1. CDC UPDATE Conference for Food Protection Executive Board Meeting Park City, Utah AUGUST , 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

2. 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

3. 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

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

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

7. 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 Please Contact for additional information

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

9. Performance Metrics: Improved Surveillance

10. 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

11. 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

12. 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

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

14. 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

15. 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.

16. 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

17. 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, (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

18. 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.

19. 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 data set shows the highest percentage of the outbreaks reported had 7 food workers to 1 manager.

20. 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 randomly selected restaurants in selected jurisdictions in EHS- Net sites 20

21. 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

22. 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

23. 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

24. 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. 24

25. 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

26. 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

27. 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?

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