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Pulsenet: on the Front Lines of Foodborne Disease Surveillance

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Pulsenet: on the Front Lines of Foodborne Disease Surveillance ISSUES IN BRIEF: ON THE FRONT LINES OF FOODBORNE DISEASE SURVEILLANCE APRIL 2013 PULSENET ON THE FRONT LINES OF FOODBORNE DISEASE SURVEILLANCE National Molecular Subtyping Network for Foodborne Pathogens Illnesses caused by foodborne pathogens continue to be a major burden to the health of Americans. New Centers for Disease Control and Prevention (CDC) estimates released in 2011 highlight 31 major pathogens causing nearly 9.4 million foodborne illnesses and contributing to more than 1,300 deaths in the United States annually. Salmonella ranks among the top four pathogens the early detection of the clusters which resulted in the associated with foodborne illness, causing an recall of contaminated products from the marketplace. estimated 1.0 million illnesses and a leading cause More importantly, by detecting outbreaks and finding of hospitalizations per year.1 Moreover, estimates by the gaps in our food safety systems, the food industry, Scharff suggest the economic burden due to these regulators, and the public get critical information illnesses is enormous, ranging from $51.0 billion to needed to improve the safety of our food supply. $77.7 billion annually.2 PulseNet, the National Molecular Subtyping Network Public health departments across the country continue for Foodborne Disease Surveillance is a national early to heavily invest time and resources in investigating warning detection system for outbreaks caused by multistate outbreaks. In a typical year, over 1,500 pathogens such as Shiga toxin-producing Escherichia coli local disease clusters and 250 national or multistate (STEC), Salmonella, Listeria monocytogenes, Shigella and clusters are investigated. In 2010, multistate outbreak Vibrio spp. Established in 1996 by the CDC, four public investigations resulted in the identification of health laboratories, the US Department of Agriculture diverse products contaminated with disease-causing (USDA), and Association of Public Health Laboratories microorganisms, such as shell eggs (500 million (APHL), PulseNet has since grown to over 85 laboratories recalled), alfalfa sprouts, cheese, frozen entrees, frozen consisting of local and state public health laboratories, imported mamey fruit, shredded lettuce, beef, and state agricultural laboratories, and US Food and Drug red and black pepper on salami products. In addition, Administration (FDA) and USDA food regulatory other hazards were identified as important causes laboratories. PulseNet uses DNA fingerprinting to track of human illness, such as contact with pet African and detect clusters of foodborne pathogens. Pulsed- water frogs and reptiles fed with contaminated frozen field Gel Electrophoresis (PFGE) is the standardized rodents.3 Due to the nature of these diffuse outbreaks subtyping method used by all participating PulseNet and wide distribution of cases within the United States, laboratories. The power of the network is in its ability it is likely that many of these outbreaks would have for the participants to share and compare patterns gone undetected using traditional epidemiological and to communicate findings in real-time. In 2010, and laboratory tools. In these instances, a real-time the PulseNet network detected over 1,800 clusters of laboratory surveillance network, PulseNet, was critical in foodborne pathogens. PULSENET DISEASE SURVEILLANCE APRIL 2013 1 The Association of Public Health Laboratories (APHL) control diseases domestically and abroad. In 2011, is a member based non-profit organization which APHL administered a survey to assess the capability represents local, state, agricultural, and environmental and capacity of the PulseNet network during the 2010 laboratories. APHL works to provide its membership calendar year and to determine changes in laboratory and the public health laboratory community with practices since the last PulseNet network assessment in information, resources and training to provide a solid 2008. This Issue Brief presents the survey findings. public health infrastructure that works to prevent and METHODS In May 2011, APHL conducted a survey to assess 9 local public health laboratories, 3 state agricultural member laboratories’ capacities and capabilities for or veterinary laboratories and one state chemistry conducting molecular subtyping (PFGE) through the laboratory. A similar survey was conducted in 2009 PulseNet network for the 2010 calendar year. The survey to assess activities for the 2008 calendar year. Some was sent to 68 public health, agriculture, chemistry comparisons are included in this report for questions and veterinary laboratories-which included 54 state that were largely unchanged between 2008 and 2010. and territorial public health laboratories, 9 local public The survey was administered through SPSS mrInterview health laboratories, 4 state agricultural or veterinary (version 4.5), a web-based repository and survey tool. laboratories and one state chemistry laboratory. Of those Descriptive analyses were conducted, and responses surveyed, APHL received 60 responses —comprised of 47 were grouped into three main categories: surveillance, state and territorial public health laboratories, cluster detection and laboratory workflow. PULSENET SURVEILLANCE Overall, PulseNet laboratories are Figure 1. Comparison of Isolates from Clinical and Non-human Sources PFGE Subtyped in 2008 maintaining their capabilities and capacity and 2010, by Pathogen to perform PFGE testing within the network. During 2010, a total of 51,785 clinical 120% and non-clinical isolates (Shiga toxin- 100% producing E. coli (STEC), L. monocytogenes, Salmonella, Shigella, Campylobacter, and 80% Vibrio spp.) were PFGE subtyped by PulseNet 60% % isolates from clinical and non- laboratories, which is an increase of human sources PFGE subtyped 7% since 2008. Overall, the number of 40% (2008) laboratories providing PFGE subtyping % isolates from clinical and non- human sources PFGE subtyped remained relatively constant since 2008 20% (2010) with the exception of Campylobacter, which 0% increased from 24 laboratories in 2008 to 33 laboratories in 2010. Collectively, over S. Typhi Shigella 13,300 PFGE gels were processed by member E coli 0157 S. Enteritidis Campylobacter STEC non-0157 S. Typhimurium laboratories in 2010. L. monocytogenes All other Salmonella Secondary enzyme testing increases the discriminatory power of the subtyping enzyme; whereas, only 14% of Salmonella isolates method and can be useful during an outbreak were routinely subtyped with a secondary enzyme. investigation. In 2010, secondary enzyme testing in Moreover, approximately 66% of Salmonella isolates public health laboratories varied markedly among were only subtyped with a secondary enzyme when a pathogens. Among STEC and L. monocytogenes, over cluster or multistate outbreak had been detected and 87% of clinical isolates received into the public health 79% when second enzyme testing was requested by laboratories were routinely subtyped with a secondary epidemiologists. 2 APHL PUBLIC HEALTH LABORATORY ISSUES IN BRIEF Although the majority of laboratories Figure 2. Number of Clinical Isolates PFGE Subtyped by Pathogen in 2008 and 2010 have the capability to perform secondary enzyme testing, such additional routine 30,000 testing on large volume of isolates 25,000 can strain already scarce resources. However, requesting secondary enzyme 20,000 testing during an outbreak investigation 15,000 may delay the response time of an Total # of clinical isolates PFGE 10,000 subtyped (2008) investigation and subsequent recall of a product from the market. Only 10 5,000 Total # of clinical isolates PFGE subtyped (2010) laboratories (17%) reported being able 0 to respond immediately to requests for second enzyme testing. Twenty-three Vibrio S. Typhi Shigella laboratories (38%) reported responding to E coli 0157 S. Enteritidis STEC non-0157S. Typhimurium Campylobacter secondary enzyme requests within 5 days. L. monocytogenes All other Salmonella During 2010, public health departments reported a total of 85,438 clinical cases of Although PFGE has utility in detecting clusters of Shiga toxin-producing E. coli (STEC), L. monocytogenes, foodborne pathogens, newer methods, such as Multiple- Salmonella, Shigella, Campylobacter, and Vibrio spp. Of locus Variable-number tandem repeat Analysis (MLVA), reported cases, public health laboratories received an have proven to be useful in confirming clusters for E. coli estimated 68,663 (80%) clinical isolates for laboratory O157 and Salmonella.4-5 Laboratories within the PulseNet testing. Of these, 50,226 (73%) of isolates were network assist with evaluation and implementation PFGE subtyped. Among specific pathogens, most L. of new molecular subtyping tools, such as MLVA. monocytogenes (97%) isolates which were received in Twelve of the 59 laboratories (20%) reported performing the public health laboratories were PFGE subtyped subtyping methods other than PFGE. Eight laboratories followed by O157 STEC (95%) and non-0157 STEC (88%), (13%) performed MLVA testing and the remaining 4 and all Salmonella spp. (79%). Lower percentages were laboratories performed a third method MLST (Multiple- found among Vibrio cholerae (55%), Shigella (48%), and Locus Sequence Testing) or other methods. This was Campylobacter (27%) isolates. The number of laboratories an increase from 2008, in which 12% of laboratories which received isolates from non-human sources (i.e., reported performing subtyping methods other than food) for PFGE subtyping remained relatively constant, PFGE on
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