Influenza and Pneumonia and Foodborne Illness Megan Davies, MD State Epidemiologist Division of Public Health NCDHHS

Pneumonia: The Big Picture Leading cause of death globally Major public health problem in the US –>55,000 deaths (2006) –1.2 million hospitalizations (2006) Many types can be prevented with vaccines –Influenza (flu) –Pneumococcal –Haemophilus influenzae type b (Hib) –Pertussis (whooping cough)

Influenza: Burden of Disease Important cause of morbidity and mortality –36,000 deaths/year –226,000 hospitalizations/year Infection rates highest among children Serious illness and death more common among –Persons aged ≥65 years –Children aged <2 years –Persons with certain underlying conditions (e.g., asthma, heart disease, diabetes)

ACIP Universal Flu Vaccine Recommendation (2010): Rationale Vaccine is safe and effective in all age groups 2009 H1N1 affects young adults disproportionately Complications occur even among adults who are not in high-risk groups Eliminates confusion about who should receive flu vaccine

2009 H1N1 Vaccine: North Carolina’s Response Identified by CDC as one of the top three states for 2009 H1N1 vaccine administration 637,596 doses administered during first eight weeks of response

Pneumococcal Disease Second most common cause of vaccine- preventable death in the U.S. (after influenza) Major syndromes include –Pneumonia –Bacteremia –Meningitis

Pneumococcal Pneumonia 100,000 to 135,000 cases requiring hospitalization per year Responsible for up to 1/3 of community- acquired pneumonias and up to 1/2 of hospital-acquired pneumonias Common bacterial complication of influenza and measles More fatalities in elderly

Pneumococcal Vaccines Conjugate vaccine (PCV7/PCV13) recommended for –All children aged 2–59 months –Children aged 60–71 months with certain underlying medical condition Polysaccharide vaccine (PPSV23) recommended for –All adults aged ≥65 years –Persons aged 2–64 years who are at increased risk for invasive disease

Effect of Pneumococcal Vaccine * Rate per 100,000 population Source: Active Bacterial Core Surveillance/EIP Network Invasive Pneumococcal Disease Incidence by Age Group, 1998 and 2002

PCV7 intro- duction Effect of Vaccination: Invasive Pneumococcal Disease Among Children <5 Years of Age, 1998–2006

Pneumococcal Polysaccharide Vaccine: Missed Opportunities Healthy People 2010 goal: 90% coverage for persons >65 years 2003 BRFSS: 64% of persons >65 years of age ever vaccinated Vaccination coverage levels were lower among persons years of age with a chronic illness

Foodborne Illness

An illness caused by infection with a virus, bacterium, or parasite transmitted on food Examples include –Hepatitis A –Salmonella Spp –Cryptosporidium parvum

Foodborne Diseases Matter Foodborne diseases are common –estimated 76 million illnesses and 323,000 hospitalizations occur each year in the U.S. Foodborne and diarrheal diseases can be devastating: dehydration, kidney failure, mortality among immunocompromised, and fetal death –estimated 5,000 deaths/year

We Still Have a Lot to Learn 1,300 + foodborne outbreaks are reported to the CDC every year, on average 6% multijurisdictional 60% of recent high-profile foodborne outbreak investigations found new pathogens or new food vehicles causing the outbreak

Foodborne Disease Investigations, NC (Annual averages, ) Disease Agent Cases/yrHospitalized*Deaths* Salmonella %.4% Campylobacter 67316%.2% E. Coli / STEC 12225%.2% Hepatitis A 7024%0% Shigella 23117%0% Listeria 2986%8% Typhoid, acute 670%0% * Reported Hospitalization & Deaths: based on data

Burden of Foodborne Diseases From Angulo et al, United States Department of Agriculture Report to Congress Food Safety and Inspection Service United States Department of Agriculture Washington, D.C. March % of all cases 2% of all cases Confirmed cases reported to health department or CDC

Foodborne Disease Investigation Sporadic cases –Sensitive professions Foodhandler, childcare worker Outbreaks –Classic point source –Contaminated product PFGE clusters

Pulsed Field Gel Electrophoresis (PFGE) Patterns

Salmonella Typhimurium 2009 Associated with PCA Peanut Products

Impact of PCA Peanut Butter Recall Economic Impact In United States –Estimated $1 billion impact –20% decline in peanut butter consumption in January In North Carolina –23% decline in peanuts planted –Substantial number of employees laid-off

Foodborne Illness Prevention Inspections –Farms –Production facilities –Food service establishments Consumer education Outbreak investigation –“Removing the pump handle” –Product recalls

Prevention at the Source NCDACS Food and Drug Protection Division –Protects the food supply, from farm to fork –Regulatory programs include Food Feed Drugs NCDENR and Local Health Departments –LHD Environmental Health staff trained and authorized to enforce state laws and rules by DENR –710 local EH staff authorized to conduct food service inspections currently in NC

Food Safety on the Farm Inspection and testing of animal feeds at the manufacturing and retail levels –Salmonella, aflatoxin, pesticide residue, and guaranteed analysis –BSE Pesticide screening of fresh produce Pesticide and aflatoxin screening of milk NCDACS Food & Drug Protection Division

1,565 manufacturing and distributor firms subject to inspection –Sandwich and prepared salad manufacturers –Bottled water, juice, and beverage –Seafood processors and retailers –Canneries (low acid and acidified) –Bakeries –Dairy manufacturers and farmsteads –Egg Producers and Distribution Manufacturing and Distribution NCDACS Food & Drug Protection Division

4000 retail facilities under inspection Respond to consumer complaints –Over 400 in 2008 Risk-based retail surveillance program –Based on recent recalls, outbreaks, import alerts, and consumer complaints Retail NCDACS Food & Drug Protection Division

Types of Facilities Regulated Food Service Establishments –Restaurants –Food Stands –Mobile Food Units –Push Carts Institutions –Hospitals –Nursing/Rest Homes –Prisons –Local confinement facilities –Residential Cares Lodging Establishments –Hotels –B & B Inns/Homes Child Care Centers Schools Tattoo Artists Public Swimming Pools Resident Camps NCDENR Environmental Health Services Section

Food Service Establishments Inspections of food service establishments –Mandated to take place 1-4 times per year minimum –Frequency based upon risk involved in procedures used by establishment –Follow-up inspections may be performed –Inspections in response to complaints, suspect behavior, etc. can be performed at any time NCDENR Environmental Health Services Section

Top 5 CDC Risk Factors Unapproved sources of food Poor employee hygiene Contaminated equipment/cross contamination Improper hot/cold holding temperatures Improper final cooking temperatures NCDENR Environmental Health Services Section

Inspection Methods Out-of-compliance risk factors corrected immediately or within 10 days Chronic violations addressed through risk control plans or enforcement actions Long-term compliance achieved through behavioral changes NCDENR Environmental Health Services Section

Prevention of Foodborne Illness at Home Clean Wash hands and surfaces often Separate Do not cross- contaminate

Prevention of Foodborne Illness at Home Cook Cook to proper temperature Chill Refrigerate promptly

Bon appetit and Gesundheit!

Many thanks to: NCDENR NDACS NCDHHS CDC