

52. Cryptosporidiosis in Minnesota* Ù Swimming in public pools (e.g. hotel or school) Ù Drinking Well H 2 0 Ù Visting a farm Ù Living on a farm & age < 6 yo Ù Not living on farm, but with exposure to cattle and to manure * D Soderlund et al, Intl Conf Emerging Infect. Diseases, 2000